Tom Frieden, MD, MPH, on reaching the unvaccinated and masking [Podcast]

In today’s COVID-19 Update, a discussion with Tom Frieden, MD, MPH, former director of the CDC and president and CEO of Resolve to Save Lives in New York, about reaching the unvaccinated, masking and how to think about breakthrough infections amid rising cases in the U.S.

Learn more at the AMA COVID-19 resource center.

Speaker

• Tom Frieden, MD, MPH, president and CEO, Resolve to Save Lives

Unger: Hello, this is the American Medical Association's COVID-19 Update. Today we're talking with a friend of the update, Dr. Tom Frieden, former director of the CDC and president and CEO of Resolve to Save Lives in New York, about reaching the unvaccinated, masking and how to think about breakthrough infections among rising cases in the U.S. I'm Todd Unger, AMA's chief experience officer in Chicago.

Well, welcome back, Dr. Frieden. When we spoke last in May about reaching the vaccine hesitant, a lot of the focus was about access and now that getting a vaccine is a lot easier, what do you think is the biggest roadblock to getting people vaccinated right now?

Dr. Frieden: Well, really what we're seeing is different barriers in different communities. There are still some communities that have difficulties with access, whether it's hours, or language, or concern about payment or other issues but the greater problem in most of the country are people who either underestimate the risk of COVID or have concerns about the vaccine that haven't yet been addressed.

Unger: In terms of those two things, I just want to talk a little bit more about that and especially about the latter. Where is that biggest opportunity about things that haven't been addressed yet, if you were going to zero in on that?

Dr. Frieden: On the one hand, I don't think there's any one thing, any magical key that's going to unlock resistance. On the other hand, the best place to address it is in the clinician's office. People trust their doctors, their pharmacists and others, and this is really where we can make the biggest difference increasing vaccination levels. I wish we could have every single doctor's office in America providing vaccine and offering it to every single person who attended visits on every single visit. Not just doctor's offices but dentists, hospitals, emergency departments, all medical facilities, all visits. That makes a really big difference. We know that from other conditions.

The second thing that's going to make a really big difference is, sadly, the increase in cases and eventually hospitalizations and deaths that we're likely to see. Cases are on a steep incline. We don't know how long they'll continue increasing and how high that increase will be. I've noted that if our increase is similar to the increase in the United Kingdom, which actually has an even higher vaccination rate than we do, we would have 200,000 cases a day diagnosed by early September.

The third thing that I think can make a really big difference is sharing stories of people who are struggling with long COVID. We need to do a better job understanding how to diagnose and treat long COVID but it's clearly the case that there are hundreds of thousands of people who are struggling with breathing, irregular heartbeat, difficulty concentrating, problems with smell and taste many months after supposedly recovering from what might've been a very mild illness with COVID. And the more people are aware of that kind of unpleasant, potentially disabling long-term consequence, I think the greater the willingness to get vaccinated will be.

Unger: Well, given what you talked about in terms of rising cases here, and those were some big numbers in terms of possible projections out there, does the language change now that we're talking about cases going up pretty dramatically due to the Delta variant?

Dr. Frieden: Delta is doubly infectious so we have to double down on our levels of protection. That's why it makes sense where the virus is spreading to add a double layer of protection with mask in addition to vaccination and indoor spaces. Basically what Delta does is it shortens the fuse between the beginning of widespread transmission and widespread transmission. That means we have much less time to adjust.

Unfortunately, we are seeing too many people vulnerable to COVID because they haven't been vaccinated. Vaccines are remarkably effective and, overwhelmingly, we're seeing severe illness and death in people who haven't been vaccinated. It's heartrending to see the news stories and hear the stories about people who are deathly ill in the intensive care unit saying, "I wish I had a vaccine." And there's still time to get a vaccine. And I just encourage every medical provider, every health care provider to encourage every patient at every interaction to get vaccinated. Because I think the hesitancy, reluctance to get vaccinated is going to decrease as cases increase and people recognize that getting vaccinated is a way not just to save lives but to get our kids back in school learning in the fall, which is so very, very important, and get our jobs back and our economy humming again.

