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Anthony S. Fauci, MD, returns to JAMA's Q&A series to discuss the latest developments in the COVID-19 pandemic, including the continued importance of nonpharmaceutical interventions (masking, handwashing, physical distancing) for managing rising case numbers in the US and globally. Recorded October 28, 2020.
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>> Howard Bauchner: Hello, and welcome to Conversations with Dr. Bauchner. Once again, it is Howard Bauchner, Editor in Chief of JAMA, and I'm here with Tony Fauci, who at this point I think needs no introduction. Tony is the Director of the National Institute of Allergy and Infectious Diseases. Welcome, Tony.
>> Anthony Fauci: Thank you, Howard. Good to be with you.
>> Howard Bauchner: So, it's been a very, very difficult week. But before we get to that, I want to let our, let our watchers and ultimately our listeners know that you received an extraordinary award two weeks ago, the Presidential Citation for Exemplary Leadership was awarded to Anthony S. Fauci from the National Academy of Medicine. It's the first time it's ever been awarded. And I just want to read very briefly from the award, for enduring visionary guidance to the field of biomedical research globally and nationally, unprecedented public service as Director of NIAID for nearly four decades, distinguish service as a trusted advisor to six presidents during public health crises, including HIV/AIDS, SARS, Anthrax, Influenza, and Ebola. Congratulations, Tony.
>> Anthony Fauci: Thank you very much, Howard. Appreciate it. Thank you.
>> Howard Bauchner: Seventy thousand deaths a day. Or rather, 70,000 cases a day. Almost 1,000 deaths. CDC released a paper indicating through October 30th, October 3rd, approximately 300,000 excess deaths through October 3rd. Steve Wolf a week before, same estimate in JAMA. By the end of the year, between 4 and 500,000 excess deaths. Where are we, Tony?
>> Anthony Fauci: Well, we're not in a good place for a couple of reasons. Well, first of all, the numbers that you mentioned. As I've told you, remember, the last few times you and I were together chatting, the thing that had disturbed me so much is that we never got down to a low baseline after we had the big initial surge that was dominated by the New York City Metropolitan area. We got down to about 20,000 cases a day. Then when we try to reopen the economy, we surged up, as you remember, from Florida, Georgia, Texas, Southern California and Arizona, we went up to 70,000 cases a day, then gradually came back down and got stuck at around 40,000 per day, until most recently when we edged our way up to 50, 60, 70,000, and we even reached 83,000 cases over the last weekend. And now we're averaging about 70,000 a week. That's a bad position to be in when you look at the map of the country and the heat map color when you see red dots, which indicate that that part of the county, the city, the state is having an uptick in cases to the point that you're having the number of cases. The reason all of those things together put us in a very precarious position is that as we continue into the cool months of the fall and soon the cold months of the winter, we're starting seeing something going in the wrong direction. We should have been way down in baseline and daily cases, and we're not. We're going into a precarious situation where much of what we're going to be doing is going to be indoors as opposed to outdoors. And wherever you go in the country, you call up, you talk to your friends in the trenches, they're telling you that they're seeing cases going up virtually at all ages, all groups at the same time. That's not good. And then the third thing you superimpose upon that, as we go into the holiday season, where naturally the tradition and the customs are for gatherings and traveling. Again, all a bad recipe for a tough time ahead.
>> Howard Bauchner: Tony, over the weekend, I, you know, we've spoken enough, and you've mentioned masking, social distancing every time we've spoken. But over the weekend, I think you were more outspoken about it, questioning whether or not it's time for a national mandate. And on Monday, we released a viewpoint. Your two co authors were Andrea Lerner and Greg Folkers entitled Preventing the Spread of SARS CoV 2 with Masks and Other Low Tech Interventions. Is that where we need to go, Tony? Do we really need to get masking to 90, 95% of the population?
>> Anthony Fauci: I think we do. Whenever we looked around at what other countries have done, and even in individual situations in our own country, there's no doubt that masking, and as I made the title of our paper in JAMA, Howard, in other low tech type interventions, if you, if you put masking with keeping distance, as in avoiding congregate setting and crowds and try to do things outdoors more than indoors, it makes a difference. It really, really does, Howard, you know, I mean, we don't want to shut down completely. I mean, that's almost radioactive now when you say that because of the situation of not wanting to hurt the economy. Well, if you don't want to shut down, at least do the fundamental basic things which are really the flagship of which is wearing a mask. And that's the reason why we've got to do it. We can't have this very inconsistent wearing that you see where you see some states that absolutely refuse to wear a mask. And as we've said on our broadcast in previous times, Howard, it almost becomes a political statement. We've got to get away from that.
