COVID-19 Update With Dr. Tom Frieden

COVID-19 Update With Dr. Tom Frieden

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from State and Local Conference Calls and Webinars

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Public Health Threats and Pandemics

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Dr. Tom Frieden, senior fellow for global health at CFR and former director of the Centers for Disease Control and Prevention (CDC), provides an assessment of the current status of the COVID-19 pandemic and the progress made on vaccine development.

Learn more about CFR’s State and Local Officials Initiative.

Speaker

Tom Frieden

Senior Fellow for Global Health, Council on Foreign Relations; Former Director, Centers for Disease Control and Prevention

Presider

Irina A. Faskianos

Vice President, National Program and Outreach, Council on Foreign Relations

FASKIANOS: Thank you Maureen, and good afternoon. Welcome to the Council on Foreign Relations’ State and Local Officials Webinar. I'm Irina Faskianos, vice president for the National Program and Outreach at the Council on Foreign Relations. We're delighted to have participants from forty-nine states with us today. Thank you for taking the time from your busy schedules to join this discussion, which is on the record. As you know, CFR is an independent and nonpartisan membership organization, think tank, and publisher focusing on U.S. foreign policy. Through our State and Local Officials Initiative, we serve as a resource on international issues affecting the priorities and agendas of state and local governments by providing analysis on a wide range of policy topics. And we are also the publisher of Foreign Affairs magazine.

So we're very pleased to have Dr. Tom Frieden with us today. We've shared his bio, so I'll just give you a few highlights on his distinguished career. He is the president and chief executive officer of Resolve, a $225 million, five-year initiative housed at Vital Strategies. Resolve aims to save millions of lives from cardiovascular disease and to prevent epidemics. He is also a senior fellow for global health at the Council on Foreign Relations. So we're very fortunate to have him as part of our community. Dr. Frieden previously served as director of the Centers for Disease Control and Prevention and as commissioner of the New York City Health Department. He's a physician trained in internal medicine, infectious diseases, public health, and epidemiology, and has published widely-cited research on a broad range of topics, and has been really on the forefront of looking at COVID-19 and what we are all living through now. So Dr. Frieden, thank you very much for being with us today. I am going to turn it over you to give us an update of where we stand, where things stand with the COVID-19 pandemic including progress on treatment and vaccine developments. We're all looking very carefully at what's going to happen as schools are reopening and colder weather is on its way.

FRIEDEN: Great. Thank you so much, Irina. And thanks to all of you who've joined. There are so many questions that come up over and over again, I want to make sure we have time for a discussion, but I thought it would be helpful to take us through some basic slides at the outset to give us a sense of where we are, where we're going, and what some of the main issues may be. This is a little bit of a complicated slide, but it's really quite an important one. COVID is so unusual, because it is mild for some people and severe for others, but there is a pattern. For people over the age of sixty or those with underlying health conditions, the severity is actually similar to the severity of the 1918 pandemic. For kids under the age of twenty, it's more like a mild-to-moderate flu season, which means sometimes deadly, but usually mild. For people between twenty and fifty-nine, who don't have underlying conditions, it is somewhere in-between. Now, the cost of epidemics and pandemics can vary widely. We have SARS, we have H1N1, we have H5N1, we have Ebola, and then, we have COVID. $9 trillion. And this is really a loss of money and a loss of lives that is in many ways preventable.

We also see persistent and exacerbated inequalities in health outcomes. Racial disparities in health and healthcare are stark, they're persistent, and they're unacceptable. They're a symptom of broader structural systemic social and economic inequalities, and we see essentially the confluence of three things: more exposure, more underlying disease, and less access to care. A disproportionate burden requires a disproportionate response. What you see in the graph here, from CDC data, five-fold increased hospitalization rates of African Americans, Latinx, and American Indian, Alaskan Native populations. We have to transcend a lot of false dichotomies. And I have to give credit to the journalist Ed Young, who today wrote an article about nine pitfalls that people fall into, and false dichotomies is one and the other eight are all worth listening to and reading about also. It's not about closed versus open, we were never fully closed, we won't be fully open, and we won't be fully open even after there's a safe, effective, and accessible vaccine. It's more like a dimmer dial than an on-off switch. It's not about health versus economy. Unless we get our economy back, there'll be deadly health effects, but we can only protect livelihoods by protecting lives. It's not a question of whether it's overblown or catastrophic.

It's severe for older and vulnerable people and it's mild for a lot of others. There are two fundamental arms of the response. Starting safer, reducing the spread of COVID through the three W's, wear a mask, watch your distance, wash your hands, and box the virus in with a comprehensive test, trace, and isolate strategy. Now, a lot of questions about vaccines and we can talk more later, bottom line, we do not yet know whether there will be a safe and effective vaccine. There are grounds for being guardedly optimistic that vaccination may be possible. We can and should begin now engaging with communities to share information, listen to perceptions and concerns, and develop linkages. But even with a vaccine, the pandemic will continue for some time, and comprehensive prevention and control measures will be needed. Now since we have a lot of cities on the line, I wanted to talk for a moment about the role of cities. Density, unfortunately for those of us who live in big cities, is a driver of the pandemic. Large numbers of people living in a smaller geographic area. More frequent contact means more disease spread. More central to commerce and culture means more travel. But disease that starts in the city doesn't stay in the city. It travels out to suburbs and rural areas. The cities have, in some cases, more resources and capacity for local action. And there are a lot of things that need to be implemented locally. So cities can be pathfinders and often act more quickly. Whether that's on isolation of cases and quarantine of contacts, or restrictions on indoor public gatherings, or school and work closures and adaptations, or sheltering in place when absolutely required.

