Lessons from abroad and from here in Maine

It’s been several weeks since we’ve had a not-so-brief COVID-19 update from Dr. Dora Anne Mills, but now she’s back to take us on a journey around the world. First stop, Maine.

I’ve taken a bit of a break the last several weeks from writing regular not-so-brief updates on the pandemic, and have instead posted a few brief updates. Although my work related to COVID-19 and a backlog of pre-pandemic work has continued to keep me very busy, I felt the need to take a respite as much as I could. After all, it may be a long and arduous fall and winter. I hope everyone has also been able to take some deep breaths and find some joy this summer.

My mother used to advise me during stressful times to make sure to find something joyful every day to be grateful for and to look around and help others who are less fortunate. I remember her telling me about the year during the Great Depression she had to disrupt her college education. Having grown up on a potato farm in a very rural area of northern Maine, college quenched her thirst for journeying with others through books and Socratic discussions. But her parents were struggling, and she needed to return to the farm. At first, she felt a great deal of self-pity. However, after a short while, she saw that many of their neighbors were barely surviving under worse hardships. Although her parents were gradually losing much of the farm due to financial hardships, they were able to help feed some of the neighbors. With little entertainment available, after farm work and household chores were finished for the day, my mother and her family played cards. She read a great deal, especially books about other countries since she dreamed of one day traveling.

After a year, with the help of some relatives, she was able to return to college. She eventually became a high school English teacher, married my father, raised five children, and traveled to numerous countries. Years later, she told me when she looked back on that year during the dark times of the Great Depression, she realized what a gift it was. She had learned to find joy in many otherwise mundane activities, in the closeness she felt with her family, and in helping neighbors.

Although I was planning on traveling internationally this summer, I am grateful for remaining in Maine, where I have found such joy in watching sunrises over the ocean, hiking in the mountains, and seeing sunsets over the lake. However, reading about the pandemic activity across the globe has also taught me how unpredictable it is and how appreciative I am to be living near family and close friends. I thought I would share a few recent gleanings from elsewhere in the world.

SOUTH KOREA, which was touted for its quick and successful actions to contain the virus, is now seeing its highest numbers of cases since early March. A large proportion emanates from an outbreak among the worshipers in a megachurch in the greater Seoul area as well as an August 15th rally attended by many of the church members to protest the government’s pandemic restrictions, especially on religious in-person gatherings. As a result of the growing pandemic, restrictions are now tightened in the city and surrounding provinces, disallowing people from assembling, including in churches. Many schools are closed or can only have one-third occupancy. Masks are already required. Because cases are now increasing in other cities, health officials are warning of an imminent nationwide surge. The country’s first surge in February also emanated from a church, one in the city of Daegu. As a result of these surges related to religious gatherings, some of which have been in defiance of restrictions, tensions are rapidly rising between some of South Korea’s religious leaders and those in government or who support the government.

NEW ZEALAND, with the enviable advantage of being an isolated island, managed to go over 100 days without any new cases. However, these last two weeks, an outbreak erupted in the Auckland area, which has now spread, with the country reporting 114 active cases. Restrictions have been re-imposed, resulting in people working from home, restaurants and bars limited to takeout and delivery, and gatherings capped at 10 and only allowed for weddings and funerals. Genetic analysis indicates the SARS-CoV-2 virus causing this outbreak is not exactly the same as the one that instigated the spring surge. Where this virus may have been imported from is being investigated. The answer will surely shed some light. COVID-19 seroprevalence studies in the U.K. indicate about 6% of adults in the U.K. have been infected. This compares with 0.6% of the adult population who have been reported with the disease, indicating, as other studies have, that the real number of cases is about 10 times the number who have acutely tested positive. The highest rates were among young adults, racial/ethnic minorities, and those living in London.

In ITALY, recent data indicate about 2.5% of the population have antibodies. With wide variation in different regions, the hardest hit area of Lombardy has a prevalence of 7.5%. Although the percent of the population immune that is needed to confer herd immunity is not known, it is likely to be at least 60 – 70%, which is far greater than these studies are indicating. This is another signal that we will not be able to let our guard down until a safe and effective vaccine is widely administered.

Globally, the newest hot spot is INDIA. As a result, Asia now has higher numbers of daily cases than North and South America, the latter two having been the continental hot spots the last three months.

