How the numbers have changed since May 5, 2020, the last time I shared an update about the number of confirmed cases of COVID-19. Sources: Johns Hopkins COVID-19 Interactive Map and the Maine CDC. (Time: 9:00 am EDT)

  • Number of confirmed cases of COVID-19 around the world: Was 3,603,217 and is at this moment 4,197,142.
  • Number of confirmed cases of COVID-19 in the United States: Was 1,180,634 and is at this moment 1,347,936.
  • Number of confirmed cases of COVID-19 in Maine: Was 1,136 and is at this moment 1,328.

These numbers only tell part of the story. There are other important numbers: People who have died, people who have recovered, for instance. The sources I cited above should have those other numbers. And there are so many questions to ask. A big one lately is about easing restrictions and opening businesses. Is it really safe for me to go out? What do I need to do to protect myself and others? Will life ever return to “normal” again?

Dr. Dora Anne Mills

Lots of questions and one of the people I trust for answers — insightful answers — is Dr. Dora Anne Mills. She was the director of the Maine CDC and the State’s Health Officer for 14 years. She is currently the Chief Health Improvement Officer for MaineHealth.

Dr. Mills has been sharing information about COVID-19 on her Facebook page. She calls them Not-So-Brief COVID-19 Updates. Because not everyone is on Facebook or has access to the information, with her permission, I have been sharing some of them on the Catching Health blog. This is her latest update, which she posted Tuesday, May 12, 2020. Thank you, Dr. Mills.

As Businesses Reopen, Don’t Forget to Smile and Bring Along Some Patience with a Mask

Like everyone else, I’m slowly getting used to new ways of doing things. I’ve learned to keep a mask in the car, since I otherwise often forget to leave home with one. The mask and hand sanitizer fit very well in the cupholder of my car. Besides, I no longer need it for a cup, since long drives fueled by coffee are a thing of the past. Instead, I’m zooming everywhere, from my desk and from my living room. I’ve learned to zoom so well that the quirky 1970s tv show I loved as a kid is no longer the first thing I think of when I hear “let’s zoom”.

I’ve learned that since grocery shopping takes more time, including waiting in line to enter the store, I can save time by shopping once every two weeks. I’ve recently noticed that people grocery shopping seem less fearful than a few weeks ago as if we are all getting used to things that were unheard of until now.

For instance, just last month, saying hello to someone in the store elicited a look of suspicion. The other day, I saw an older gentleman I thought I might know, so I instinctively smiled. He said, “it’s funny, I can tell you’re smiling, even though you have a mask on”. We both chuckled, and even though he turned out to be someone I did not know, it was heartwarming to share that brief interaction.

I’ve learned that it doesn’t matter if my home is cluttered. The kitchen is often stacked with one or two weeks’ of groceries. With food insecurity on the rise, what previously would have been considered clutter, is now a gentle reminder of how fortunate we are. The living room is stuffed with my kids’ activities – my daughter’s sewing projects and my son’s set up for online math tutoring. But who cares if things are cluttered? No one is visiting us anyway!

Testing the ice

With the economy opening up, many are asking if people can travel, if people can gather together, and when certain businesses can open up. Before reviewing how we can safely engage in this newly opened world, I think it is important to review why it is critical we tip toe. It is like testing the ice on a Maine lake in November. It is not thick enough to hold our full weight.

We know the virus that causes COVID-19 is not going to disappear anytime soon and is a silent and bad actor. First, the virus is found across the world in every country anyone has looked for it, so thinking it will disappear is akin to magical thinking.

Second, several studies indicate that a significant proportion of transmission is from people who do not have symptoms. Estimates range widely, from about 10% to 80% of all people who have COVID-19 may have contracted it from someone without symptoms – who were either pre-symptomatic before they got sick, or who never came down with symptoms. In other words, this virus has a tremendous ability to silently spread.

Third, the coronavirus causing COVID-19 has proven it is a bad actor that can rapidly spread. Very importantly, besides spreading from one province in China across the globe in only a few months’ time, this virus has shown repeatedly it has the ability to rapidly and silently cause widespread illness within a community.

Hard lessons

Take the Skagit Valley Chorale, located in Mount Vernon, Washington, a small city of just over 30,000, about the same size as Bangor. It is located in a rural area of the state, just over an hour’s drive from Seattle. On March 10th, a chorus gathered for rehearsal. Although there had been cases of COVID-19 reported in Seattle, there were none reported near Mount Vernon or in Skagit County. Businesses and schools were open, though people were urged to take precautions. Chorale members were sent a message about these precautions, including recommending they not attend if they had any symptoms or if they were at high risk. As a result, only 55 of the 120 members attended that evening. The singers were greeted with hand sanitizer, and they all kept some distance, including forgoing the usual hugs and handshakes. They rehearsed for 2 ½ hours, then parted ways.