The three W's are really important and I think we always look for the new, exciting, different things, expensive, but often it's the tried and true. One of the world's leading vaccine experts said something to me very interesting a couple days ago. He said you know a vaccine probably isn't going to be as effective as everyone wearing masks. That's really a striking comment when you think about how much focus we have, appropriately, on a vaccine, but how we haven't really gotten it right with masks. Indoors, outdoors, when you're near others at home, if you're not well, you need to wear a mask. You don't need to wear a mask when you're outside physically distant from others or if you're at home and don't feel sick. Some masks are better than others, but any mask is better than none. N95s we would like to keep for healthcare workers, but there really should be enough for everyone. Standard surgical masks may be much more effective than most of the cloth masks that are used, but not all cloth masks are the same and proper fit is important. You know if neither is wearing a mask, there's a high chance of transmission. If the ill person is wearing a mask, it's a low chance of transmission. If both are wearing a mask, it's the lowest. When all of us wear masks, all of us are safer. Between April 8 and May 15, fifteen states and DC mandated masks by all people when in public. States that mandated universal mask-wearing had statistically significantly larger declines in cases, and those continued for every five days the mandate was in place, it's like a dose response relationship. Twenty states that had only employee mandates didn't see significantly increased decreases.

The box-it-in strategy is the strategy we recommend for the control of COVID. Testing widely and systematically, being strategic, isolating promptly, and tracking how prompt isolation is, contact tracing to find and warn contacts and quarantining contacts for fourteen days. We have a lot to learn. How can you reduce the time from infectivity to isolation? How can we warn contacts promptly so they're quarantined before they get infectious? And how can we provide safe, acceptable, temporary housing to cases and contacts to prevent household spread? This slide outlines best practices from around the world, incentives to better support cases and contacts on isolation and quarantine, care packages, core resources, financial support. This is really important. If you're asking someone to stay home for fourteen days, you need to support them or to help them come out to a different place where they won't spread it to their household members.

Children are much less likely to experience severe COVID, they may be less likely to get infected, they may be less likely to spread infection, but we don't know that for sure. The science is still evolving; we have lots to learn. Schools are top-of-mind. Here we are after Labor Day and we know that schools are essential to educational and social development. We have to try to get kids back in school physically. I agree with that. But there's no way to do that unless we're going to control COVID in the community. That's going to be key. Within schools, there are things that can be done that are basic safety measures, shielding the vulnerable, reducing risk by for example, not having choirs. Keeping the virus out by, for example, having everyone wear a mask, making sure that no one sick comes to school, forbidding non-essential visits, reducing occupancy, especially indoors, going outdoors to the extent possible. Reducing mixing among students and staff at pods or cohorts so that if you do have a case, you don't end up having to close the whole school. Masking up. Implementing new protocols for hand-washing and sanitizing and cleaning and limiting sharing of supplies. And despite all of that, preparing for cases. There will be cases. So you need to function as if the virus could arrive at any moment and be ready to respond, continue teaching, and prevent a large outbreak.

A best practice from around the world and around the country is an alert-level system. We think four levels is probably the best. It tells people, what's the risk, if you're at increased risk, should you go out or not? Do you need to wear a mask everywhere? There are different things that can be done at different levels. And I've thrown up here a few examples. This was just released from California. They have a tiered case rate. Again, they use a four color but they point out we're not at green yet and we won't be for quite some time. This is Utah which did this really first, they're at orange now. They have a whole approach for what you can do at different levels. You know, Ohio, they provide gating criteria, giving a sense of how bad the outbreak is in different areas and that has implications for the activities. Austin, Texas has another risk alert system. I've just thrown these up as examples. I wish there were a national standard and everyone on the same page. But barring that, we look at best practices from around. Determining what's safe. I'm going to give you a simple formula - five factors. What's the prevalence of COVID in the community? What's the proportion of people without masks? How good or bad is the ventilation? How many people are there and how long is the exposure? So if you're outdoors in a low-prevalence community, you have almost no risk. If you're indoors for a long time with a lot of people and a high prevalence community, without people wearing masks, you have the highest risk.

Risk communication is so important and it's one of the things that has been most problematic about the U.S. national response. Information needs to be easily understood and communicated through trusted, accessible channels. Be first, be right, be credible. These are the CDC risk-communications principles. Be consistent, competent, objective, express empathy, sincerity, transparency, answer the questions that people have about their level of risk. What specifically can they do, and what is happening?

We need also to address the needs of COVID-19 and beyond. Infection prevention and control in healthcare settings isn't nearly as good as it needs to be. Broadband internet needs to be much more widely available. We have too many kids who, not only can they not go to the school, but they can't get high-speed internet. They don't have hardware, software, or connection to participate and that's a digital divide that is unacceptable. We have to reorient our healthcare system to really empower primary care. We have to scale up telemedicine and that's one thing the federal government has taken good steps on. We have to increase team-based care and financial incentives for prevention, and sustain funding for global health security to protect ourselves from microbial attacks from anywhere in the world. The CDC and state and local health departments need sustained support. We can keep this country safe now in and in the future. We've had many years of underfunding, but there are ways to prevent, detect, and respond. We can't afford another multi-trillion dollar pandemic, but we can afford the health security to prevent it. So I'll stop there. That was a whirlwind tour through some basic concepts. I wanted to get through them quickly, so we have plenty of time for conversation.

