Big Books & Bold Ideas with Kerri Miller

Minnesota health officials discuss COVID-19 transmission in the state

Two women sit at a table and speak.
Minnesota Department of Health Commissioner Jan Malcolm, right, speaks at a press conference alongside State Infectious Disease Director Kris Ehresmann in St. Paul, Minn., in March.
Evan Frost | MPR News file

Updated: 5:48 p.m.

Minnesota set a record high for new COVID-19 cases over the weekend, just weeks before the school year is set to get under way. This has many Minnesotans worried that their friends and families are not taking the virus seriously enough.

Minnesota Department of Health Commissioner Jan Malcolm and Director of Infectious Diseases Kris Ehresmann acknowledged those concerns in a conversation with MPR News host Kerri Miller on Monday.

A portion of this conversation has been transcribed and lightly edited for clarity. Listen to the full conversation with the audio player above.

How have we gotten accustomed to the idea that 1,000 Americans are dying a day from this disease and that is a plateau that may not last once we get to fall. How have we adjusted to the idea of this?

Commissioner Jan Malcolm: That's a really incredibly important point. I think hearing these numbers every day, we've gotten almost numb to it, it feels like, and we really have lost sight of the fact of what a sweeping catastrophe this is across the globe and in the United States. The rate of speed with which this virus moved around the world and has just come to upend everything is just breathtaking and it does seem like we just aren't quite, haven't wrapped our heads around how serious this really is.

Do you think it is still that enough of us do not have a family member who has been seriously sickened by this or we don't know anybody who has died from this?

Malcolm: I do think that's true for many of us that we may know somebody who knows somebody, but still a relatively small proportion of us have been touched by this in a really direct personal way and I agree with you that will change as this progresses.

Kris, I was reading an interview that you did recently with Stat by Helen Branswell and you were telling her about your dad being invited to visit some of his friends. He went and she said he wore his mask and he was doing the elbow bump instead of the shaking of hands. You said, ‘And the people kind of acted like, 'Oh, you drank that Kool-Aid' rather than we all need to be doing this.’ Tell us a little bit more about what your dad saw.

Director Kris Ehresmann: He was invited to an outdoor gathering and so being my dad, he wore his mask and he got there and no one else was wearing masks. When he came, they said, “Oh, you're one of those people” and they wanted to shake hands and he did the elbow bump. He was a little surprised and I was a little discouraged, just simply because my dad is older. He's elderly and, and these people, some of them were healthcare workers, and so they commented on how they wear masks all the time at work.

That disconnect was a little bit concerning to me. And particularly, as you've already mentioned, we're seeing the case numbers really continue to climb. There's no abatement. And so that worries me when people have that perspective. It's a silly way of looking at the world that “Oh, you're wearing a mask, like you believe in the pandemic,” and it's like, “Yeah, there is a pandemic going on.”

Listener question: I live in southern Minnesota, a very rural area, and many of the people that I talk to and that I see believe it's a hoax. They're getting most of their information off of Facebook, the false information. They're not believing Dr. Fauci and the credible doctors. They are still going into the stores refusing to wear masks. How do we go about combating misinformation? 

Malcolm: Thanks for what you're doing to try to help educate your fellow Minnesotans. It is so dangerous, just the fact that we can't seem to agree on fact, these days. Things do get filtered through kinds of political beliefs or other things or just mistrust in general of institutions, and that is a huge public health risk in and of itself if we can't agree on what is the science and what is accurate information.

I am hopeful that with more and more people speaking out, more business leaders speaking up, for example. People should talk to their own trusted physicians, nurses, others, but we really need public figures of all political persuasions, all walks of life, to speak out, so that it's not just in a well, if you either believe in the state or local health department or you don't. It's so, so important that other public leaders also weigh in and help to try to persuade the folks that they really have a lot of sway with.

A listener tweeted and says there’s endless bad information that many people believe, a lot of which comes out on social media. He adds in the lack of executive branch leadership for a national response and that he doesn't think it's we as a country are numb to this as much as we feel helpless to do anything to stop it. Do you think that's part of the equation here? Even though there are measures you can take, this seems very overwhelming.

Ehresmann: Certainly. I absolutely agree with the thinking that yeah, this is overwhelming for people, and it may seem like pandemic global worldwide — it's too big. What can I do? You know, the journey of 1,000 miles begins with the first step.

I think that we need to think about — You know what? You cannot control what the president decides to do. You cannot control what they decide to do in New Jersey. You can't even control what the governor decides to do. But you can, as an individual, take steps to protect yourself and protect the people around you. You can make sure that you're socially distancing, that you're wearing a mask to protect the people around you when you're out and about, that you're following all those things.

I recognize that this seems just huge and you think, does it make a difference? But if each person is doing what they can do, then collectively we will have an impact. 