JAMA last week published some observations from India on the possible added benefit of face shields, when combined with masking. Community health workers in Chennai, India, while providing counseling to patients and families, were getting infected with COVID-19 at a high rate. Twelve out of 62 contracted the disease in only a few days’ time, despite wearing surgical masks and adhering to other mitigating strategies as was possible. Not all of the patients and families being counseled were able to mask, and it is unclear if distancing was always possible. Face shields were then provided to the community health workers to wear in addition to their masks. Over a subsequent 41-day period, none of the remaining 50 community health workers tested positive. This was a very small study, but adds some evidence that face shields, when worn with masks, may add benefit when there is close contact with those who have COVID-19 or who are at risk for COVID-19, and when other mitigating strategies are not always possible (such as distancing and others masking).

I should mention that face shields are currently not a suitable substitute for masks, since traditionally they are open at the bottom and sides, allowing respiratory droplets and aerosols to dissipate. They are designed to fit over masks and to provide eye protection for the wearer. But new devices are being experimented with, so perhaps a more effective substitute for masks will emerge.

EUROPEAN UNION (EU) countries are seeing spikes in cases, which seem to be due to gatherings as well as people returning from holidays after the June travel restrictions were lifted. Especially hard hit is SPAIN, with its 7-day average of cases approaching the peak seen in April. Reports mostly blame young people for partying as well as gatherings of extended families and friends. After what was one of the strictest lockdowns in the spring (requiring everyone to stay indoors), it seems that people threw off the chains of the restrictions and congregated, which sparked outbreaks and now a surge. The government has reinstated a number of controls, including face mask mandates and outdoor smoking and drinking bans. Demonstrators have protested these actions, including spreading false claims about why there is a resurgence of COVID-19.

FRANCE has also seen increases in cases due to returning travelers and people gathering. As a result, the department of labor has mandated that face masks be worn in all indoor work settings unless an employee is alone in an office. Masks are already mandated in many outdoor and indoor public places as well as other workplaces.

Schools across the EU are just starting to re-open after the summer holidays. So far, some re-openings have also been associated with some upticks, especially in places that do not require most of the major preventive strategies. For instance, more than 40 schools in Berlin have had cases or outbreaks, though the city’s laws do not require masks in the classroom, and physical distancing has been nearly impossible to fully implement in their overcrowded schools.

DENMARK re-opened schools on August 10th. They were the first EU country to reconvene schools in the spring, when they started with primary schools after a nationwide 3-week shutdown, then re-opened middle and high schools several weeks later. Interestingly, they resumed schools this spring before re-opening many businesses, since schools were considered an essential service. Denmark did not see an uptick in outbreaks due to schools in the spring, so I am curious to see if that is replicated this fall. Denmark does not require masks in schools. Health officials there have said this is possible because of their very low rates of pandemic activity (which are among the lowest in the EU) and because they have implemented many other strategies, such as capping class sizes to 10 – 12 students; maintaining physical distancing of six feet; cohorting students and staff; assuring classroom settings are well ventilated, including the use of outdoor classrooms; and implementing hygiene measures.

An analysis by epidemiologists in BRITISH COLUMBIA using their surge data indicates that at 50% of normal contacts (i.e. people having 50% of the normal daily contacts with people), COVID-19 spread stays low. However, even a small increase to 65% of normal daily contacts can result in a rebound of new cases and a surge. This may explain why the layering of measures is so important, to keep close contacts to a minimum. In other words, even if we are with other people, so long as we’re masked, distanced, outdoors if possible, and maintain hand hygiene, we reduce our contacts, and therefore decrease the chances of contracting and transmitting COVID-19. However, we really can’t let up, since even a slight increase in our contacts with others results in an increase in transmission.

In summary, scanning what is happening in other countries I believe shines some light on helpful lessons for us, including cautionary tales:

• Protests against government restrictions in South Korea and Spain show that the U.S. is not the only country facing polarization. Some divisiveness is from science being pitted against religion, e.g. in the case of South Korea and the United States. Some is from science being pitted against the instincts and desires to gather, especially among young people and extended families, e.g. in the case of Spain and the U.S.

Unlike any other disaster, the science is clear that in a pandemic, it is deadly for people to gather together, with as few exceptions as possible, and only if mitigating strategies can be implemented, such as distancing, masking, keeping the gathering as small and as short as possible, and ventilating or holding the event outdoors.

How to build public support for these scientific strategies is a critical dilemma to solve, especially in societies that easily dismiss science and do not have a strong value of sacrificing for the common good. To many, it seems very ironic that some churches across the globe are fighting science and encouraging their members to do harm to others by supporting them to congregate in-person and not mask. However, it is heartening to see that most faith leaders and religious institutions see science as not being a contradiction, and have actively sought ways to worship safely, including outdoor and online alternatives.