FASKIANOS: Fantastic, thank you so much. Let's go now to all of you. If you click on the, look at the bottom of your screen, and you can raise your hand there. Or if you're on a tablet, you can click on the upper right hand corner, the "more" button, and you will see the "raise hand" there. So please, when you accept the unmute prompt, please say who you are and where you work and what city, state, to give us context for what you're dealing with. So let's first go to John Clark.

Q: Hi, doctor, can you hear me okay?

FRIEDEN: Yes.

Q: Good. I was a military fellow at CFR several years ago. Now I'm a defense contractor with Lockheed Martin. And I've been watching the Dispatch for the death rate and it looks like it's gone down to three percent of the total cases, total positive cases. And I'm just wondering that, over time has in fact, the disease become less fatal? Thank you.

FRIEDEN: Yeah, that's a great question. First off, the number I look at most is what's called the excess mortality rate. And the Economist news magazine, for some reason has the best sight on this for all states in the U.S. and for a few dozen countries. Because, there are a lot of COVID deaths that don't get measured as COVID deaths. And that's a problem. Also, how do you know how many infections there are? So there was a very interesting recent study from Iceland that suggested that about one in three hundred people with infection die from it. The percent mortality rates of diagnosed infections aren't very relevant, because we know that we're missing five times, ten times as many cases as are actually infected. So both the numerator and the denominator are problematic. We think the death rate for COVID, first off, it increases really rapidly with age. So it's quite low at young age and quite high at older ages. So if you ask, what's the case fatality rate, the right answer from an epidemiologist is what's the age and underlying condition breakdown of the population that it's in, because it'll be very different in a nursing home, for example, from an Army recruit place.

But if you look at the U.S. population, the death rate is somewhere around a half a percent, about one in two hundred people. Now think about that. We've had two hundred thousand deaths, and there are more deaths than have been documented. And so there have been more than forty million infections in the U.S. by that calculation, it's a quick way of estimating it. It's been said that the death rate is a fact. Everything else is an inference. But over the last few weeks, I've been wondering is the death rate even a fact when people are questioning things and some of the more, kind of, off-base things are well, if people died from COVID, but they also had diabetes, they didn't really die from COVID, did they? Well, if you had cancer and you died from lung cancer, but you also had diabetes, you died from lung cancer. This is the way we count things in public health, it's the multiple cause death certificate, but the deaths that are attributed to COVID are those that the doctors say this person died from COVID. And we know in some states, it's actually quite a few more excess deaths than COVID deaths. So there may be quite a few uncounted COVID deaths. But the short answer is in the U.S. about one in two hundred. About 0.5 percent.

FASKIANOS: Thank you —

FRIEDEN: Sorry, I'm sorry, I didn't answer your other question. Is it getting better? We don't know. It's a really good question. If you look at China, at Wuhan, their initial case fatality was extremely high, and then it went down to 0.7 percent. Now is that because they diagnose people better or they got better at it? There's a recent theory that's getting a lot of ink that if you wear a mask, not only are you less likely to spread COVID, that's true, you're probably less likely to get it, that's almost certainly true. You may be less likely to get it severely, because maybe I only get a few virions rather than a whole slug of virions, and maybe the severity of disease is related to the inoculum. We don't know, that's a theory.

FASKIANOS: Thank you. Let's go to Liz McNabb.

Q: Hi, good afternoon. My name is Liz McNabb. I'm the district director for State Assemblywoman Cottie Petrie-Norris in Irvine, California, and I'm curious how you would approach the, if there's not going to be a national response, should we have regional responses? Or how can we de-politicize the, you know, really sad state of affairs that we're in currently in different areas of the country? And how could we make, are there realistic ways to make it better, do you think? Who should we reach out to? I mean, I guess we reach out to our congresspeople. What's your thought?

FRIEDEN: We hope so. The National Governors Association is doing some things, there are some regional compacts. Many states are taking a good approach. We released from Resolve to Save Lives, a list of fifteen essential indicators we think everyone should publicly report. California is increasing, actually, the number of those they report. And we've been in touch with them. And the risk system that I mentioned earlier is one example of that. But we're really not reporting indicators of performance. How rapidly are tests coming back? There are just three states reporting that. How quickly are patients getting isolated? Very few places reporting that. Are contacts being quarantined before they can become sick? Only Washington, DC, reports that of every jurisdiction that we found in the U.S. So I think one way of getting on the same page is what gets measured can get managed and we're not measuring publicly enough and I think more transparency is really important.

FASKIANOS: Thank you. Let's go to Kip Kendrick.

Q: Yeah, thank you very much. Kip Kendrick, a state representative out of Missouri, representing Columbia, Missouri where the University of Missouri is located. Can you comment on what some of the potential long-term impacts may be that the Journal of the American Medical Association has reported? And are those concerning? How seriously do we need to take this moving forward?

FRIEDEN: You're talking about long-term health impacts. Long haulers?

Q: Yes. Correct.