Unger: I know that you personally have participated in exploring a lot of different ways of communicating with folks, and one of the insights that we talked about before was what I'll consider a universal human truth, which is people in general don't like to be told what to do and that hard sells on vaccinations could backfire. So I'm curious how you're reconciling that kind of mindset with what we've seen over the past week, which is a lot of talk about vaccine mandates. So what's your perspective on that?

Dr. Frieden: There are a few things going on. First, as a clinician, it's really helpful to just routinize it. We do this with a variety of health care interventions, for example, "Mrs. Smith, I provide COVID vaccines to all of my unvaccinated patients, especially those like yourself who are over the age of 50. I'd like to provide the vaccine today. Would that be okay with you?" That's a very different conversation than, "Would you like to discuss whether or not to have a vaccine?" That's the first.

The second is if Mrs. Smith or Mr. Smith says, "I'm really concerned about," this or that aspect, good communication begins with listening. What are people's concerns? People have lots of concerns and it's important to listen to them, respect that they have those concerns, understand those are sincere concerns that should not be just brushed aside and address the concerns.

The third area is the mandate issue. Let's be really clear. If you're in a health care facility and someone is not vaccinated and because they weren't vaccinated they spread the infection to patients and coworkers who can die from it, that's just not acceptable. We really need to ensure that anyone who can get vaccinated does get vaccinated and that in, at least health care facilities, that's a requirement, given how serious COVID can be. Beyond health care facilities, I think you'll see an increasing number of schools mandate vaccination as an important way of staying open, perhaps not until full FDA approval is in place, and an increasing number of workplaces decide that really there's too much of a legal, reputational and ethical risk if you allow an outbreak of COVID in your business.

Unger: Speaking just on the health care worker's side, I'm sure you saw earlier an announcement from 60 medical organizations, including the AMA, supporting the use of vaccine mandates in those health care settings.

Now switching up a little bit, I'd like to talk to you about another change in guidance that we had, and that's around masking. What's your perspective on this revised guidance from the CDC this week and how do physicians frame it in a way that patients understand? I'll just tell you one of my interesting things in the headlines, you'll see things like reversal or backtracks. This is not a reversal, right? This is new guidance based on data, is that right?

Dr. Frieden: Well, whatever you think of what CDC recommended a few months ago, that was then and this is now, and we're in a very different epidemiologic situation. We have a variant that has swept across the country, that is doubly infectious, that is finding the unvaccinated and you don't have a way and a place where COVID is spreading of sifting through who's vaccinated and who's not in indoor locations. So it's very good that they're focusing on places with extensive transmission. So this is clear this is not everywhere, just places where there's a lot of spread, and that's important because that may go up and down over time. And we need perhaps to get used to the fact that in certain circumstances it's raining COVID pretty hard outside, wear a mask—when you're indoors at least.

The other issue really is that the guidance also needs to address the individual. So if someone is immunosuppressed or living with someone who's immunosuppressed, they're at risk of bringing that infection home, and I think that masks are a very small price to pay to save lives, to get our schools reopened, to get our economy working again. People are very frustrated but the bottom line is the more we mask up indoors, where COVID is spreading, the quicker we can control COVID and get the masks off again.

Unger: I'm sure you've seen a lot of the stories out there about, let's say vaccinated people being unhappy that we're possibly facing going back to masks, things of that nature. How do you suggest that vaccinated people think about masking right now and what should physicians be telling their vaccinated patients?

Dr. Frieden: I think, first and foremost, it's important to empathize. People are really sick and tired of this pandemic. They're over it. The problem is the pandemic isn't over and we're going to need to do a lot to control the pandemic, ramp up vaccination and mask up where the infection is spreading, not just to protect yourself but to protect people around you, who you might inadvertently infect. That might be the checkout person at the supermarket, that might be a parent or a grandparent, you might infect a child who then infects another child who infects their grandparent who dies.