• The outbreak in New Zealand, the resurgence of COVID-19 in the EU, the low seroprevalence rates in the previously hard-hit areas of the UK and Italy, and the study from British Columbia all indicate we have a long road ahead. In other words, it seems inevitable that we will need to maintain the major strategies of masking, distancing, hygiene, ventilation, cohorting, screening and testing, etc. for at least a few months until there is adequate administration of an effective vaccine. It is possible that those at high risk may need to continue to be vigilant for a period of time after that.

But there is also good and hopeful news:

• There are thousands of universities and other institutions pivoting research efforts to COVID-19, including trying to enlighten us on strategies such as masking, distancing, ventilation, hygiene, etc. As a result, we learn something new every day about this novel virus. I am optimistic that we will continue to improve our understanding of how to best target our mitigation strategies. For instance, hopefully, we will learn when is it okay not to mask in public. How far away unmasked people need to be from each other to be safe. The minimum level of ventilation (e.g. the number of air exchanges per hour) necessary to reduce risks. The best strategies for screening in schools and workplaces. Which face coverings are not effective.

• Influenza vaccine is starting to trickle into Maine and elsewhere. With a likely very challenging fall and winter with two major respiratory viruses – COVID-19 and influenza – along with other winter viruses, the good news is there is a vaccine against one of them. Each year in the U.S., approximately 8% (1 in 12) contract influenza; 140,000 – 810,000 are hospitalized from it; and 12,000 – 61,000 people die due to this virus. Most are preventable. The single best way we can prevent this debilitating illness and stop the spread of influenza is to get vaccinated.

Although the Southern Hemisphere was reported to have experienced a mild influenza season the last few months (during their winter), this is not necessarily the usual bellwether for us. The reason is that much of the Southern Hemisphere was in lockdown due to COVID-19 during that time. Although there are many restrictions still in place in many parts of the U.S., we are far from a lockdown. There is also a great deal of COVID-19 activity across the country, indicating that influenza is likely to be able to spread easily as well. However, we have a safe vaccine against this disease. Almost everyone ages 6 months and older can be vaccinated against influenza. So, over the next six weeks, I encourage everyone to get a flu shot. It is a positive step we can take – to protect ourselves as well as those around us.

• A few weeks ago, there were numerous news stories about summer camp outbreaks in Georgia and other states. People were wisely asking why they were allowed to open. And when they did open, why weren’t they adhering to known effective strategies, e.g. masking, distancing, and cohorting? The good news is that Maine’s overnight youth camps have recently adjourned after a successful summer. They hosted campers and staff from most states in the U.S. as well as a number of other countries. I understand that it appears we did not have one summer camp outbreak. Maine’s guidance required camps to implement all of the known effective strategies. They used a great amount of creativity to implement them and seemed to have done so very successfully.

Although summer camps are not the same as schools, the experience here this summer gives me optimism that we can do the same for schools and other venues. Having worked with many youth camp directors over the years when I led Maine CDC, I found them and their campers a most creative and flexible group. Teachers I know or have known (including my own mother, grandmothers, aunts, and nieces), as well as school children, are similarly innovative and adaptable, which are key ingredients to reopening camps as well as schools. We are also fortunate in Maine to sustain low levels of pandemic activity, although some recent outbreaks are concerning. This gives us higher chances to reconvene schools successfully in the coming weeks.

During this summer, we may not have been able to travel, but we’ve continued to learn about COVID-19, including from the experiences across the globe as well as from Maine youth camps along our lake shores and mountains.

One of the more portending lessons from around the world is that this fall and winter could be very challenging. As I write this, I can hear my mother reminding me to take a deep breath and find joy in something every day, including from helping others and watching the sunrise.

I also remember another lesson she taught me. Growing up in Maine, my mother helped teach us to ski. I remember her saying, “keep your eyes focused on the trail, and keep your knees bent and flexible so you can ski over the bumps without falling”. Indeed, we will get through the journey before us this fall and winter if we can remain focused on the trail that the evolving science is unveiling to us and if we can remain flexible.

While there are many lessons from around the globe, sometimes the most important ones are found right here at home.

Dora Anne Mills, MD, MPH, FAAP, Chief Health Improvement Officer, MaineHealth

Listen to a podcast of this update

Dr. Dora Anne Mills and her daughter

Dr. Mills’ daughter has a podcast where she has been reading her mother’s updates: Not-So-Brief COVID-19 Updates from Maine.


Thank you, Dr. Mills.

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Diane Atwood

About Diane Atwood

For more than 20 years, Diane was the health reporter on WCSH 6. Before that, a radiation therapist at Maine Medical Center and after, Manager of Marketing/PR at Mercy Hospital. She now hosts and produces the Catching Health podcast and writes the award-winning blog Catching Health with Diane Atwood.