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Double what?

June 21, 2020



Social isolation is tough. And, we’ve already talked about how expecting abstinence is not a good public health strategy. Are there modifications we can make that can hugely decrease transmission risk and also provide social and physical connection? Enter the concept of the “bubble”, “COVID-teams”, “Pods”, or “Quaranteams.”

Let’s use the term Double Bubble. For one, it’s fun to say and two, in my research for this letter, it seems to be the most popular term (likely because of one). Double Bubble refers to the concept of expanding your isolation team to include another isolation team (ie. household). This has been a strategy that lots of people (and even a number of countries including New Zealand, Canada, and Germany) have used successfully. Let’s talk about how this should work because not doing this the right way can lead to a huge amount of unnecessary risk and could damage friendships instead of strengthening them.

I think if you are considering this there are two articles I would really like for you to read (here and here). The first is from the perspective of an individual Double Bubbling with a couple of his friends. It really goes through the do’s and don’ts and the interpersonal issues. The second one addresses epidemiological and social aspects. Here is a 2 min blurb by a pediatric nurse practitioner discussing this concept on NPR’s Corona Virus Daily back on May 15. 

Again, whenever we are talking about harm reduction, we are talking about something that will confer risk. I’ve said it before and will again. Whenever we talk about risk, you need to consider your risk tolerance, your personal situation, your medical issues, and the value of the benefit the action will provide you. 

Having offered my usual disclaimer, if you are interested in venturing into Double Bubble territory, read below (but also read the two articles I referenced above):

  • One bubble: You can’t be in more than one bubble. So, if you decide to join up with a couple of friends or join two families, you can’t join another one on the side. 

  • Trust: If you don’t 100% trust everyone’s social distancing practices in the bubble, don’t join bubbles, period. If you think about it for a minute and run scenarios in your head, the lack of 100% trust will only lead to bad things (ie. having more risk than you signed up for or losing friends). 

  • Risk: Your isolation group’s risk is defined by adding up all the individual risks of every person in the group. So, let’s make up a hypothetical situation. Let’s say your isolation group (Group 1) consists of 4 people. Three people never do anything to confer any risk and one person does all the behaviors that confer risk (socially distant shopping, work, etc). This group has a 1% per month chance of contracting the virus (I just made that up but it seems like a reasonable number to work with). Group 2 consists of two people. Both of them go out and socially-distance shop. Let’s say this group has a 2% chance per month of contracting the virus.

The people in Group 1 increased their risk by 3x and the people in Group 2 by 50%. I realize I am oversimplifying. Just because someone in your household or double-bubble gets COVID does not mean everyone will get it. But, I think you see my point. You are adding the risk of the other group to the risk of your group. Hence, why trust is so important. 

  • Partnership: This is more of a partnership than a friendship. There are plenty of people I am great friends with but would never want to marry, live with, start a business with, or be part of their zombie or COVID teams. 

  • Open Communication: The more you can talk and align on the rules of your bubble, the better. If you can’t have these conversations with the people you are considering Double Bubbling with, you shouldn’t Double Bubble.  

  • Double Bubble with risk-tolerant-like and socially-distant-behavior-like people: The more similar the social distance behaviors you have before the merger, the easier it will be after the merger. 

And with that, I hope you have a framework in which to start thinking about Double Bubbles. If I missed something, let me know and I’ll share it in the next letter.  

Stay emotionally connected and physically distant,


PS: My alma mater recently reported they have developed a mouse model for COVID. This is BIG TIME for speeding up the development of therapeutics for COVID. I’ll take the credit as I went there in the mid-’90s… you know standing on the shoulders of giants. Just saying.  

PPS: Follow up on the false-negative letter. Here are two more articles that I used in answering a follow-up email question. This is a nice layperson article from Stat News that is excellent and here is a British Medical Journal article that is written for the medical community but I think it uses accessible language. Here are the main points from the BMJ article:

  • Interpreting the result of a test for Covid-19 depends on two things: the accuracy of the test, and the pre-test probability or estimated risk of disease before testing 

  • A positive RT-PCR test for covid-19 test has more weight than a negative test because of the test’s high specificity but moderate sensitivity 

  • A single negative Covid-19 test should not be used as a rule-out in patients with strongly suggestive symptoms

  • Clinicians should share information with patients about the accuracy of Covid-19 tests