Listener question: I'm a Ph.D. microbiologist and I haven't seen any studies on how fast the virus is killed in sunlight. It seems to me that people think that if they're outside, they don't need to wear masks and then they forget to social distance. What do we know about sunlight and the outdoors?

Ehresmann: Yes and to the point of sunlight, we know that for many viruses, that sunlight helps to inactivate them. I haven't seen a particular study that indicates that sunlight inactivates SARS-CoV-2, but we know that that is the case with other viruses. So sunlight certainly helps, as well as the greater airflow and just more space and the ability to socially distance.

I completely agree with the point that when people are outside, if you're outside and you're seated in a chair, and you've made sure that you're socially distanced from those individuals that you're interacting with, then taking off a mask makes sense. Do that because you're physically in place.

But the challenge is if you're standing and people just migrate closer together and so I think it's important that being outside makes things better. But it doesn't mean that transmission can't happen. And I think that's really an important point to make is, it's definitely better. But it doesn't mean that transmission can't happen and so you need to still be taking precautions, and that's why I suggest that if you're getting together with people and you're putting your lawn chairs and you're all six feet apart, you're just gonna sit there and chat, that's great. And then you can feel comfortable.Take off your mask. But if you're going to be in any kind of mingling situation, that's more concerning.

Listener question: I wonder why we're not hearing more about what it really means to get this disease and recover. We're getting statistics about how many people have tested positive, how many are in the ICU, and how many deaths there have been, but I'm not seeing a lot about the long-term effects or damage.

Malcolm: Thanks for those comments. I think you're really very perceptive and it's a good example of how the narrative around this virus is changing as we learn more.

Early on, everyone was stressing, public health officials included, that this is primarily a respiratory illness and the great majority of people have a fairly mild course, not intentionally downplaying the severity at all, but it was sort of what we knew at the time.

It is becoming so much more clear that even folks with perhaps relatively mild cases do develop these other systemic effects. This, clearly now we understand SARS-CoV-2 attacks multiple organs of the body. It's not simply a respiratory issue. I think that is an important part of our messaging, to again, get across without denying what statistical probabilities are for different people in different risk groups that even for younger, healthier people, there can be very, very serious consequences to this disease, to themselves, as well as what we keep harping on about: risk to others that you can pass the virus to.

When President Trump persistently for four or five months says it's a case of the sniffles, it's like the flu, 99 percent of people are just fine. They don't even know they've had it. Commissioner, that does get into the discussion stream and I think there are people, I don't know what their politics are, but they are legitimately confused about a message like that coming out of the White House.

Malcolm: There's no question that there is still that sort of competing set of narratives around there, which unfortunately does seem to have sort of a political overtone to it about whether this is a serious public health threat or overblown and whether the public health mitigation measures are needed or excessive.

That just is repeated day after day after day and layer on to that the fact that even the health messages have shifted over time, as we were just talking about, as we've learned more. Yeah, people are confused. But I'm just very hopeful that with a growing chorus of voices around, more concurrence on what the science is showing and the severity of this, that some of that hopefully will start to break through, but I couldn't agree more that the mixed messages and, and the pretty consistent underplaying of the risk in some circles is really damaging.

Kris, Dr. Michael Osterholm teamed up with Neel Kashkari of the Federal Reserve Bank in Minneapolis and wrote an opinion piece. One of the things they said was to successfully drive down our case rate to less than one per 100,000 people per day, we should mandate sheltering in place for everyone but the truly essential workers. By that, we mean people must stay at home and leave only for essential reasons: food shopping; visits to doctors; and pharmacies, while wearing masks and washing hands frequently. Can you see something like that happening at this point?

Ehresmann: Well, I don't deny the rationale for what they have proposed. But as we talked about the public seems to be in a very different place with this pandemic than they were in March. And so it may be difficult to get people to reconsider something like that, and I'm not sure what it will take because, as you said, 1,000 deaths a day. That’s not right, yet people seem okay with it. So I think that's the challenge.

We're at sort of a different place in people's minds with this virus and they don't seem to be taking it as seriously as they need to. I think it would be difficult to do, but that doesn’t mean that we shouldn't consider it if it's going to be effective.

Kris, do you think it's a time to seriously consider that again?

Ehresmann: My concern is that we're going into fall. We're looking at colleges and some schools being back in session. We're going into flu season. I think we need to be thoughtful about how we approach the fall because we could certainly see case numbers increase even more than we have. I think it's something that we have to be thinking about. We have to constantly be looking at the data and looking at whether or not it's time to to dial back and I desperately wouldn't want to do that. But on the other hand, many people are not following the guidance and that is certainly causing challenges.

