February 24, 2021

Prospect Sconsultation

The health experts

Transcript: Coronavirus: Leadership During Crisis with Anthony S. Fauci

20 min read

DR. FAUCI: Thank you, David. Good to be with you.

MR. IGNATIUS: So, Dr. Fauci, every time we think we see some light at the end of the COVID tunnel, we worry that there’s another train coming at us, and I want to ask you this morning to help us understand what we should worry about, what we should welcome, and what we don’t know enough about yet to have a clear view.

So, let me begin with this issue of the new variants of COVID-19. You said on Friday that these new variants, which appear to be more infectious, maybe more deadly, maybe harder to treat, could outnumber the old virus by March or April, and I want to ask how concerned you are about these new variants and about the possibility that they might produce another surge of the virus that would be difficult to handle.

DR. FAUCI: Well, we take them very seriously, David. RNA viruses, which SARS-coronavirus-2 is, mutate readily, and they mutate much better when they replicate a lot, like when you have a lot of infection in the community.

What we have seen evolve over the last few months is something that is not unexpected. There were mutations, many of which have no functional relevance at all. They don’t change anything functionally about the virus, but every once in a while, if the virus replicates enough, namely when there’s a lot of infection in the community and in the world, you get mutations that do impact the virus’ function; for example, could make it more transmissible, could have an effect on making it more dangerous in the sense of causing more serious illness. But importantly, it could ultimately evade or avoid the protective effect of both monoclonal antibodies and the antibodies that are induced by a vaccine.

So, what we’ve seen in mutations that are noteworthy. One was first noticed in the UK, and it’s a different lineage referred to as “B117.” That increased the transmissibility of the virus, and just recently, the British colleagues have said that it actually increases somewhat the seriousness of the infection.

We have that mutation in the United States now in several states, over 30 states, and well over 400 instances of that.

One thing about that, that it doesn’t seem to evade very much at all the protection that you would expect to get from the vaccine, a mutation that’s much more concerning and problematic is one that has evolved to be the dominant virus in the Republic of South Africa, and that is one that has the terminology “B351.”

That one has now taken over in South Africa, and it is concerning because it much more evades the protective effect of antibodies that are induced by the vaccine, not enough to make the vaccines not effective, but it makes them less effective. So rather than really, really very good protection, it diminishes it somewhat but still is within the range of protection.

We know that from data that we got from a recent vaccine study from J&J, Johnson & Johnson, and their subsidiary, Janssen.

What we have to be careful of is that as the virus continues to replicate, it will accumulate more mutations, and even though we still have a degree of protection from the vaccines that are used, there are two issues that need to be addressed. A, we’ve got to do good surveillance, namely do genomic sequencing surveillance so that we know when these mutations arise in our country; and B, we need to be prepared to upgrade the vaccines if it turns out that they evolve more to completely avoid the protective effect of the vaccine.

So, there are challenges ahead. We can meet them, David, but it’s something that we really do need to take very seriously.

MR. IGNATIUS: So, let me just press on the most worrisome example you cited, the South African variant. How concerned are you that this could get out into the population in the U.S., and beyond that, Dr. Fauci, what’s the chance that we could get a super resistant version of this virus, something that’s, in effect, super drug resistant, very, very hard to treat? Do you see that as a possibility, and what would you recommend if that appeared to be developing?

DR. FAUCI: Well, David, let me answer your first question first. Well, we know now that the South African mutant is, in fact, in this country. There have been two cases that have been recognized in South Carolina and one in Maryland. The fact that they are recognized in people who have not had a trip to South Africa means that there’s community spread, and more people are infected. You cannot even imagine for a moment that it’s going to be staying essentially restricted to just a few people. So, it’s here, and it likely will spread more.

In answer to your second question, that’s always something you have to consider as a possibility. If you don’t, then you’re not being realistic. However, experience tells us that we have the capability from a scientific standpoint of when a virus mutates and does evade, for example, the antibodies that a given vaccine is inducing, that you almost certainly can modify that vaccine to be able to adequately address the new mutant. But it’s something that you have to stay ahead of. You have to stay one or two steps ahead of the game, but you don’t want to frighten people. But you could say always that this virus, which is an extraordinary virus in what it can do, I mean, its capability of extraordinarily efficient spread, understanding when you try to contain a virus either with a drug or vaccine, what it does, it gets pressure to mutate, and the more pressure you put on it, the more it mutates.

But as I’ve said many, many times and I would like to say it again so people could understand it, the best way to prevent the evolution of mutations is to suppress the replication of the virus in the community, which means that we need to vaccinate as many people as quickly as we possibly can and as efficiently as we possibly can, because when you suppress this replication that right now is very rampant when you think of all the new cases every day, not only in the United States, but in the world, that leaves an open playing field for the virus to mutate.

You constrained it a bit by vaccinating people. You diminish its capability of mutating. So that’s one of the really strong reasons why we need to really push ahead with vaccinations.

MR. IGNATIUS: So given that rapid replication and the dangers that you just discussed, one of your colleagues, Michael Osterholm, who is a top epidemiologist, was part of President Biden’s transition team on the pandemic, said that the U.S. needs to “call an audible,” as we say in football, with its vaccination program and start giving single doses to as many people as possible to get ahead of a likely surge and to do precisely what you were describing, which is to reduce the playing field. Is he right, and if not, why not?

DR. FAUCI: Well, it isn’t a question of right or wrong. What Michael is saying is that we need to vaccinate as many people as possible with the doses that we have.