FRIEDEN: Yeah, because there are going to be long-term societal and economic and healthcare impacts also. But in terms of the long-term impact to individuals who've gotten the disease, we really don't know. We need to get more data. In fact, this is the kind of situation for which disease registries are really, very useful, where you can monitor people over multiple years to get a sense of the range of illness. One of the things that has concerned me for quite some time, is that the symptom of anosmia, you can't smell, or dysgeusia, you can't taste, that's not actually about your nose and your tongue. That's about your brain, that's about your central nervous system. And we don't know what kind of long term consequences that might have, with fifty million people already infected in the U.S., even if the rate of adverse long-term reactions is a tenth of a percent. That's a lot of people. So I think we don't know what the long-hauler experience will be.

Certainly, many people are suffering from this, a wide range of problems. You've probably seen at least one professional baseball player aged twenty-seven. Previously healthy, has inflammation of the heart. We don't even know how common that is with influenza. So there's just still a lot where we're not, we don't know, but we need to support patients. We need to learn more, when to try different things to see if things will be effective. We don't think this is a reflection of long-term infection. This is maybe the result of the inflammation that occurred because a lot of the illness from COVID is from a very severe inflammation that can occur with it.

FASKIANOS: Let's go to Dawn DiBlasi.

Q: My name is Dawn DiBlasi and I'm from Somerset County, Maine, I'm the county administrator. And I'm very concerned about the fact that—Maine has so few cases—half of my employees don't believe in it and half of them do. It's been very politicized in this area. And I'm struggling because my commission is also a split. And recently, they changed the mask policy in the building. And we were to wear the masks in common areas. We were not required to wear them in our offices once we were there in our office by ourselves. But now the policy has been changed to say, as long as you can be six feet away from each other, you don't need the mask in the common areas. And I'd like to get your take on that if I could. It's getting very stressful in my building.

FRIEDEN: So here's one area where I think those essential indicators and the risk alert systems are really relevant. And this is why we released them. Maine has a very low rate, you're doing well. It's not one size fits all for the country. I would want to know the positivity rate and the testing rate in your county. I'd want to know the epidemiology of the cases in your county. And if it were relatively controlled, I wouldn't be too concerned about that change in process. On the other hand, I would certainly want to emphasize also that, you know, mask wearing is something that we need to get used to. And the more we do it, the more we're safe, it's going to be around for a while. But Maine is one of those places that's got pretty low rates. And so I'd follow the state government recommendations, but I'd try to understand the epidemiology in the county.

I don't mean to avoid your question, but I think if you're talking about New York City in April, then everyone's got to wear a mask at all times. If you're talking about Alaska now, which has an extremely low rate, then that kind of a rule makes perfect sense. But just as all politics are local, all public health is local and epidemiology is local. So if you know that red, orange, yellow, green grading, then I would say you know what, red and orange, you really should all wear a mask indoors. Yellow is probably okay. If you're down to green, it's probably okay. If you don't, or something like that it. It really depends on the local epidemiology.

Q: Would you say that, is there going to be any further danger when winter comes and we're closed in?

FRIEDEN: Yeah, we don't know. The truth is a bunch of people said, oh it's gonna go away in the summer. I never said that. Because we've never seen this before. But most respiratory illnesses do get worse in the winter. If you look at meatpacking factories, which in the U.S. and in Europe, there have been a bunch of outbreaks. You know, they're basically artificial winters. It's cold in there. And they've had explosive spread. One of the things we don't know really is, is that from what we call aerosol or airborne? Is it from fomite or a contaminated surface? Even very good public health experts looking at the same outbreak in the same meatpacking factory, I was on a call with them, one of them said it was definitely aerosol. The other one said it was definitely contaminated surfaces. So I mean, the certainty here, generally correlates with the lack of information. And we just don't know entirely, but I do think it's likely to get worse in the winter. And one thing that we would say is people with underlying conditions need to be particularly careful. People who are older need to be particularly careful.

FASKIANOS: Thank you. Let's go to Tiffanie Fisher.

Q: Hi, thanks. Thank you for your presentation. It was very helpful. This is Tiffanie Fisher. I'm a councilwoman in Hoboken, New Jersey. I have two and a half questions. One question is in terms of what's included in the overall count, recently I know a number of people have been taking the antibody test, and are those, should those, if people test positive for having either the current antibody or the one indicating that they've had it previously, are they and should they be included in the numbers? That's the first question.

The second question is, you know, you talked about how the risks change based on age and as people get older, or if they have underlying conditions, the risk is greater. What are we, in Hoboken and I'm sure in other communities, you know, we have an at-risk population just because of age and I hear all the time from neighbors and members of our community that are in the older category, that they're afraid to go outside. They're afraid to walk on our waterfront because they see runners running by without a mask on or people you know, coming close to them. I mean, what is the message that we can give to them and is there any type of you know, communication that we can provide to them that would give them maybe more comfort to be able to go outside and not have to just stay in their home.