Listener question: I've seen some health care workers on social media say that quarantine isn't worth the cost on mental health and that people with depression or suicidal thoughts will end up having reduced mental health services, which can be dangerous, or even more dangerous than COVID-19. I'm wondering what the reality of that is.

Malcolm: Great point and certainly mental health is a huge issue that has been exacerbated by this pandemic. But certainly, the point of balance applies across other health concerns broadly and certainly we know the economic devastation that comes with these broader measures has its own short- and long-term health consequences. Balance is the thing that is then elusive, but it remains kind of the goal to strike that right balance between measures that we need.

I just want to reinforce Kris' earlier point that we so strongly believe that if folks were following the guidance that is currently in place with the current set of the governor's orders around capacity limitations and social distancing and mask wearing, we could make a real difference and we just really want to stress how important these weeks are leading up to the fall that anything we can do, everything we can do to kind of control community spread now is going to help us with what we know is going to be a challenge in the fall.

We've heard about cases ticking up on Saturday and then not quite as much on Sunday in Minnesota. I remember when the CDC came out to say the real case count is far higher than the daily statistics that we're seeing. How do you factor that in?

Malcolm: We've been saying quite consistently for a long time now that what we know about laboratory confirmed cases is truly the tip of the iceberg. I think CDC's estimate was 10 cases for every one lab confirmed and we've felt that that's probably pretty reflective of our experience in Minnesota as well. I think it would probably be a good idea to continue to reinforce that point with the public, that the true impact is much broader than these daily numbers.

The other thing, and this is kind of a data geeky thing, but it's useful, I think, for people to know, when we report every day about cases, what we're reporting is the laboratory confirmed cases that come back from processing on the prior day. Then from an analytic perspective, we go back and attribute each of those cases to the date on which the lab specimen was actually collected. We consider that sort of the onset date of the case. That's important because there's so much variability in lab processing time, especially in some of the national labs now being really slow and turnaround because of volume.

So each day's numbers are not the full picture and not the picture that ultimately emerges. So on our website, we post lots and lots of different statistics and visualizations based on the date of onset or when the specimen was actually collected and that gives you a better picture of what's actually happening.

If we have 5 million confirmed cases in the United States and you have to really multiply by some factor, we are in a much more dangerous place than we think we are. 

Ehresmann: Oh, absolutely. And what we see is that each case, to get more cases, and it's a stone into a pond, and then the ripple effect and so we see the initial cases and then we see the downstream effect, which is a couple weeks out, we see more and more cases from those original cases and when the number of original cases increases, the secondary spread increases. Absolutely.

We're in a place where all of the cases that we're seeing now are going to continue to result in more cases. I do think it's important that we acknowledge that while our laboratory testing has increased phenomenally, there are still limits. Yes, people have to realize that the number of cases that we're reporting is not the sum total of all the cases occurring in Minnesota.

Listener question: When are we going to see more testing activity in the northwest suburbs? Recently, the Star Tribune published an article pointing to our greatest fears and something that we knew all along because of the high number of immigrants who work in the long-term care facilities. Many of those folks live here in Brooklyn Park, in the northwest suburbs and so we've seen a lot of cases in our community. I'm a city council member here in Brooklyn Park. And it's a real issue. 

Malcolm: I totally agree with you that we need to continue to expand testing in the communities that we know are facing particular impacts of COVID-19. We have been stressing that people should go to their health care provider to get tests.

The health systems have done really a great job trying to expand testing, but in addition to what's going on in our clinics and hospital systems, we have been really building up and intend to build up more these community testing events that really can be brought out to the community, especially in areas where there are concentrations of populations that may have trouble getting access to clinic based testing, or it's just for some people, it's a better option, a more comfortable option to, to be tested in a community setting by organizations that they know and so forth. So that is a priority of ours.

We just are starting a new website to post where there are upcoming community testing sites and I will check and certainly pass along if Brooklyn Park and Brooklyn Center aren't yet on the list. I'll certainly bring that back to the team. So thank you for the suggestion,

We had so many calls about the governor's decision on schools and then how school districts are going to handle this. What kind of comfort would you give parents who are really undecided about what to do with kids this fall?

Ehresmann: Just as the commissioner mentioned earlier about the idea of balance, one of the things that we've worked with the Department of Education on is how do we balance making sure that kids have the opportunity for in-person education when it's appropriate, because it's so essential.

All of the public health considerations and so the goal has been to help districts have options so that they can weigh what's happening in their community and look at disease activity within their community and use that to help drive their decisions.

Certainly, we've seen transmission in children and we've seen it, more transmission, particularly in the middle school and older grades, than we have in the elementary and younger ages. I think what parents would want to consider is if you have a child that has underlying health conditions, and you're concerned about that, that certainly is something we know that there are things that make anyone at greater risk for severe disease and so that would be a consideration.

