Public Health Weekly

Keep Your Mask On and Your Guard Up

The latest Covid insights from former CDC Director Tom Frieden

Dr. Tom Frieden
Medium Coronavirus Blog


Photo: Timothy A. Clary/AFP/Getty Images

Are we finally nearing the new normal? By May things will be much safer, but we’re not there yet. Vaccine rollout continues to gain momentum, saving lives. Cases are still trending down, although the declines are slowing. But transmission is still high in most of the country, and variants could quickly derail the progress we’ve made. We need to hang in there.

Farewell Covid Tracking Project

I want to offer a huge thank you to all who worked on the Covid Tracking Project, which wound down this week. Their final weekly metrics are reported in the graphs below — this comprehensive level of data collection and analysis has not quite been replicated by Centers for Disease Control and Prevention (CDC), but its weekly Covid Data Tracker is getting there. The blip in case decrease last week seems to have been mostly weather-related, with cases still trending down, but we’re not out of the woods.

Bookmark this for future reference (I did) on where to find and how to use Covid data. As impressive and helpful as this effort was, I hope we never again need something like this — and that the federal government never again abdicates its responsibilities.

Look at the orange line in the graph below of new cases. I’ve drawn in a heavier black line to highlight the dip, which is most likely due to both the effects of bad winter weather throughout much of the country (less testing leads to less diagnosis) and an actual slowing in the rate of the decline. Note that the slope of the black line is less acute than that of the orange line. This may be because there are more exposures and increased spread of variants.

Deaths down, risks remain

Now some really good news. As I’ve predicted for the past few months, we’re seeing a rapidly decreasing case fatality ratio with an even more remarkable decrease in nursing home deaths. This is the direct impact of vaccination: It saves lives. Within a month or less, the number of deaths should decline to less than 1,000 a day. This is still horribly high, but much lower than it’s been for many months.

For some perspective: Nationally, there are more than 50,000 cases diagnosed per day, or about 15 new diagnosed cases daily per 100,000 people. This translates to about one in 6,500 people in the United States diagnosed every day. (Remember, too, that only a fraction of cases are ever diagnosed, and that infected but undiagnosed people can still spread the virus.)

People are infectious for roughly seven days (possibly 10 with some of the variants). So let’s assume that about one in every 1,000 people is infectious at any given time. If only one in two to three infections is diagnosed, it’s more like one in 400 people. In a month, if you have contact with 100 people (and some people in frontline positions have many more than that), there’s a one in four chance of being exposed. That’s not small.

Complacency = death

It’s still raining Covid pretty hard out there. There’s now twice as much testing than there was in September, with similar case counts, so there’s been real progress. But, as an example, there are still more than 3,000 new diagnosed cases a day in New York City, at least 10 times more than outbreak investigation and control can realistically manage. And with the increased danger posed by more infectious variants, we’ll need all the tools at our disposal to prevent yet another wave of widespread disease transmission.

By next week, we’ll hit the milestone of 100 million total infections in the United States and, possibly as many as 1 billion globally. Stay tuned — I’ll discuss these estimates and the basis for them in my post next week.

The more contagious P.1 variant, first identified in Brazil, is concerning. So is the increased spread in children (but with no increase in severe illness), although this doesn’t change what should be a policy priority: to open schools and keep them open with proper mitigation strategies. More infectious variants will become much more prevalent in the United States, but if we’re careful, they won’t drive a fourth surge.

Vaccines work, but keep masking

On vaccines, the theme of the week is more. More good news. More people getting vaccinated. More vaccine options. And soon, much more vaccine access. Once you’re vaccinated, there are a lot of things that you can do with relative safety. Get a haircut, see the dentist, ride the subway, hug your grandkids, take that long-delayed vacation.

But don’t assume that vaccines provide perfect protection, and continue to mask up. If you’re older, remain cautious about gatherings with people outside your immediate household. If you develop any Covid symptoms, get tested as soon as possible.

Interestingly, CDC data suggests that the vast majority of people who got the first dose of vaccine are returning to get the second dose. This is encouraging and a pleasant surprise.

Vaccines are astonishingly effective, safe, and increasingly available — at least in the U.S. and some other wealthy countries. But persistent national and global vaccine inequities are unethical and dangerous, and the U.S. is in a unique position to fix this problem.

There are many routes to vaccine efficacy. Some interesting data shows that vectored vaccines (J&J, AZ/Oxford, Sputnik) may provide stronger immunity after one to two months. How long immunity lasts from single-dose vaccines has yet to be determined. And although we have highly effective vaccines from which to choose, there is still much, much more we need to learn about them.

Stop the madness about mask mandates

How do you solve for a governor like Abbott? (And others. Many others.) If the Occupational Safety and Health Administration can enforce worker safety standards for private business — many of which are support mask mandates — businesses might ask governors to do the right thing and enact (or at the very least not preempt) mask mandates.

There’s some great new CDC data on how face masks reduce Covid cases and deaths. Simply put: Science saves lives. Great to see CDC back in the game.

Cool it just a little bit, public health. Reopening — while still managing to avoid superspreader events — as cases fall and vaccines make Covid much less deadly may be wrong but may be defensible. However, relaxing mask mandates is not defensible. The only freedom masks inhibit is freedom of the virus to spread and kill people.

After Florida repealed its motorcycle helmet law back in 2000, helmet use dropped from nearly 100% to about half. This reduction in helmet compliance was at least partially responsible for a sharp increase in motorcycle fatalities. Costs of emergency medical care for motorcyclists hospitalized with head, brain, and skull injuries more than doubled, from $21 million to $50 million. Mandates work. Reversing mandates reverses progress.

Adapting to a new normal

Covid may never go away completely, but we can minimize its dangers. What will change as we tame Covid? Less travel. Fewer meetings and conferences. More (but less than now) Zoom. We may never see birthday candles in the same way. The virus adapts. Unless we adapt, it will continue to control us. The more we adapt, the more we can control it. Masks help, and they will also help control seasonal influenza. I don’t know of anyone who wants to get the flu.

“Throwing out preclearance [mask mandates] when it has worked and is continuing to work to stop discriminatory changes [infections and death] is like throwing away your umbrella in a rainstorm because you are not getting wet.”

— The Notorious RBG



Dr. Tom Frieden
Medium Coronavirus Blog

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