FRIEDEN: Great. Well, first antibody test results should be captured separately from polymerase chain reaction (PCR) and antigen results. Antibody test results indicate the possibility of past infection. They have false positives, they have false negatives, we don't know what a positive means. So keep them in a separate bucket. They're not that meaningful, because there have been six million diagnosed cases of COVID in the U.S. and there have probably been about fifty million infections. So we're not counting those fifty million, and someone who's got a positive antibody test but wasn't counted because they didn't have a positive PCR antigen, they're one of the forty-four million or so that weren't diagnosed. So it's not that important, in most circumstances. So keep that separate. The difference is the antigen test. These are just coming out now. And we need to make sure that those get counted. That's the likelihood that there's actual active virus that need to be followed up as well. In terms of reassuring people at risk, outdoors is way, way safer than indoors. One analysis of multiple studies suggested that your risk of getting it outdoors was nineteen times lower than your risk indoors. Another analysis of more than a thousand people who got COVID, where they could find where they got it, only two got it outdoors, and that was people who were talking very close together for a long period of time.

I think we get into what I sometimes called the slippery slope to zero risk. Very difficult to get to zero risk. So yes, is it possible the jogger running past you infects you? It's conceivable, it's very unlikely, particularly not if you're wearing a mask. We wish they were wearing a mask also. This is one of the reasons it's a little more complicated when you're outside because you don't know when you're going to be within six feet of somebody else. But the risk is really very, very low, because it's about dilution and diluting the amount of virus in the air.

FASKIANOS: Thank you. Let's go next to Christine Hunschofsky. And hopefully I pronounced that correctly.

Q: I'm Christine Hunschofsky, I'm the mayor of Parkland, Florida. And I had some questions. We've had quite a bit of community spread in our area. Our percent positive testing numbers are now going down in Broward County. However, our testing is also going down. So the question I get from people all the time, and I'm going to ask you, is can we trust those percent positive if our testing rates have also decreased?

FRIEDEN: So you look at them together. If you had to look at one number, you'd look at the percent positive. What is it in your area? Christine?

Q: The percent positive right now in our area is approximately 3.7 percent.

FRIEDEN: So that's relatively low. So if the number of tests is going down and the percent positive is going down, that's somewhat reassuring. You do want to know who's getting tested. And whether, for example, in one place, they were testing a bunch of low-risk people. Suddenly, it looks like the percent is going down because you tested a bunch of low-risk people. You really want to know what's the percent positive among people who you're suspecting of having COVID. If you're doing it as screening for college kids going back that's not very relevant. But you also want to look at where are the cases, how many of them are have a known source case? How many of them are actually getting isolated promptly to get a sense of your control measures? The way I think of it, if you're over 10 percent positivity that's extremely high. If you're between five and ten and increasing, that's very worrisome. If you're over five, it's not great. If you're under five, it's better. If you're under one, it's even better. In New York City, New York State, actually, we've been under one for a month now. And that's, they did one hundred thousand tests the other day. So, a lot of testing.

FASKIANOS: Thank you. Let's go to Carolyn Lopez.

Q: Good afternoon. I'm Carolyn Lopez. I'm a family physician and president of the Chicago Board of Health. I have two questions. First is, do we have any more information about the role of the live market in the development and transmission of the virus, the SARS-CoV-2 virus? And the follow up question is how concerned, if at all, should we be about any local live markets? For example, markets that sell live poultry, providing butchery on-site? And should we be concerned about them relative to transmission of, or development even, of novel viruses?

FRIEDEN: Thanks very much, Dr. Lopez. So, on the one hand, we really don't know a lot about the origin of this virus. The initial thought that it was in one live market doesn't seem to be accurate. That may have been the source of a super spreading event that brought it to people's attention, but it does appear to have been spreading before that time. But this is really still all being investigated. Not much data is publicly available about it. And we really don't know.

Interestingly, China had another cluster about two months ago. And that came from a frozen food market. I think about the meatpacking factory, and the published data on that suggest that it was a reimportation from Europe, possibly with some food items that resulted in spread of that. But I think right now with forty thousand cases a day diagnosed and probably two hundred thousand infections a day. This is not a major concern. If we get to a level of trying complete control, it may be more, but right now the focus has to be on providing support to patients with COVID, providing support to people who are exposed, finding ways to make sure that people get isolated faster. That time between when you first get sick and when you're isolated, that's when you're spreading the disease. If you can't get someone isolated sooner, you're going to have more spread of the disease. And then also making sure we do a better and better job finding the contacts and warning them that they been exposed and getting to quarantine before they get sick. That's how countries all over the world have stopped this and that's what we need to focus on.

FASKIANOS: So Tom I'm going to take two questions from the chat then go back to the long list of questions of raised hands. So from Renee Moke, who's a public health director for Bismarck, North Dakota, she asked about your presentation. You say there no specific data sets that are used at standard across the board for risk levels. What data or stats do you feel are the most important to track to determine risk levels for states and communities? And then from Josh Karpis in California. He's in Los Angeles County, local businesses are near revolt wanting to open and want justifications on why businesses can open and others can't. He works for a state legislator. Any advice on how to support the health orders that are based on science when businesses can give a long list of examples of decisions that on its face do not seem to make sense without personally knowing the data. So -

FRIEDEN: Sure, let's take them one at a time. We've circulated the fifteen essential indicators. I think there are two things to look at. One is, what's your level of risk? And there is a positivity rate by state and by county that's now on one website, and we can share that. That wasn't available even a week ago. So positivity rate is very important. I think knowing the total number of cases, the testing rate, the positivity rate, and the unlinked infections gives you a sense of how much disease is spreading without being controlled in an area. So that's very important. I also think it's very important to know how well is the area doing controlling it. And we're really looking for places anywhere to begin publicly reporting more data. How long is it taking tests to come back? What proportion are within one day, within two days, what's the median time? And we've just seen that added to the California site, Alaska, and North Carolina. So there are three states, three out of fifty, do that now. We'd like to see time from symptom onset, or at least when the test got taken, to isolation. We've only seen that in a couple of states, but that's really essential. And then time from exposure. Well, actually, rapid quarantine means, what proportion of today's cases were identified contacts who had been warned, who have quarantined, and they developed their illness or infection while they were quarantined. That's the success, that's the outcome variable for contact tracing. Only Washington DC reports that, so we want to see more places report things like that so we can have accountability for progress.