>> Howard Bauchner: Tony, why do you think, you and all are old enough to know, we grew up not wearing seatbelts. I mean, I used to go around in the back of my parents' car, there were three of us rumbling all around in the backseat. And then almost no one I know ever gets, doesn't get in a car and put their seatbelt on. It's just normal behavior. And it hasn't been politicalized. How do we get there with masking?
>> Anthony Fauci: You know, well, we get there by looking at the consequences of what happens when we don't. I mean, that's the thing that we have to sort of shake each other by the collar and say, take a look at what's going on. Look at the data. It speaks for itself. We're in a very difficult situation. And countries that have done it the other way have done it and been successful. So, let's put aside these extraordinary excuses for not doing it when we're dealing with a situation that's not trivial. You know, we have 225,000 deaths. The modeling tells us we're going to get 100 or more thousand as we get into the winter. That is just something that's unacceptable, Howard.
>> Howard Bauchner: Over the last few weeks, this so called Great Barrington Declaration has emerged. And then there's been the John Show kind of rebuttal. It's been interesting to see it play out. Any comments of any shred of possibility of getting to herd immunity through infection of healthy individuals?
>> Anthony Fauci: No. The data tells us that that is not the case. You know, I don't want to be saying anything pejorative against the people who believe that. But for goodness' sakes, take a look at the data. I mean, the declaration in and of itself says two things. One, we don't want to shut down. Of course. Nobody wants to shut down. I absolutely agree. There's no doubt about that. We don't want to shut down. The second thing, we want to protect the vulnerable, such as those in the nursing home. Both of those things are apple pie and motherhood. There's no doubt. But implied in that declaration, which, whenever you speak to people, I'm not sure they fully understand, that means if you just let everybody get infected who's going to get infected, no masks, don't worry about crowds, have people do whatever they want to do, that you're going to be able to protect the vulnerable. When you look at the statistics, in society, in the community, more than 30%, that's a conservative estimate, of people who are the vulnerables, those who have diabetes, obesity, hypertension, chronic renal disease, not to mention the elderly, you look at those people, if you let everyone get infected, the data tells us that A, we're not able to protect them in the community. You may be able to do a lot of good testing on nursing homes, get the staff tested, get people tested, great, let's do that, let's protect the nursing homes. But how are you going to protect the people in society who have diabetes, obesity, hypertension, chronic lung disease? Are you just going to let them get infected? You can't do that. What the numbers and the history have told us, if you do that, by the time you get to what you would think might be herd immunity, 70, 75%, it's an estimate, no one really knows what herd immunity is for this disease. But let's assume it's around 70% or so. Do you know how many deaths you're going to have before you get there? That's an unacceptable pathway. We get to herd immunity from a vaccine. That's how you get to herd immunity. Not by letting everybody get infected.
>> Howard Bauchner: Tony, there's a slew of questions, so I'm going to go through them, not necessarily in the order that they came in. Thanksgiving is coming up, and then the December holidays. People get on the airplane and they get together with their families. For the first time in many years, my brother's not having Thanksgiving because it would be a gathering of 20 people. So, for me, it's changed. Is your sense that airplane travel is safe? I know people have different risk tolerances. But do you have a sense if airplane travel is safe? That's a question. And then what would you recommend around Thanksgiving, Christmas, Hanukkah, Kwanzaa, and the December holidays?
>> Anthony Fauci: Well, you know, we're hearing variable things about airplane travel. One report, it's really very safe, they have HEPA filters in, the air gets flowed out, not a problem. And then you see incidences just like last week where there was a plane that was a seven hour shot, I think it was to Ireland, and it wound up having a cluster of people that ultimately led to 59 infections. So, I mean, yeah, I guess it's, it depends on what you mean by safe, Howard. Everything is relative. You know? Is it risky? Yes. But what's the relative risk? And people are going to have to make that decision based on what they feel is the best thing for the safety of themselves and their family. So, you asked the second question, besides airplanes, is what about the upcoming holidays?
>> Howard Bauchner: Yeah.