Three weeks later, 45 were ill, three hospitalized, and two dead – all either with laboratory-confirmed COVID-19 or with consistent symptoms. Since lab testing was limited, not all those recovering at home were tested. In interviews later, no singers reported having symptoms at the time of the rehearsal.

Some of the earliest spread of COVID-19 in the U.S. can be traced back to a Boston conference of Biogen executives in late February. Attended by 175, at least 99 who were residents of Massachusetts became ill, and an additional unknown number carried the virus to at least six states, the District of Columbia, and three countries.

A 40th birthday party on March 5th in Westport, Connecticut attended by 50 resulted in over half of them becoming ill, and from there the virus spread throughout the community via silent spreaders who attended soccer games, workplaces, and family dinners.

Not all of COVID-19’s spread has been through large events. Just before becoming symptomatic, one man in Chicago attended several smaller events – a family takeout dinner with two others, a family funeral, and a birthday party with nine others. Epidemiological investigation indicated that as a result, 16 people ages five to 86 were infected, resulting in three deaths, including the man himself.

Not all super spreading events take place in cities. One of the earliest hardest-hit areas of the country was an area of rural Georgia, where COVID-19 took off after silent spread among attendees of two funerals in late February and early March.

Erin Bromage, PhD, a biology professor at University of Massachusetts has written a wonderful blog post that a number of you may have likely already seen since it’s been widely circulated. He reviews several of the well-known super spreading events and what they have in common, including:

• 10 out of 21 becoming ill with COVID-19 after eating together at adjoining tables at a restaurant in Guangzhou, China;

• 94 out of 216 becoming ill while working on the same floor of a South Korean call center; and

• 24 out of 72 becoming ill after attending a curling event in Canada.

He also reviews a couple of the numerous reports of super spreading events emanating from conferences, meat packing processing plants (115 outbreaks across 23 states with 5,000+ infected and 20 dead), and family gatherings such as birthday parties, funerals, and weddings.


What are the lessons from all of these events and other studies from the literature? Risks for viral transmission appear to increase with these factors, which spell GET IT:

• GATHERINGS: Groups of people in close proximity, the more people and the closer they are, the riskier.

• ENERGETIC exhalations: Activities that involve singing, loud talking, screaming, or other exhalations or verbalizations that require more energy than normal indoor talking. These behaviors are known to project higher concentrations of viral droplets and project them farther than six feet.

• TRAVEL: Activities that result in travel, e.g. people gathering who then disperse, or people who travel from afar to visit or for business.

• INDOORS: Indoor locations, especially if the ventilation is low.

• TIME: The longer the contact – more than 10 minutes, for instance, the higher the risk.

In other words, the COVID-19 virus loves to hitchhike where people gather, through energetic voices, where people travel, in indoor places, and where people connect for a period of time.

Why masks and when

The incidences mentioned above and others in the literature indicate that maintaining six feet social distancing is not sufficient in a number of circumstances, such as indoor open workplaces and activities that involve loud talking or singing. This is one of the several reasons that universal masking or facial covering is now required.

For instance, in grocery and other large stores with social distancing, the shoppers may have a fairly low risk. The spaces are large; the numbers of people allowed in the store are now limited; the ventilation is usually quite good; shoppers are usually in the store for less than an hour; and generally speaking, there is no loud talking or screaming. However, for the workers, such as those bagging groceries, their exposure is potentially much more significant. And for shoppers at high risk for severe disease, their risk has significant consequences.

Masking or facial coverings help protect everyone, and in the case of stores, they especially help protect the employees and customers at high risk. If someone you know is not convinced, then watch the video linked to below on droplet spread when someone is talking – masked versus unmasked.

As we reopen, these factors should be considered. For instance, guiding questions include, do the business or activities:

• Result in people GATHERING;

• Involve singing, loud talking, or other ENERGETIC exhalations;

• Result in people TRAVELING;

• Involve INDOOR activities;

• Involve prolonged potential exposure over TIME?

Can these factors be modified and can the business or activity be carried out safely?

Hair salons? Golf courses?

People in a number of states have asked why certain businesses such as golf courses and hair salons have opened sooner than others. Although few businesses get a perfect score on these above factors, for people getting their haircut: gathering is minimized; customers generally do not travel far to get their hair done; and the activity does not involve loud talking or energetic exhalations. Gathering potential can be minimized through requiring appointments only and that clients stay in the car until the hairdresser is ready for them. Although the activity is indoors and can involve an hour or two, the business can be modified to improve safety, such as having both the hairdresser and client wear a facial covering or mask and having the hairdresser also wear a face shield.

Likewise, with golf courses, gatherings and unnecessary interactions can be minimized by not allowing the clubhouses to be open, by requiring pre-paid appointments with set time intervals, by having golfers remain in their cars until their appointment time, and to then proceed to a pre-positioned sanitized cart and to the first tee without personal contact. Travel can be minimized by limiting golfing to in-state members or to those who have quarantined. Masks or facial coverings are also required for employees.