And at Resolve, feel free to reach out Renee and we'd be happy to work with you if you want to try to do that in Bismarck. In terms of California, I think what we need to try to do is make very clear the reason and the rationale and the justification of the restrictions that are made. Businesses are having a hard time; we want them to reopen. There are some adaptations. Some states early on said, hey, if you're allowing pick up to front door, you can open. That makes a lot of sense for a lot of businesses. Bars, big problem. Bars are a spreader area. If you look at that formula I had before, people talking loudly for a long time with a lot of people in a small space, but not much ventilation, really difficult. Outdoor dining much safer than indoor dining, indoor dining, yes, it can become like the bar, especially when you close the bar. So these are these are tough decisions. That's one reason we really encourage the alert levels so that everyone instead of yelling at public health, let me open. They say hey, let's work together to get down to green so that we can open and stay open because we've done it safely.

FASKIANOS: Thank you. Let's go next to Katie Lang. You need to accept the unmute prompt. Okay, let's since we have so many questions I'm going to go to Katie Scott next.

Q: Hello, I unmuted myself I believe.

FASKIANOS: All right. Is this Katie Lang?

Q: Nope, it's Katie Scott.

FASKIANOS: Okay, Katie Scott first.

Q: Hi, my name is Katie Scott. I am a Washtenaw County Commissioner. I'm also a cardiovascular ICU nurse and a soon to be graduate student for my master's of public health. I'm just a little bit busy. And one of my passions is obviously public health and here in Washtenaw County, it is the home of the University of Michigan, where we have students who are back in full. It's raised some angst in our community about students coming back and what it might do to us in Michigan and whether it will become a ground zero site in Ann Arbor because of the students coming back. I know that the university has pledged to do pretty extensive contact tracing, but I'm wondering if there is a point where contact tracing becomes a futile project or not a good use of public health dollars or time. At what point do you say the numbers are so high and going up so quickly that it's time to shut this down and send the students home? I guess that's the crux of the question.

FRIEDEN: That's a great, it's a great question. And thanks for the work that you do, and good luck in your career. You're ideally trained for this and other public health areas. I think that the challenge really is that there is no number. But basically when you can't keep up, then it's going too fast. And we paid a lot of attention to not being able to keep up with getting people into intensive care units. But we also need to think of, can we keep up with testing, contact tracing, isolation, quarantine. I was hearing about one college which, you know, the frats had huge outbreaks and off-campus housing, big outbreaks. And that's going to spill into the community. There's no way it's not. So I think we need to figure out ways to keep everyone as safe as possible. And it's not maybe the greatest risk on campus, the greatest risk may be off-campus. And Irina, I know that we always stick to time at CFR so we've got exactly fifteen minutes and we've got at least nine more hands raised. So I will try to be quicker in my responses so we can get to everybody.

FASKIANOS: Great. All right. So I promised the other Katie to go next, Katie Lang.

FRIEDEN: She's put a question into the chat maybe she's having trouble with -

FASKIANOS: Okay, so why don't you just do that?

FRIEDEN: Right, the county clerk from Granbury, Texas. Are there any cases of COVID deaths that don't have underlying conditions? Yes, absolutely there are. One of the things that's kind of sad is most Americans over the age of sixty have underlying conditions. In fact, about 70 percent of Americans over the age of sixty have hypertension, as just one condition. About 20 percent have diabetes. So yes, there certainly, sadly, are people who have no underlying conditions and die from COVID. We don't know why that is. Is it a different strain? Did they get a larger dose? Were they unlucky? Did they have a different genetic makeup? Had they experienced different exposures to COVID in the past? But this is a virus that should not be underestimated by anyone.

FASKIANOS: Thank you. Let's go to David Tarnas.

Q: Aloha, thanks for your presentation. It was very interesting. I'm a state representative in Hawaii. And my district is the rural district in the north part of Hawaii Island. Our state, we're struggling to get the percentages and the metrics that you describe under control before we open up to out of state travel. Right now it's a mandatory fourteen-day quarantine. We're currently finalizing, the administration, the governor, is finalizing a pre-travel testing program that would give you an exemption to that fourteen-day quarantine. Question is, you know, what are all the details? If you had if you could give some advice to the governor about what would be that pre-travel testing? Would it include not just pre-travel testing, but also when you arrive? And do you need to have some quarantine after you arrive? What would you suggest? Just for that particular concern of unique nature for Hawaii because we depend on tourism, so we have to open. But we have to do it safely.