>> Anthony Fauci: What about the times when families get together? You know, Howard, you don't want to be the grinch that stole the holidays. But I think one family group and individual has to take a look at what the risk is to your particular situation. If you have people in your family group that otherwise would have gotten together for Thanksgiving, well, Christmas is way down the pike, let's just take Thanksgiving for the time being, if you have people like elderly or individuals who are compromised because of underlying conditions, you want to take a couple of steps back and say, is it worth it for this year to bring those people together when you don't know what the status of everybody in that pod that you've created is? And the reason I say that and I feel, you know, a concern about not doing that, that serious consideration, is that if you look around the country now, that many of the infections are in small family and friend gatherings, such as dinner parties and small social gatherings. It's interesting. I made a call two nights, last night, what's today, yeah, last night, and I do that about every couple of weeks with people in the trenches. In Chicago, New York, New Orleans, LA, Seattle, and I say, what are you seeing in your community? And they're seeing, interestingly, they're seeing, in addition to the places that are keeping bars open, and most of them are not, that these innocent family and friends gatherings, six, eight, ten people come together in someone's home, you get one person who's asymptomatic and infected, and then all of a sudden four or five people in that gathering are infected. So me, that's the exact scenario that you're going to see in Thanksgiving. So, that doesn't mean everybody should be calling Thanksgiving off. Of course not. But if you're in a situation where you have people who are vulnerable and you really want to be safe with them, you might want to not bring them together into a big dinner or a big gathering where you have the possibility of a high risk of infection. So, that's really what I have to say about that.
>> Howard Bauchner: Tony, there's quite a few therapy questions. I'll, I'll give them to you one at a time. But they are linear. So, firstly, the status of Interferon was a question. Where are we with Remdesivir in the sense that, you know, JAMA and other journals have really clearly identified corticosteroids as the standard of care. In fact, mortality rates have been halved both by just better care and steroids, and it's a little unclear what the role of Remdesivir is now. So, Interferon, Remdesivir, and then quite a few questions on preventing progress or disease from progressing. And we've talked about the monoclonal antibodies. But, so, Interferon, Remdesivir, the monoclonal antibodies.
>> Anthony Fauci: All right, open question still with Interferon as opposed to Remdesivir and steroids in which you clearly have randomized placebo control trials. You're absolutely correct. If you look at the study of the randomized placebo control trial with Dexamethasone, no doubt it significantly diminishes 28 day mortality. In hospitalized patients, either requiring ventilation or i Flow oxygen. Remdesivir, a little bit different. It's a direct antiviral. So, you would think that it would do better earlier in the course of disease, but it's been tested in hospitalized patients who require oxygen or who have some element of lung involvement, and it diminishes the time to recovery. There's a question about its effect on mortality. It almost reached significance in the study that was done ACT study. But when you looked at the study that was done oversees, when it was compared in a trial that had multiple limbs, it did not diminish mortality. But it still has a benefit for diminishing time to recovery. Those are things that are looked at later on. The real question, Howard, that we have a lot of enthusiasm about, is exactly what you said. What can we give to a patient to keep them out of the hospital? They're symptomatic, but they're an outpatient. We want to prevent them from progressing. So, let's go down on what we have. What we have is convalescent plasma, which has an emergency use authorization based on noncontrolled studies. There have been a couple of controlled studies from foreign countries that show, in fact, it does not work. However, we need to get more data on that. Then there's the issue of hyperimmune globulin. Studies have already started. No data yet to say anything. Then there's the issue of monoclonal antibodies. Monoclonal antibodies, if you look conceptually, and from the standpoint of pathogenesis, they would best be given early. And studies from the Regeneron product and the Lilly product have shown suggestion that you have a benefit on an outpatient basis. Both of those products, which are similar in many respects, because they're both monoclonal antibodies, are now being considered for an emergency use authorization because of some favorable data. However, in a recent study that was done at an NIH sponsored study, what there was was the looking at a monoclonal antibody in hospitalized patients with a little bit more advanced disease. About three or four days ago, the study was stopped because of futility. Mainly, it didn't look like it was going to get any benefit at all, so they stopped the study, which underscores, Howard, what I think the concept should be, is that if you're directly going after the virus, either with a monoclonal antibody or plasma or hyperimmune globulin, you better do it early before someone gets advanced disease. Once you get advanced disease, as you said, something like Dexamethasone, or perhaps some of the other blockers of inflammation, will be the way to go.