So, as things reopen, expect a number of changes. Before you go to a business, you may want to check out your state’s guidance so you know what to expect. Maine’s checklist is linked to below. Since it takes about two weeks (one incubation period) to determine if there will be too large of a rise in cases due to businesses reopening, and since COVID-19 has demonstrated an ability to surge very quickly, public health experts and business leaders agree it is important that reopening is gradual.

High-risk individuals

Those at high risk for severe COVID-19 need to continue to stay home as much as possible. But it is also important to remember that a large proportion of the population is considered at high risk. For instance, they include:

• the 22% of Mainers who are 65 or older (16% nationally);

• 42% who are obese (especially the 9% with severe obesity);

• 33% with high blood pressure;

• 11% with diabetes;

• 11% with asthma in Maine, 8% nationally (especially the 2/3 of these who are on daily medication for asthma);

• 6% with COPD/emphysema; and

• 3% who are immunocompromised.

It is virtually impossible for all of these people to isolate at home for the foreseeable future. Most live with other people, who may not be in a high-risk group and who may work, but who make it harder for those at high-risk to maintain complete isolation. Additionally, about 10% of those who are hospitalized in the U.S. with COVID-19 do not have any identifiable risk factors.

And no, we cannot simply let everyone who is at low-risk get infected and think we’ll have herd immunity (the proportion of the population with sufficient immunity to protect even those who are not immune). Current evidence is that we cannot achieve herd immunity until there is a vaccine. In other words, social distancing, masking, and vigilant hygiene are likely with us for at least a few months, perhaps 18 – 24 months. (See several articles on these topics, linked to below.)

The bottom line? To stay safe, if you are in a high-risk group, you should continue to stay home as much as possible. Whenever any of us are with non-household members, we should:

• Wear a mask. Whenever the six feet distance cannot be assured, wear a mask, including outdoors and especially if there is expected to be a lot of talking, and especially if it involves loud talking (or singing). In other words, if you are walking or visiting with a friend outdoors, wear a mask. If you are walking with a household member outdoors in an area where others commonly walk, then wear a mask.

• Maintain six feet distance between you and others.

• Avoid in-person gatherings, especially indoors. This means if you need to visit with loved ones, minimize the numbers of people present and time spent together, visit outdoors, make sure everyone is masked, and always maintain six feet distance.

• Minimize travel or being with people who have traveled. Especially avoid exposure to those from where there is much more viral transmission e.g. those from out of state.

• Take advantage of the outdoors!

• Wash or sanitize your hands multiple times per day.

• Make sure you and anyone you’re interacting with are not ill and do not have any symptoms of COVID (e.g. new cough, shortness of breath, fever, chills, headache, muscle ache, sore throat, loss of sense of smell or taste).

When you’re a customer

AS A CUSTOMER: If you are engaging with a business or service that is now open:

• Make sure everyone can maintain 6 feet distance to the extent possible.

• Make sure the employees, other customers, and you are all masked or are wearing facial coverings. Sometimes employees may instead be behind a new plexiglass or similar shield.

• If all parties cannot be masked at all times – such as during a haircut – make sure the person wearing the mask is also wearing a face shield. Goggles or glasses are permissible but a face shield is preferred.

• Look online or call ahead to see if you can make an appointment for the service, and if so, wait in the car until it is your appointment time.

• Shop locally as much as possible in order to minimize travel (and to keep them in business).

• If the business offers outdoor service – e.g. outdoor dining, then use that option.

• Use curbside pick-up, delivery, and takeout options whenever possible.

• Minimize time where close interactions are necessary. For instance, if you need a haircut, forgo having your hair dried.

• Minimize touching any goods except for those you are buying. Minimize touching common surfaces. Try to use contact-less payment methods.

• Bring hand sanitizer with you and use it after you’ve touched a common surface or have left the business.

• Very importantly, be kind, be patient, and tip as much as you are able.

Yes, be kind, be patient.

Businesses and employees are stressed financially and from being on the frontlines. They and all of us have sustained losses – loss of a loved one, loss of a job, loss of financial stability, loss of being physically close with loved ones, loss of a way of life. We also live with some fear – fear of becoming ill, fear of losing a loved one, fear of losing a job. As our communities open up, I think it is important we remind ourselves that as we learn new ways of living and doing business, we are all living in an unprecedented and surreal time, during which there has been much loss and there is much fear.

But there are some things that the pandemic cannot take away from us, such as the ability to learn new ways and the capacity to show kindness and patience. It’s wonderful that these are also contagious and help mitigate the pandemic. We can gather together or zoom online. We can sing in the shower. We can travel through our memories. We can enjoy the outdoors. We can spend time with a good book. And also remember that a mask cannot hide a smile.

Dora Anne Mills, MD, MPH, FAAP

Listen to a podcast of this update

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

Additional information

Added note

The amount of work and research that must go into these updates is mind-boggling. Thank you, again, Dr. Mills for your dedication.