Public Health Weekly

It Ain’t Over ’Til It’s Over

The latest Covid insights from former CDC Director Tom Frieden

Dr. Tom Frieden
Medium Coronavirus Blog


Photo: Mario Tama/Getty Images

The U.S. has now hit two milestones in the Covid-19 pandemic: 100 million total infections (most of them undiagnosed), and as reported by the CDC, 100 million vaccine doses administered.

In the race of vaccination vs. variants, we’re gaining on the virus. It’s slow progress that we hope to accelerate as more people get vaccinated. But nobody should declare victory in the third quarter. As I’ve said before, safer doesn’t mean safe.

Encouraging progress

CDC reports encouraging progress in its weekly Covid summary and website, both of which continue to get better:

  • 11% decrease in cases this past week;
  • Test positivity rate is down by 11%, to an encouragingly low 4.1%;
  • Vaccinations are up to 2.2 million per day, an 8% increase over the prior week;
  • 65 million people have received at least one vaccine dose and 35 million are fully vaccinated;
  • Deaths are down 19% — this decrease is happening faster than the case decrease, and represents thousands of lives saved by vaccination.

But better doesn’t mean good. Rates are lower, but some concerning indicators are still still very high:

  • More than 50,000 new cases a day;
  • Nearly 5,000 hospitalizations last week;
  • More than 1,400 deaths a day.

Variants remain concerning

Right now we’re in a race between vaccination and variants. Which of them wins will determine whether there’s a fourth surge. Variants are spreading, and may now be responsible for more than half of Covid-19 cases in New York City and a growing proportion elsewhere.

Think of the most concerning variants as the “B1 bombers”: the B.1.1.7 variant, first identified in the U.K., which is more infectious and likely more deadly, and which is doubling in the U.S. every 10 days; the B.1.351 variant, which emerged in South Africa and reduces the effectiveness of some vaccines; and the B.1.526 variant, which is spreading rapidly in New York City. All of these variants increase the risk that the virus will overcome immunity from natural infection.

Fortunately, per the New England Journal of Medicine: The Pfizer-BioNTech vaccine appears to overcome the P.1 variant first identified in Brazil, another of the more concerning variants. But that’s no guarantee that new variants won’t escape vaccine-induced immunity. The more the virus spreads, the greater the risk.

Is a fourth surge looming?

Will there be a fourth surge in the U.S.? Those who answered this (admittedly unscientific) poll are optimistic there won’t be.

How well variants do depends partly on the virus, but mostly on us. That’s why it’s critical that we continue to wear masks, maintain distancing, and vaccinate quickly. It’s a mistake to lift mask mandates while the virus is still spreading at dangerous levels throughout most of the country.

And, as reported in BMJ this week, the variants may well be more deadly. Now that we can see that there may be an end in sight, we don’t want to let down our guard too soon. The pandemic isn’t over. Not in the U.S., and certainly not globally.

People who have been vaccinated aren’t out of the woods. We can’t assume that the vaccine has kicked in to provide sufficient protection until two weeks after full vaccination.

Getting vaccines into arms

The CDC has issued guidance on what people who have been fully vaccinated can safely do — and what they should not do. This guidance, with the science brief that supports it, is a good example of evidence-based recommendations. As noted in this week’s JAMA, we need to have a clear discussion of what this guidance means for people day-to-day. As more data become available and more people get vaccinated, these recommendations will evolve. That’s how science works.

No vaccine is 100% effective. And every vaccine has some rate of adverse reactions — but the risks from vaccines are much less than the risks from infection.

Scaling up vaccination requires using multiple platforms: mass vaccination sites, networks of doctors’ offices and pharmacies, pop-up locations — even mobile vaccination clinics to go door-to-door in hard-hit and hard-to-reach communities.

Soon we will go from having too few vaccines to having too few arms to put vaccines into.

We need to continue to find and address barriers to vaccination, to access, to understanding, and to acceptance. And as a recent poll indicates, there are wide gaps in people’s willingness to get vaccinated.


We should open schools and businesses safely. However, restaurants, bars, and large indoor events are much riskier, especially in places without mask mandates. A new MMWR study shows that masks work, and that places allowing on-premises restaurant dining had higher case and death rates. No worker should be avoidably exposed to Covid, or have to plead with a customer to mask up. OSHA should act.

Approximately 1 of every 200 Covid-19 infections in the U.S. results in death, and therefore, with more than 500,000 deaths, there have been more than 100 million people infected already. (The 100 million estimate is also consistent with serological studies and epidemiologic models suggesting that 25–30% of Americans have been infected.) Globally, with a younger population, there may be one death per 300 or more infections — but we also know that Covid deaths are under-reported. There may have already been a billion Covid infections globally.

Five points to end the week

First: Covid is far from over. Have a look at the map from The New York Times below. It’s still raining Covid pretty hard out there.

Second: Think about the next generation and how they will be affected by the pandemic in the long term. This cohort was to have been dubbed Gen Alpha, but now maybe they’ll be Gen C (for Covid), skipping A and B after Generations X, Y, and Z.

Third: We need to recognize the failures at local, state, national, and global levels. No institution got it right. U.S. public health systems had pre-existing conditions that increased our vulnerability. We need long-term solutions.

The Trust for America’s Health just released a good report: Ready or Not? Sadly, the verdict right now is NOT. We can change that. We need to improve emergency response, public health, and primary care. In an article in AJPH, I’ve outlined what’s needed broadly and specifically on cardiovascular health. Even before Covid arrived, U.S. life expectancy was lagging behind other countries’ — we have more disability, more illness, and earlier death.

Fourth: We must build health resilience against Covid and other health threats, including the leading preventable killers. The Biden-Harris Administration can build on the success of stopping Covid, starting first with preventing heart attacks and strokes, which will kill nearly a million Americans this year. As we explain in an article just published in JAMA, most of those deaths can be prevented.

And fifth: Stay safe. Keep masking up. Remember the mantra: patience, discipline, solidarity. The sooner we get to the new normal, the better we will all do.

“It ain’t over ’til it’s over.”

— Yogi Berra, Great American Philosopher (and Catcher)



Dr. Tom Frieden
Medium Coronavirus Blog

President and CEO, Resolve to Save Lives | Former CDC Director and NYC Health Commissioner | Focused on saving lives.