One of the real challenges of addressing COVID in the polarized environment that we live in today is that there is ... I don't know if there's a better illustration of the reality that we really are all connected. What happens anywhere in the world, anywhere in the country, whether it's the emergence of a new variant that's more dangerous or the rapid spread of infection creating waves of infection that go through many states, there are a few things that can illustrate as powerfully how truly interconnected we are and that's for better and for worse. It's for worse, because yes, we are susceptible to disease threats that emerge from anywhere in the world and we're connected. We're not going to turn off the world connectivity because of COVID or anything else. It's continuing. But it's also for good because we're connected in ways that we can work together to develop new vaccines, to mask up together, to figure out how to get our kids back in school and learning and to save lives.

So I think ultimately, the message is a message of hope that wearing a mask for some time in some places is a way of showing that we care about each other, and we care about our kids going to school and that we can get through this pandemic. And if we do it together, more of us will make it through.

Unger: What do you say in regard to breakthrough infections? That's been obviously in the headlines as well. Vaccinated people very concerned about this. Do you have any perspective ways that you talk about it?

Dr. Frieden: The COVID vaccines are astonishingly effective, but like every other vaccine, they're not perfect so we are inevitably going to see breakthrough infections. And the more infections we see overall, the more breakthrough infections we're going to see. If we see the kind of big wave that I'm afraid we may see in the coming month or so, we will see lots of breakthrough infections. The vast majority will be mild, some will be severe, and tragically, some will result in death but that risk of death is something like 100 times less than if those people hadn't been vaccinated.

Unger: So you mentioned earlier too about schools. Schools are now, believe it or not, right around the corner from the start of a new school year and we're back at the center of a mask debate, is there a clarification from the CDC on that? Can you share with us what you and your team have found as you looked deeply at the issue of reopening schools safely?

Dr. Frieden: The first thing to be really clear about is that it's enormously important to resume in-person learning for students. Students learn better. And without that, you exacerbate what have already been horrific educational inequalities.

Second, that it's possible to do so safely. That requires having a layered set of protections, vaccination being crucially important. And I'm encouraged with the data that suggests that more than 80, 85% of teachers have already been vaccinated. That's a really good result. Also, all kids 12 and up who can be vaccinated should be vaccinated. Vaccines are one.

Masks are a second layer of protection. Increasing ventilation is another layer of protection. Identifying when there are cases and rapidly intervening so they don't spread widely is another layer of protection. And then having for those very few people who have underlying conditions that make it so that they may not be protected by the vaccine, for example, people with solid organ transplants, those individuals may need some sort of reasonable accommodation to keep learning or teaching offsite.

Unger: Well, last question, and I think one thing we've learned here is that there's no roadmap and this is not a predictable situation we're in, but when you think about the outlook for the U.S. and for the rest of the world, are you in the worst is behind us camp or we don't know? What's your prediction?

Dr. Frieden: In the U.S. I think certainly the worst is behind us. That doesn't mean that it's smooth sailing ahead. We've got big challenges in places, particularly where vaccine rates are low and Delta is so infectious that we may see lots of cases though not nearly as many deaths where vaccine rates are relatively high.

Globally, however, is a very different story. It's quite possible that we've not seen the worst of this globally. There are many countries that have not been hard hit. We need to do much better increasing global access to vaccines and in the interim, tamping down spread globally.

Unger: Well, Dr. Frieden, thank you so much for being back here with us today. It's really great to hear your perspective. That's it for today's COVID-19 Update. We'll be back with another segment shortly. In the meantime, for resources on COVID-19, visit ama-assn.org/COVID-19. Thanks for joining us and please take care.

Dr. Frieden: Thank you.

Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.