The Truths & Untruths of COVID-19 with Dr. Tom Frieden '82

How safe should we feel around people who've been vaccinated?
I'd still have a mask on indoors, but you are safer.

Could we achieve herd immunity by Labor Day?
There have been so many false dichotomies in this response and one of them is herd immunity. It's really a question of degree. ‘How explosive the virus will be?’ depends on how many people remain susceptible to it. We're still going to have to social distance. We're still going to need to test, isolate, quarantine, and contact trace. Vaccination is likely to help us get back to close to a new normal by the fall of 2021.

Please discuss the safety of immunotherapy and the COVID-19 vaccine?
There's not a lot of data about this. Everyone, if they fall into a category to get vaccinated, should get vaccinated the moment it’s their turn. There's one article that just came out explaining that people on immunotherapy are a little bit more likely to get severely ill.

Would you get more or less protection from the vaccine if you're previously infected?
We don't know. 

What do you think are missed opportunities with regards to the vaccine rollout?
The way to think about the vaccination rollout is to think of platforms. The health care platform, the pharmacy platform, the points-of-distribution of mass vaccination centers are a platform. And then community outreach sites for vaccinations are a platform. All those platforms need to be improved, including adult vaccination, which is very poor in the U.S. One of the big problems is that we have such poor primary care in this country.

Traditional vaccines such as MMR prevents the virus, whereas the current COVID-19 vaccines appear to prevent disease, but not the virus. Is this because it has not been measured whether you can spread the virus, or is it known that if you get vaccinated that you can still harbor the virus?
We don't know whether the current vaccines can prevent you spreading the virus as well as it prevents you from getting sick from it.

How certain can you be that for the younger population (20 - 40 y.o.) that there will be no long-term side effects which might appear years from now?
There's still a lot we don't know in terms of long-term side effects. We don't know that there won't be long-term side effects from the vaccine. We don't know there won't be long-term side effects of the virus. As far as we know, getting the virus is a lot worse than getting the vaccine, including long-term effects. 

With such a short time to develop and test this vaccine, how can we be sure that the new delivery technique used, mRNA, will not have effects beyond instigating an immune response in our cells? Is there a chance the foreign elements introduced could alter other aspects of the cells, or infiltrate the nucleus of the cell, causing unwanted modifications? Also, why is dosage not relative to the size/weight of an individual?  
Remember the mRNA vaccine does not introduce any foreign elements into your cells. It's not relative to the size or weight of an individual because our immune system is about the same.

There’s a recommendation to omit vaccinating those who've had the illness or are COVID- positive…
That's a theoretical suggestion. I would vaccinate people who have the antibodies from prior infection, but if they wanted to defer because they think they're protected, that's okay. If they were at very high risk because they're elderly, I would say, take the vaccine. We’re confident that the vaccine will protect you. 

What's the risk of people getting together for vaccination?
Very little. Everyone is masked. They're trying to increase the amount of ventilation in those spaces. I think go ahead and get vaccinated, but wear your mask and if you can get a KN95 or N95 mask, that’s great.

If you have received both doses of either vaccine can you still get COVID?
Yes, that's possible but it's quite rare, and so far no serious illness has been seen in fully vaccinated people. 

Some people are able to get the vaccine easier than others. Can there be national playing field?
Yes, I do think that there was a pitting states against the other instead of learning the best practices and having lessons learned. I think the idea is the federal government will set the framework, but then leave it up to the states for how to implement that framework as effectively as possible.

And what about concentrating on getting the first dose done and letting boosters wait?
The UK has had explosive spread of the variant virus, and so that may well be a reasonable approach there. Also, some of the vaccine they are using is different, and there is now some evidence that a longer interval for the AstraZeneca vaccine might be as good or better, but I wouldn't delay the second dose in the United States based on the information we have. 

Do we know whether the vaccine stops those who receive it from infecting others or how well it will work against the new variants?
The vaccines are working and so far, yes, but there’s much we don’t know, and it depends on which variant and which vaccine.