FRIEDEN: Yeah, well, I've been following the big increase in cases in Hawaii in the last few weeks, and I'm not sure what's driving that. I think, obviously, the safest thing is to quarantine. Now, you could quarantine in separate locations that are tourist, you know, tourist-friendly. The problem with testing is that you shouldn't rely on it too much. Even if someone tests before they get there and when they get there, the incubation period is between two and fourteen days. So if they get exposed on the plane over and you test them there, they could get infectious a week later. So I guess I don't have a great answer for you. But I would say whatever you do don't let down your guard, even if you test everyone. Don't have indoor, lots of people in bars in one place because you're gonna have the risk of explosive spread. And then you'll be taking one step forward and three steps backward. But I know it's an important issue. Because of quarantine, Hawaii had been doing so well before, in terms of a low number of cases. So I'd try to understand what's happening, and I'd try to be supportive of your local and state health departments of what you can do to balance those economic necessities, which are really important, with preventing the kind of spread that's going to poison the well for any kind of tourism.

FASKIANOS: And we are going to collect all these links and Dr. Frieden will allow us to send out his presentation. So we'll put all this in an email as a follow up, because I know there are a lot of links going on in the chat. So let's go to Janice Weiner next in Iowa.

Q: Hi, my name is Janice Weiner, and I'm on the city council in Iowa City, Iowa, which as you may know, has been one of the top places for COVID, which is not exactly how we wanted to earn the number one spot. After about thirty-five thousand students came back to campus and we're not tested. Our governor has declined to put in place any kind of face covering mandate. We as a city and our county put in place face covering mandates, although she told us we couldn't. Our numbers were coming way down until the students came back to town. They seem to be going down again, but given the lack of leadership at the state level here, to be honest, what is our best way forward?

FRIEDEN: You know, these are really hard questions. But I think face coverings are really important. One of the things that we're enthusiastic about is Philadelphia, actually measures adherence with face coverings in indoor locations, on buses and in stores based on security camera footage, and then publishes that on a weekly basis. And that, indoor and outdoor, we're working on a protocol for that. And we've worked with some other places so that you can get everyone working together and say, listen, this is just, this isn't about separating people from one another. This is about separating the virus from people. We wear a mask to be responsible, we wear a mask, because we care about other people. And I think it's very unfortunate that masks have been politicized in this way because it's really the least expensive way we have to get our economy back. And so whatever argument works, masks are important. Looking at local spread is important. The universities are going to be a challenge. I'm not a big fan of testing low-risk university students. I think it's very expensive and it's not clear how much good it's going to do. If people do it, fine, but don't rely on it. What you have to rely on are doing the things that will reduce the risk of spread, three W's. Wear a mask, wash your hands, watch your distance. And restrict those indoor gatherings that are going to be very problematic, choirs and things like that, and do a better and better job finding and stopping outbreaks. You find cases before they become clusters and find clusters before they become big outbreaks.

FASKIANOS: Oh, I'm on mute. Thank you. So in the chat, we had a question from Dr. Patricia Cafaro. The progress made on status of vaccine development, in addition to the four bullet points mentioned on your slide, and any thoughts you have on making the vaccine mandatory. Of course we need to produce enough of the vaccine to administer it, but your thoughts on that?

FRIEDEN: Well first we have to make sure the vaccine is safe, effective, accessible, and trusted. And that means being very transparent with the data. That means that it has to go through the FDA Advisory Committee, the CDC Advisory Committee. We have to see the data transparently, we have to recognize that there may be safety concerns and be upfront about those. There's a prioritization of people to get the vaccine, that's very important. I think that the one group that might end up getting mandated in some states are people who work in nursing homes, because the residents are so vulnerable to death from COVID. But I don't see this being mandated anytime soon. Because we don't yet have a vaccine. We don't yet know that it's fully safe and effective. But if I were to predict what might be a mandate of some states at some point in the future, that's very hypothetical. That's the one group that I think you might need to look at carefully to say, listen, if you come in here with COVID, either you have to test every day, or you have to get vaccinated, or both. Because when COVID gets into a nursing home, it's really devastating and the death rate can be very high.

FASKIANOS: Thank you. Let's go to James Jayne.

Q: I serve as the county manager of Coconino County, Arizona, home of the Grand Canyon. We have been doing large scale mobile testing since March. Free to the public, we continue to do it. We currently have a contract with, an agreement with Arizona State University for saliva testing through the first week of October. Again, it's free to the public, anybody can get it. There's no condition for it. We are making plans for the fall. And just wondered, you'd mentioned some comments, Dr. Frieden, about testing. We're making plans for the fall just wondered what your thoughts for or suggestions as we look at continuing large scale, free public mobile testing after the first week of October?

FRIEDEN: Well, I think it's a great thing to do. I don't want my comments about testing to be anti-testing in any way. My point is just it needs to be part of a comprehensive policy and program. So I would hope that you're looking at who you're testing, who's positive, how quickly are you getting them isolated, are you finding their contacts, are you quarantining their contacts because that's how we stopped spread. So I think as part of a comprehensive program it can be terrific and looking at saliva versus nasopharyngeal hasn't been done enough and that needs to be done under program conditions, because it's a lot simpler to get saliva. Looking at antigen and PCR at the same time, really important. So I would say, keep doing it, but look at what you're doing. The best public health program is the program that continuously assesses its data and continuously improves based on what they find.

FASKIANOS: Thank you. Let's go to Angenie McCleary. You hit the unmute button prompt.