>> Howard Bauchner: Tony, quite a few questions about vaccines. I spoke to Paul Offit yesterday who you know well is on the FDA Advisory Board. I've been a little disappointed with one of the companies, I think it's Moderna, who keeps saying, well, they'll receive an EUA in November, December. That's not their decision. That's the FDA's decision. So, I wish they would just change their language and just say they're going to apply for an EUA at some point. What's your sense of where we are with vaccines, Tony?
>> Anthony Fauci: Well, just that. You know? We have five of them that are now in Phase III trials. The federal government has been making investments either in the development or implementation of the conduct of the clinical trial. Of six of those five are in Phase III, two of them, one that you mentioned, Moderna, the other one is Pfizer, are advanced enough in that they're fully enrolled, and they're now collecting data as to events, namely infections. But when you look at the data, it's event driven. One can say when you get to 32 events or 52 events or 152 events, you'll look at the data by the data and safety monitoring board. I figure, Howard, though, you never know for sure, that somewhere around December, you'll start to see companies with enough events to have the DSMB look at the data, and then it's up to them to recommend that the company can then move forward. By moving forward, you're absolutely correct, they can apply for an EUA from the FDA. And the committee that you spoke about was the Virbac [phonetic], Virbac [phonetic] committee. And the Virbac [phonetic] committee is saying, you know, that's great, they'll come, we'll take a look at it, but we want to see good enough safety data, and even prolonged efficacy data. So, we're going to find out from that time in December when at least one in maybe two of the five companies would have put in for an EUA exactly when the EUA will be granted. Could be January, could be later, we don't know.
>> Howard Bauchner: Tony, people have now, with some faith that we'll see a vaccine very late this year, early into the first quarter of next year, begun to think about distribution of the vaccine, vaccines. Logistically, it is complicated. I've said that I think, you know, the National Academy of Medicine, ACIP are recommending healthcare workers get, be Phase 1A. That's about 20 million by the estimates I've seen. That will be distributed through hospitals. And I think will largely be successful hospitals have done this before. They likely will be able to store it. Buttoned the 20 million, the next 100 million are community based individuals who don't come to hospitals to work or necessarily for care. Are you beginning to see robust plans for the logistic distribution of vaccines, Tony?
>> Anthony Fauci: Oh, yeah, absolutely. That's a great question, Howard. Certainly, the ultimate responsibility for that lies with the CDC that has traditionally been the case. However, this time around, Operation Warp Speed has brought in a four star general from the United States Army, General Gus Perna, who is a logistics and supply chain specialist. And he is heavily involved now with the CDC in making sure that things like cold chain issues, distribution, supply chain things will run smoothly for that second, third, fourth, and fifth layer, because the advisory committee on immunization practices, which is complemented by the National Academy of Medicine, will have like five levels of the distribution.
>> Howard Bauchner: Right.
>> Anthony Fauci: One, you mentioned as the first, then the second, then we get to the third, and then the fifth is everybody else.
>> Howard Bauchner: Tony, when the data come in to the FDA and the FDA advisory panel sees it, you're the most respected physician in the country. People just trust you. And it's well earned over four decades. How are you going to think about safety? Personally for yourself, for your family, and then for the larger society. People trust you. What you say, what you think, how you act is so important to the American populous.
>> Anthony Fauci: Right. Well, a couple of layers of that what I'm going to do. I'm going to do what any citizen could do, but I'm also going to take, because of my experience with science and vaccines and infectious disease, I'm going to look at the data myself. So, I trust, because they are independent good people who I know, and I actually appointed the head of the DSMB, and I know the group well, they're a good crew. They're going to come through and make a good evaluation. The second layer are the career scientists at the FDA who are absolutely committed to the safety, the welfare of the American public to get out a safe and effective vaccine. You have the commissioner of the FDA has publicly vowed
>> Howard Bauchner: Steve Hahn.
>> Anthony Fauci: He's going to look at this in a completely apolitical way. And then you have the Virbac [phonetic] committee, which is going to advise the FDA commissioner about what decision he should make regarding the EUA. And superimposed upon all of that, Howard, the data are going to be public. It's not going to be something that's going to be arcane or secretive. It's going to be public. So, if I see a vaccine where clearly the efficacy looks good and the safety data are sound, which they will be, then I would, without hesitation, take that vaccine myself.
