Welcome back to another week! If your kids’ school year has begun, whether remotely, on-site or on a hybrid schedule, I hope it’s going well and they’re staying safe and healthy!
If you live in a northern climate, then the weather’s probably getting chillier and after six months of social distancing, the call of your favorite restaurant or café may be getting more and more attractive. Unfortunately, a recent study published in the CDC’s Morbidity and Mortality Weekly Report (MMWR) suggests that spending time in restaurants, bars and coffee shops during the COVID-19 pandemic may be one of the riskiest choices we could make.
While previous studies have described risk factors and possible exposures among people diagnosed with COVID-19, this is the first published case-control study comparing potential exposures among people with COVID-19 (cases) against those among people with similar symptoms who tested negative for COVID-19 (controls). Case-control studies are important to help separate potential risk factors that are more common among cases from those that are common among everyone. To use a simplified example, if we only described things that the cases had done before they had become infected, we might find that nearly all cases slept and ate. However, if we compared them to controls then I suspect we would find that similar numbers of case and controls slept and ate before they got sick.
The MMWR study describes 154 cases and 160 controls seen with cough and other respiratory symptoms at 11 outpatient healthcare facilities across the United States. CDC staff interviewed both cases and controls over the telephone about their age and gender, other medical conditions, symptoms, close contact with other known COVID-19 cases, face mask wear, and locations where they had spent time during the 14 days before they became sick. Both groups had similar age ranges and genders, but more COVID-19 cases were Black or Hispanic, consistent with previous reports that Black and Hispanic Americans have been disproportionately affected by this pandemic.
Perhaps unsurprisingly, more cases than controls had close contact with another COVID-19 case, most commonly a family member. On the other hand, more controls than cases had high risk conditions for COVID-19, suggesting that healthcare providers at the participating sites may have tested more patients with high risk conditions than patients without high risk conditions.
Cases were much more likely than controls to have spent time in a restaurant in the 14 days before they had become sick. Among the subset of cases and controls that had not been exposed to a known case of COVID-19, more cases had spent time in restaurants, bars and coffee shops before getting sick. In contrast, similar numbers of cases and controls had spent time in other public settings, including shopping, offices, hair salons, gyms, public transportation and religious gatherings.
Additionally, cases that spent time in restaurants or bars were more likely than controls who had done so to report that no or few people in the restaurant or bar had worn face masks, while controls were more likely to report that nearly everyone had worn face masks. However, personal face mask use was similar among cases and controls.
While this is the first study of its kind, the finding that people with COVID-19 were more likely to have spent time in restaurants, bars or coffee shops is consistent with previous reports of clusters and outbreaks of COVID-19 associated with restaurants in China, Japan and Korea. Additionally, a study published in Health Affairs in May 2020 found that closure of restaurants and entertainment centers in the U.S. reduced increases in new cases of COVID-19 by four to six percent.
With the focus on public transportation, work, shopping and schools, it may seem surprising that restaurants were higher risk than any of those locations. However, I suspect that the biggest risk factor in restaurants, bars and coffee shops may be that patrons can’t wear masks while eating or drinking. One can easily wear their mask throughout an entire shopping trip, at work, school or while getting their hair cut. (Indeed, a July 2020 MMWR article described how consistent face mask wear prevented spread of COVID-19 at a hair salon.) However, we have to remove masks to eat or drink. Additionally, while the CDC recommends wearing face masks at all times in public other than while eating or drinking, it’s easy to become complacent and leave the mask off once you’ve removed it.
I’ll admit that last month, as summer wound down and COVID-19 activity remained low in my local area, I ate indoors at more than one restaurant. As nice as it was to eat at an old favorite restaurant, this journal article has made me rethink eating at restaurants. I’m going back to curbside pickup and eating at home for the time being.
If you do choose to eat at a restaurant, then I recommend that you wear a mask any time you’re not eating or drinking, even if you’re seated with members of your household and six feet away from other people. You never know when your waiter or waitress will drop by your table or another patron may pass near by you. Even if they’re wearing a face mask, the risk of COVID-19 spread is lower if you’re both wearing masks.
If the restaurant has outdoor seating or a patio, then select the outdoor option as long as weather permits and outdoor seating is available. While this study didn’t distinguish between indoor and outdoor eating, it makes a certain amount of logical sense that outdoor eating areas may be less crowded and better ventilated than indoor areas.
I also recommend that you take a quick look around a restaurant, bar or coffee shop the first time you visit it since the COVID-19 pandemic began. Are all of the waitstaff and most of the patrons wearing face masks? Are tables or booths spaced at least six feet apart and/or is every-other table or booth closed to patrons? If not, are there physical dividers such as polycarbonate barriers separating tables or booths? If the restaurant isn’t maintaining social distancing and mask wear, particularly among the wait staff, then choose a different restaurant or consider getting take-out instead.
Stay healthy, stay safe, and stay home when you can,
🍽️ Dr. B