How effective are the vaccines?
Highly effective. 90% plus for any illness and close to 100% for severe illness.

What about age alone as a priority for vaccination?
We're already recommended vaccination for all over age 65, but essential frontline workers are important for the equity issue. They may be less likely to die if infected, but they're also much more likely to get infected.

Discuss the two mRNA vaccines and the fact that this technology is new for vaccines – especially reflecting on any long-term effects they could potentially have? 
We don't know, in all honesty. The fact is those vaccines disappear and they're degraded in your body over time. They train your immune system to fight the virus and that's a great thing.

What would be the consequences of someone getting vaccine #1 and not being able to get vaccine #2 when it’s time for the second shot? 
Probably okay. The CDC came out saying it's okay if you have to wait a little longer than the recommendation for the second vaccine, but ideally, keep to the schedule as recommended.

What are the differences in the types of vaccines produced by pharmaceutical companies?
We’ll have to see. We really don't know what the protection is going to be and how long it's going to last, so that's critically important. Many top doctors from such prestigious schools as Harvard, Yale, Stanford, Oxford, and many other places around the world are on record saying the COVID-19 virus is no more dangerous than the flu and that the vaccine has been rushed into production without the usual safeguards and is already causing serious allergic reactions and shock and are recommending against taking the vaccine.  

Do you agree or disagree?
I disagree. The flu killed 20,000 people last year. COVID killed 20,000 people last week. There have been some really irresponsible statements out there. The vaccine development and production followed every single safety check, it just did those safety checks more efficiently.

What is a realistic vaccine timeline?
Hard to know when we will be getting more vaccines. We’re not getting the information from the past administration we should be getting.

Might we expect a shift in the way vaccines are distributed with the new administration?
Yes, competently for a change and with collaboration. With the past administration, I feel like their approach was to blame the states. It really was a case of “Look, it's all the states’ fault”. The vaccination campaign is tough. Let's all do it together with states, federal government, cities, and localities all working as one. It’s going to be tough particularly because we're going to have too little in a few months and then we're going to have to really make sure that we work together to get the vaccine to everyone, especially getting the vaccine out to hesitant communities and disenfranchised places and populations.
 
How soon will other vaccines be approved and available?
Johnson & Johnson (J&J) will be approved as early as the next couple of weeks. They’ll submit to the FDA next week, but availability may not be for a couple of months. They apparently have had some vaccine manufacturing problems, so we'll see.

How long will the mRNA vaccine work?
We have no idea. It could be a year, could be two years, could be lifetime. We just don't know.

Would you advise us to get the Pfizer vaccine?
Yes! Yes! I will get mine the second I can. It's really, really important to get vaccinated and these are very effective vaccines. They were rigorously tested and it's a fantastic technology. I can't guarantee that it's going to last for five years, but the study showed in a placebo-controlled double-blinded study that no one who got the vaccine got really ill. It is a good vaccine. It’s a new type of vaccine, but it's highly effective. And the Pfizer and Moderna vaccines are almost identical.

Is there a chance that vaccinated persons will continue to be vectors for viral spread?
We don’t know, but we think vaccinated people are less likely to spread the infection. However, even after being vaccinated, wear a mask and keep distance.

Should we just give a single dose of the vaccine?
The problem is there are too many unknowns about that. What’s really dangerous is that it might promote vaccine resistant forms of the virus, for example.

If you've received both doses of the vaccine and waited 14 days and then you're exposed will you be asked to quarantine?
 CDC has just recommended that people need not quarantine in this situation, and, realistically, I think people won't quarantine, but you can't assume that you won't be able to spread it further so you need to be careful.

Will a vaccine be given equitably?
I worry it won't be. We're not equitable in so much that we do in this society. I think if it's going to be equitable, we need to put a focus on reaching poor, Black, LatinX communities, reaching rural communities, urban communities in city centers - the areas that are not receiving as much access as they should.

How is this "UK strain" being tracked and what new considerations are there for therapies?
Sequencing of the virus is not simple; it takes a few days. It's not just about sequencing, but it’s about combining understanding the sequencing with understanding the epidemiology - the trends in people. That’s crucially important.