>> Howard Bauchner: One last question, and then just some other observations. Tony, anything crossing your desk that's really unique or you were surprised to see in terms of prevention or treatment?
>> Anthony Fauci: You know, not really, Howard. I think everything now, because of the sensitivity of it, is becoming so transparent that it's out there for people to hear about, either through the grapevine or through publications like JAMA, really quickly. It isn't like years ago where it would take six or seven months to come out. The turnaround now is extraordinary. So, I don't the thing that came across my desk that I was very impressed with was actually last night. I had the opportunity to do a chat like we're having here with my colleagues in Australia in Melbourne who I've known for decades through the HIV channel, because they're all HIV docs now turned COVID docs. And we, I heard from them something that was extraordinary. They had a different situation in the United States, because they're a gigantic island, and they were able to shut off introduction into the country. But they had a terrible outbreak in Melbourne with 20,000 cases. And they decided that they were going to shut down temporarily, but they were going to do something like a mandatory mask mandate, a $1,000 fine if you're seen without a mask in public in Melbourne. And over a period of reasonably short time, a couple of months, they went is from 20,000 cases to the day before yesterday they had 0 cases in the City of Melbourne. And Melbourne is a sophisticated big city in a big Western like country. And then you look at the cities around here. You know, when you talk about, like I live in Washington, which is doing pretty well, so we're doing okay, we had like several hundred to a thousand cases yesterday. And you look at some of the other cities. So, the thought of a major United States city having no infections on any given day, boy do I long for that day, Howard, when you and I can be talking about that. But the fact that it was accomplished in a major cosmopolitan city in a country like Australia made me feel that there is hope for us to get this under control.
>> Howard Bauchner: Yeah, there was an interesting report today I read, you know, about Melbourne finally opening up and people being outside. And some people were a little anxious about going outside, having been kind of locked down. I think it was for almost 120 days.
>> Anthony Fauci: Right.
>> Howard Bauchner: So, Tony, before we close, so I do want to thank a number of people who have always been helpful. There's a couple people in your office. I just want to acknowledge David and Patty. And in my office, Eric and Deanna. The four of them get us together every couple weeks. But as I always do, so it was a painful night for me last night. I'm a San Francisco Giant fan. So, when I grew up, when I grew up, my brother rooted for the New York Giants. He's older than I am. And so I, I adopted rooting for the Giants. And then I went to college in California, and I was always a San Francisco Giant fan. So, how did you feel about the Dodgers winning the World Series last night?
>> Anthony Fauci: You know, I thought it was really a good thing. They're a really, really good team. The last time I remember that happening, I think it was something like 1950 or something when I was in Brooklyn, when they were the Brooklyn Dodgers, so it was really great. So, that was the first they've won since 1988, I think. They haven't won a World Series since 1988. Yeah, so it was good to see them. You know also, Howard, that I think was also pretty symbolic about that that I liked, the baseball enterprise, the teams, the sport of professional baseball, MLB, Major League Baseball, they gutted it out, they tried as hard as they could to play in a bubble like atmosphere where they got everybody as protected as they possibly could, and they said, we're going to get through this year, and hopefully next year we'll be back to some formality. So, I think it was kind of symbolic. When I, you know, read that in the Washington Post this morning, that they had won, I said they did it, they got through the season, it was an unusual season, a truncated season, but they played the World Series and they won. And now the only thing I could think of is next year we're going to have a normal World Series.
>> Howard Bauchner: Yeah, I was impressed, the WNBA, the NHL, the NBA, and now Major League Baseball have all finished their kind of funny truncated systems, but they've all crowned champions. So, I want to remind our listeners, our watchers, Tony, along with Andrea Lerner and Gregory Folkers, has written a viewpoint for us entitled Preventing the Spread of SARS CoV 2 with Masks and Other Low Tech Interventions. Once again, it's Howard Bauchner, Editor in Chief of JAMA, Conversations with Dr. Bauchner. I've been talking with a gem, a gem of a human being, Tony Fauci. Tony, thank you. Stay healthy.
>> Anthony Fauci: Thank you, Howard. It's always great to be with you. Look forward to next time.
>> Howard Bauchner: All righty. Be well.
>> Anthony Fauci: You too.
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