I think in terms of encouragement, we know there's transmission but we have seen less severe disease in these age groups than we have in some of our older age groups. We know there’s an age-related risk. That's not to say that there isn't risk, but that it is age-related. I think those are all things that parents need to weigh, as they're making a decision about what would be best for their child, but certainly their individual child's own health status is something that I think is really important to consider.

Dr. Ashish Jha of Harvard, who has been doing a lot of statistical analysis on COVID-19, believes that any indoor gatherings of more than two people should essentially be banned, even with masks. If you look at high school classrooms, and you look at some of the pictures that we're getting out of states like Georgia, where older kids are in the hallways, and they're not wearing masks, and they're coming really close to each other and socializing. What do you think about the potential for disease spread in some of our high schools as they get back to in-person classes?

Malcolm: Oh, that's interesting about Dr. Jha's comments. I hadn't seen that statement. But certainly I think everyone agrees that indoor environments just do pose some additional risks, which is why I think not only paying attention to what we know is going on with spread in the community, but what is the ability of schools to put in place the best practices around prevention and mitigation is part of the whole conversation that we're having with with school districts all around the state.

But, again, I think back to the point on balance. It's going to just be critically important that we continue to keep our eyes on the data, see what emerges. We have to be humble enough to update our guidance and our advice based on new information as it emerges, and we certainly are committed to doing that.

We're told that somewhere between 65 and 75 percent of us will have to have been exposed or protected from the virus because then the virus really has nowhere to go. Would a vaccine, even if it's rolled out in January or February, come soon enough, do you think, to lower those exposure thresholds? Are we going to get a vaccine, even if it's in the new year, soon enough for a lot of us to not have to end up being exposed to stop the virus?

Ehresmann: Well, certainly I mean, one of the challenges, when you have a novel situation like this where the majority of the globe does not have any sort of immunologic interaction with this virus, even as fast as we're seeing it move, that means that when a vaccine does become available, literally everyone needs to get it. That certainly makes things challenging.

One thing that's happening now that's different than what usually happens with vaccines is that usually you go through all of the the safety checks, which are all happening, but you don't start manufacturing or you don't start any sort of production until a vaccine has passed all of those safety checks because obviously, if it doesn't get to that point, you don't want to have invested the resources.

That's a little bit different with the COVID vaccine. They're actually producing the vaccine even as it's being tested and there's a chance that a huge amount of that vaccine will just get wasted if it doesn't meet the criteria. But the goal is that there will be a vaccine available as soon as possible after a vaccine has been identified as being safe and effective. So that's something that's slightly different so that will help.

But we do know that when the vaccine is first available that we will have to prioritize who receives the vaccine, whether it's individuals that are in essential service roles, and individuals who are at highest risk for complications of disease. That will be a challenging time. But at least the good news is that there have been some investments that have been made to say we're willing to have to trash a bunch of vaccines with the goal of having a vaccine that does meet the criteria, have some of it manufactured right away. 

Given the timeline and the way the virus is spreading, it seems like even as the vaccines whenever we get them roll out, many, many of us are still going to be vulnerable. Right?

Ehresmann: Absolutely. Yes. There's going to be a time frame where we have a vaccine, but not everyone who wants or needs to get the vaccine will be able to access it.

And then that would make us susceptible to the virus. 

Ehresmann: Yeah, that we will remain susceptible. We're susceptible right now and we'll stay susceptible until we can get the vaccine. 

I think people think once the vaccine is announced, it's over. But it's not going to be over.

Ehresmann: No, it'll still take time. 

Listener question: What is the current thought about immunity if you've had the virus? I had it in late March and early April and I do wear a mask still, because I think it makes other people feel safer. But I'm just wondering, am I still at risk? 

Malcolm: I think we are still learning and there's still just so many unanswered questions about the degree of immunity. It seems to vary from person to person, and how long it lasts. There, unfortunately, is not a lot of certainty. I think you're wise to continue to take precautions. But Kris may be more up on any more recent studies on that than I am. But I think the question is still just a very open one.

Ehresmann: We're looking at that. At this point, CDC is recommending that once 90 days have passed and someone's had COVID-19, that if they would develop symptoms again, or develop issues, that we would think about, could this be a reinfection. We really don't have enough information to know at this point. But we are going to be looking at that.

There's a lot of research going on right now into how long will the immunity last, not just from having experienced the disease, Kris but also from a vaccine, right? There's no guarantee that you are forever then immune to this virus if you've had a vaccine.

Ehresmann: Absolutely. People need to remember that we have some vaccines, like the measles vaccine for which we expect that individual to have lifelong protection. But we have other vaccines, tetanus, you get that every 10 years and the influenza vaccine is necessary every single year. We're going to have to be monitoring post-COVID vaccines, how this virus or how this vaccine reacts with the virus and what duration of protection we have. 

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