Could you also speak to the chances (if such stats exist) of long-haul COVID syndrome and how to identify the syndrome and, if there is any way, how to prevent it?
We don't know! There’s so much we don't know. But we do know that people who are hospitalized for COVID are not bouncing back quickly. 

What is the current thinking with respect to immunity caused by previously documented infection? 
Reinfections are rare. They're documented but they're rare – so we know it happens just as vaccine failure happens – but the immunity is pretty strong. There are three or four studies that have come out about this that indicate people with prior infection or prior antibodies are very unlikely to get the same strain again.

Do children spread it?
Not much but they do spread it some. 

Can someone who had COVID-19 in the past few months be a carrier?
Very unlikely. After 10 days, there are no documented cases of spread. So, 10 days after you’re diagnosed, you're non-infectious to others with one rare exception of someone who's got a severe immunosuppressive condition and may be able to harbor the virus for a long time. That's rare. Basically, someone who's had it before should still wear a mask, but they're probably safe.

To what degree are the new variants likely to increase the risk of infection via fomite exposure?
Fomites are contaminated surfaces. We've gotten so interested in the idea of aerosol spread that we haven't really focused on contaminated surfaces. We don't know whether the variants will be more or less infectious that way. I think spread can happen through fomites, but I don't think that means you need to sterilize your groceries. I do think that means that you need to think about doorknobs and elevator buttons as being possible contaminants.

Myth or not? Natural selection tends to favor mutations that make the virus less virulent and deadly because those are more likely to spread?
Half-truth. For those of you who remember the movie and book The Andromeda Strain, the virus gets harmless and wafts off into the air. Wouldn't that be nice. There is this reasoning that says that a virus that kills everyone quickly is going to die out soon and so that virus won't spread. Unfortunately, it's not so simple. The virus that causes COVID is highly infectious for a few days and then isn't very infectious even a week into illness. What if it made you infectious a week or two into illness, so a new strain increases what's called viral load for a longer period of time. The result is a more infectious virus and one that is more likely to make people sicker. There's no guarantee that it'll become less virulent over time.

Could we have some immunity from other Coronaviruses?
That may be going on in some parts of the world, but we don't know. You have a lot of really smart, knowledgeable people vigorously disagreeing about whether that happens or not.

What are the prospects for cheap, at-home universal testing?
We’ll see. These tests aren't that accurate and so we have to look at the real role of home testing. There have been a lot of promises regarding what those tests will do. It may be useful, but we really have to see.

Treatments?
Colchicine
Just not studied enough. There is some promising data, but we just don't know.

Remdesivir
Mixed data; not clear; may be useful

Regeneron 
May be useful, but we don’t know nearly enough.

It's amazing we have any treatments at all, because usually viruses aren't really that easy to treat. The fact that Dexamethasone reduces death by 20-30% is really important.

Vitamin D as a treatment?
So, Vitamin D. There is a fair amount of evidence that if you have adequate Vitamin D, you're less likely to get severe illness from a variety of infections. I worked a lot on tuberculosis and it seems to be the case in tuberculosis. It's not as a treatment, but as a prevention. Jane Brody is probably the best personal health journalist out there and she's written some on vitamin D for the New York Times. Fundamentally 500-1,000 international units of Vitamin D daily or once a week 5,000-10,000 is ideal. About half of Americans are deficient, and African-Americans are more likely to be deficient. Having enough Vitamin D is important, but I wouldn’t rely or think it's a magic pill. It's just sensible to do.

What does mask wearing look like for the long term? Should our practice change with the new variants?
Yes, on the long term and maybe yes on the variants. I think cloth masks were good when we didn't have enough, but really surgical is better than cloth and N95 or KN95 is better than surgical. And for cloth masks, which can be fine, a tight fit and multiple layers can make them much more effective. So, upgrading our masks is really important.