Q: Thank you. I didn't realize I did that. This is Angenie McCleary, Blaine County Commissioner, the home of Sun Valley. We were, as you may know, one of the hottest spots in the country. We now have extremely low numbers. For all summer we've had zero to three cases per day and have gotten things under control, I think largely because of mandates having to do with face coverings. This is something Idaho hasn't done and our health district of eight counties isn't willing to do but Blaine County has done. My question, you've talked about the risk strategy of face coverings. But what about gatherings? As a resort community, we have a lot of weddings that take place here. A lot of gatherings both indoors and outdoors, particularly with winter coming, more indoor is my concern. You mentioned also bars, but my real question is about the mitigation strategy of limiting group size at each risk level. And I can't find good data. I'm certainly working with our local hospital and doctors and common sense but guidelines for social gatherings both indoors and outdoors at each risk level. I was wondering if you have a comment about that.

FRIEDEN: Right. I don't think there's any hard and fast rule. Outdoors is safer than indoors; fewer people is safer than more people. People from fewer places is safer than people from more places. People wearing face masks is safer than people not wearing face masks. We have seen outbreaks from weddings, from social events, from barbecues. So this idea of people congregating without a mask indoors is problematic in some areas. Now, maybe with antigen testing you can drive that risk down even further because it's very rapid. It will miss some people but that may be a way of moving further and we may see that used increasingly, but I don't think there's any simple answer here to moving forward. I wish there were.

FASKIANOS: So I'm going to try to squeeze in one last question. And the last one goes to Reggie Williams, and my apologies that we couldn't get to them all.

Q: Good afternoon. I'm Reggie Williams. I'm retired. I'm a bus driver. I'm on the board of supervisors. My question is that, are we worried more about optics instead of safety and prevention of the spread? Now example, I drive the school bus. We have kids going to school. So the other day I asked supervision, because after I've made a run, I was checking temperatures and normally when we check a temperature on kids it'll give us some type of indication of some type of sickness. So when I got to the office, they said you can't check temperatures because we'd made our mind up, you know that evidently not to check temperatures on a school bus. Most bus drivers are elderly. So when you get on the phone, when I got off and asked the question, and they told me that, I kind of got a little upset. Because the consistency in our answers, and I've been following this from the very beginning, even at the board of supervisors meeting when it first came out when I was on, I masked up. We was trying to pass something in the county before the governor come out that you need to fast up in a locality with a very low rate. And we failed. A month later, the governor said we need to mask up. So this is, what I'm coming with is that, why can't we have something that is consistent? Example, when I see a CDC, Mr. Williams said when we ask the question. The answer was, what would you do? If it was your brother? Or your sister, or your mother, or your child? He said, I would tell them to mask up, wash your hands, and check your temperature. Nobody is seeming to saying that anymore. We are we taking out everything out the equation when we don't have a cure.

And to me, I think that maybe the numbers are causing us as people to disagree in a way that we don't mask up and we don't wash our hands and we don't check our temperature. And that's the way I see it because we are picking what we want to do in a locality. And there are places that, I think and I see them all the time and look communities that come together and did check your temperature and wash their hands and families come together, and they check for sickness. So we know that if something can't get out of a setting, then somebody's got to bring it. And by bringing it, nursing homes, somebody's got to bring it. And I'm just saying one last example. When I was at a meeting last week and a couple came up and said, my nine-year-old child got COVID. My husband has it, this in the same county, and he had COVID he's doing really well. But my son, fifteen years old, and myself don't have it. And my question was, did you tell somebody what you did so your family don't have COVID and you might be the carrier. And you're not even using the idea say, this will put you away. We got to be cautious in what we do. And we got to be responsible. And the things that we do and I think also giving back I say we think we are a little teeny bit too careful of being exactly, or fearful, of saying this is what you do. Thank you.

FRIEDEN: Great, thank you. I think you're making a lot of great points. We need to tell it like it is. Everyone needs to wear a mask to protect everyone. People who are essential workers need full protection. And that may involve Plexiglas screens, for workers in hospitals and for school bus drivers. That may involve opening windows when possible, so we increase ventilation in school buses. Making sure in some school districts that parents fill out an online form in the morning before the kid gets on the bus that they don't have any symptoms. Temperature checks are being used in some places, the limitation of a temperature check is that it may give you a false sense of security because about 40 percent of people with COVID don't have any symptoms at all. And many people with symptoms don't have fever. But that doesn't mean it doesn't have value. Some places are doing temperature checks. The key is that we are honest, up front, we're clear about what works, we communicate with the public, we share the dilemmas that we have, whether it be about masks or about vaccines, or about treatments. And with that we're most likely to be able to get people to work together to recognize that it's all of us together against this one tiny little virus and the more we fight among ourselves, the more the virus is dividing and conquering us. You're muted, Irina.

FASKIANOS: Thank you for reminding me of the guidelines. Thank you very much for doing this, we really appreciate it. There was a comment in the chat. Tom Frieden, CDC Director 2021. So —

FRIEDEN: Not gonna happen, but thank you. Thank you. Thanks for doing this, it's a pleasure.

FASKIANOS: — it's been great. And as I said to all of you, you can follow Dr. Frieden on Twitter @DrTomFrieden. We will also be sharing with you all his presentation as well as some of the links that were shared in the chat. And we will be sending out the video link and transcript for this discussion for you to review. Please send us an email to stateandlocal@cfr.org with suggestions, comments, feedback for future calls, discussions, etc., and thank you for all you're doing on the frontlines and please stay safe and well.

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