Should we change the ways we protect ourselves/others with the new variants of COVID-19?
I think basically we need not more of the same, but better of the same. So, distance indoors with people from your household, and minimize time indoors with people from outside of your household.

How safe is it to go on walks, etc. outside with friends without a mask? What is the possibility of true N95 masks (not imitation knock offs) being available to the public in the future?
Outdoors is generally okay. It depends on where you're going. If you’re out hiking in the woods, I don't think a mask is essential or necessary. If you’re passing others on the path, then it's respectful to wear a mask. I live in New York City, I wear mine and I think others should; even though I think risk of spread outdoors is way lower – by one estimate it’s 20 times lower than the risk of spread indoors.

Does running maskless in the street cause a problem?
Probably not. You'd rather see people maybe run with masks, but outdoors is really a lot safer.

Would you use a gym which does not require masks?
No way. In fact, that's one thing I'm dealing with right now. It's very important there are mask requirements.

Should everyone wear two masks?
Two masks are probably better than one but tight fitting is really important.

Do I need to do something different with friends besides the usual precautions?
Wear better masks and minimize time indoors with those who are not in your household.

Are there enough N95s?
No one knows. You can buy them on the internet now, so we need an organized response. The Defense Production Act that Carol mentioned will not solve all of the problems, it's not a magic wand, but one issue that should get resolved is the supply of surgical masks and N95s.

What did you do at Oberlin that most directly contributed to your career?
I learned to play squash and I do that regularly. And I had a great science education from Norm Craig and others in the chemistry department and a great philosophy education from Norm Care and others in the philosophy department.

How can we “Amanda Gorman” ourselves into continuing to climb this hill?
I think like many of us I was moved to tears by Amanda Gorman's poem at the inauguration. One thing that could be good coming out of all this is the recognition that we are all connected, that our fates are bound up together. If anyone isn't reaching their full potential, all of us are lesser for it.

Is airplane travel as safe as the airlines would have us believe? 
Well, the airplane trip itself doesn’t look as risky as you might think. It’s pretty well ventilated. It’s getting there, the Ubering, sharing indoor space with other people that can be a problem. The CDC recommends you limit travel to essential travel.

Governments in Africa shut down travel very quickly. I almost got stuck in Burundi.  They also insisted on 2-week quarantines for arrivals.  While it is/was in many cases a bit draconian, it may have contributed to slowing down the initial spread?
First off, they do have less COVID, so the low numbers in Africa are not the result of testing less. We are very active there in my organization, Resolve to Save Lives. Second, many countries in Africa have had really good public health responses. They know about contact tracing, they know about border controls and so there are many things that they're doing a lot better than we're doing. Third, they're a much younger population, four or five percent over the age of 65 versus 15%, 20%, 25% here and in Europe. Because of the age-related illness, you have much less illness from that. But it could be related to immunity from other Coronaviruses, it could be that it's just not there yet, we just don't know yet.

How badly were the CDC and FDA really decimated under the Trump "administration?"
Not a lot of people left the agency, but there was a real attack on science, and an attack on the CDC, especially their credibility with materials put on the CDC website that did not come from the CDC. That's really terrible and unprecedented.

How do we anticipate the next pandemic?
We can't anticipate the next pandemic, but what we do is improve our preparedness for the next time. Strengthen early warning systems everywhere around the world so we're able to rapidly find problems when they first emerge, stop them wherever possible, and prevent them where that's possible. That's going to take a long-term, sustained investment in both public health and in primary care.

A primary cause of the COVID-19 disaster in the U.S. appears to be a failure of our education system to provide a basic understanding of and respect for science. How can we best improve science education for all citizens in this country going forward? 
Great question. I'm not an expert on it, but it's something that's crucially important. If you just look even at vaccine acceptance, doctors have close to 100% acceptance of this. The more you understand it, the less you fear it and the more you can manage it.

The testing failure seems impossible to pin on the Trump administration?
I think that's right. There's truly an error of CDC, with errors of the FDA and HHS also. That needs to be reviewed externally and measures taken so that's never repeated.

Does a lockdown or partial lockdown; that decreases one’s exposure to the outside world eventually have an adverse impact on one’s immune system?
No. We're all getting exposure. The issue of when and how to lock down is really important. What we're saying is outdoors is generally fine and that message needs to get across; that it's okay to take walks, it's great to take walks outdoors, it's healthy! It's the indoor contact not wearing masks, speaking loudly with poor ventilation, at the height of COVID that's where you have a huge amount of risk.

What is the long-term impact of loneliness and social isolation?
I think it's a major issue. There are a lot of losses from this pandemic, not just lives and long haulers, but lost education among kids exacerbating social economic and economic inequalities, and loneliness and despair. We need to connect with others and find more ways to do that.

Is there a shortage in trained medical personnel?
The administration has proposed a public health job corps and that really is very important. We'll see if that's taken up by Congress, but that's the kind of thing that we need.

When and why did public health get so politicized? Did the smallpox and polio outbreaks ever became as polarizing as this pandemic?
It's a great question. I think partly it’s because everything is polarized, so public health is a microcosm of that. This has been a particularly challenging thing with issues of lockdown, and of course, politicization by the prior administration.

What’s your take on schools?
Schools are relatively safe. The issue is the social activities around school. The sports teams and clubs, the parties, the locker room, etc. That's where we're seeing spread, and not in academic settings. We have to be really careful as we open schools to minimize risk.

What’s your opinion on face-to-face teaching in elementary schools?
Schools are really important. I've been saying since last March that schools should stay open as long as possible, wherever possible, and whenever possible. The CDC came out and said very early that schools should be the last to close and first to open. There's lots of ways to minimize risk. We actually have a document on that at the Resolve to Save Lives Prevent Epidemics website. There’s a lot of concern for teachers and one of the things that we're pushing is for teachers to get vaccinated. I do think that masking will be important in schools for the long term (at least the next six months) but we'd like to get kids learning in person because that’s very important.

Is the CDC rehiring people dismissed or sidelined?
I think the CDC is going to recover from this. I think it'll take time. Trust doesn't get rebuilt overnight. Not a lot of people left and some people retired. I'm optimistic with leadership and very strong support from the administration that it's going to have a renewal.

What pandemic threat shall we expect in the future and how can we prepare for it better than we prepared for COVID-19?
What a great question. That's what we do at Resolve to Save Lives. Fundamentally we need to strengthen the public health infrastructure at local, city, state, federal, and global levels. We need to ensure we're never underprepared as we have been this time. That means being able to find, stop and prevent health threats when and where they first occur. That means there's going to need to be sustained funding for public health and also improved focus on funding for primary care and family doctors.

My parents lived through the 1918 pandemic and never talked about it. Do people just have a reluctance remembering past suffering?
It's a great question and I'm not an expert on answering. I remember something written about this. That there does seem to be a decrease in wanting to talk about past traumatic events. If people didn't forget pain in the past, there would be no second childbirths.

Once my father and I have had our second doses of the vaccine can we hang out together indoors?
What a great question! I think so, but I would still wear a mask and keep the window open, if at all possible.

Will we hear an orchestra concert again?
I think in the fall. Maybe there will be a lot of masks and more distance and ventilation, but it could be possible in the fall.

Should medical staff be required to get a vaccination in order to work?
I would say no. Yet, at some point, for nursing homes, that may be something to be considered because we don't know how well older people living in these places will be protected by the vaccine.

Did the WHO (World Health Organization) drop the ball?
Well WHO is what we make it and what we've made is a political organization, but they have great strengths. I worked with them for five years and they've done massively better with COVID-19 than they did, for example, with the 2014-16 Ebola response. There are some weaknesses and I think the WHO’s capacity is enormously important for all our safety. It's great for the US to rejoin WHO, and it's great that we'll be supporting them. 

If there is one note to end on it is that we really are all connected and WHO is one of the ways that as a world we can work together to identify problems early and work together as a world to try to solve them and maybe that's the most important thing I learned from my time at Oberlin.