The science tells us, the clinical trials–the 30,000 people in the Moderna trial and the 44,000 people in the trial by Pfizer–that the optimum approach to get a really good response is 21 days after the first dose for Pfizer and 28 days after the first dose with Moderna, you should give a boost. We know that.

What Michael was saying is that as you have limited amount of vaccine, just get as many people as possible with the first dose, and don’t worry about the second dose.

The difficulty with that, even though you can say it makes some sense and not completely ignore it, there’s a danger there. The danger is that the efficacy following a single dose is not as great as after the second dose, and if you have some optimum efficacy, you could, in fact, paradoxically be selecting for more mutations. That’s the danger there.

So, what we’re doing right now is trying to get a predictable flow of doses out there so you could get as many people in the first dose, and then as the next shipment comes in, to make sure when the second dose is due to give the second dose to people at the same time as you have enough vaccine to go to the next level of giving more people first doses.

So, it’s a question of taking a chance. It isn’t completely outlandish, but right now, what we really do need to do, David, that would solve that and not require getting back and pulling away and saying only a single dose is to ramp up the availability of vaccine doses, not only with Moderna and with Pfizer, but also with the new candidates that are coming online, like the Johnson & Johnson, like the Novavax, like the AZ and others. If we can get more vaccines into the mix, we could really, essentially, have it both ways. We can get many more people getting their first dose but also have the capability of getting a second dose.

And by the way, David, the J&J candidate only requires a single dose, as we know from the recent study. So, there are ways around that.

But again, what was proposed by Dr. Osterholm is not completely outlandish, but we think that we can accomplish the goal without doing that.

MR. IGNATIUS: Just to finish this out, Dr. Osterholm says he thinks that he’s concerned about another wave coming because of these variants in the next 6 to 14 weeks. He has an urgent time frame. What would it take for you to move to this, “Let’s call an audible. The science tells us two doses of the Pfizer and Moderna, but ah, let’s move to a different approach”? What would it take for you to move to that position?

DR. FAUCI: Well, again, if it was very clear that we really did not have enough vaccine to accomplish what I just explained a few moments ago, if there was a situation where the predictable availability was not where we wanted it to be and we say, “Well, we’re in trouble here. We’ve just got to get as many people with the first dose vaccinated as we possibly can,” but as you heard from President Biden a day or so ago, what we’re doing right now is trying to get a three-week lead time so that the locals can actually know what to expect. And they could do their planning accordingly.

MR. IGNATIUS: So, Dr. Fauci, you’ve been doing this your whole adult life, this treatment of infectious disease. Is this virus unusual in that it’s mutating in ways that are difficult to deal with more quickly than you’d expected or than would be typical with other viruses?

DR. FAUCI: Not necessarily, David, really. There are viruses that mutate much more quickly and easily, but what this virus has is a constellation of characteristics that is very problematic.

I mean, I can say–I mean, you asked me a question, of all the viruses that I’ve had to deal with in my multi-multi-decade career of now over 40 years, have I seen viruses that mutate this much. The answer is yes, but what I have never seen is the constellation of characteristics of a virus that if you want to make a metaphor out of it, is so nefarious on the one hand, it infects many, many people, has a great deal of efficiency of transmission, and yet maybe 40 percent or more of people don’t get any symptoms at all. And 50 percent of all the infections that are transmitted are transmitted by people who either never will get any symptoms or are pre-symptomatic.

The reason that’s so disturbing, because on the one hand, if you looked at that, you say, well, that’s a relatively benign virus. However, it also has the capability of selecting out vulnerables, and we know who they are, the elderly, those with underlying conditions.

Every once in a while, relatively speaking, unusual, it will get a young healthy person who has no underlying conditions, but it has this nefarious way of really getting to the vulnerables and creating a high percentage of morbidity and mortality. So, you have this unusual virus that for so many people is trivial. It gives them relatively minor, maybe even no symptoms at all, and on the other hand, it has accounted for over 430,000 deaths in the United States in a year.

I’ve never seen anything so dichotomous as that where, on the one hand, looking benign for so many and, on the other hand, being absolutely deadly for others.

MR. IGNATIUS: So “nefarious” is the takeaway word of the day for me.

We have a few questions from viewers of this program, and I’m going to offer you a pretty straightforward one, but it’s the kind of thing that lots of folks just still worry about. This is from Michael Griffis in Maine, and he asked, why are N95 masks or the equivalent for non-hospital use–why are they still so hard to find? Shouldn’t we be manufacturing them a lot more so that there’s an excess supply? Why do you think people are still having trouble finding them, Doctor?

DR. FAUCI: Well, that’s a good point in that originally, when we were talking about masks, you didn’t want to take them out of the availability of the people who really needed them, namely the people who were being health care providers.

But there’s no doubt that the classic N95 mask is the best type of a mask to use. I mean, when I’m seeing patients under conditions of containment, I wear it. I have to get fitted for it, David. In order for it to be really effective, you have to have an absolute good fit, where you have somebody stick a little tube in there and you start to breathe and realize that nothing is getting in there, but it is able to come out when you breathe. That’s a little bit complicated, but that doesn’t necessarily mean that you couldn’t have N95s.

There are different versions of it, a KN95, that isn’t a typical N95, but there is a consideration to look now at the relative efficacy of different types of masks which the CDC is starting to look at.

They are not easy to wear all day. I mean, they can be somewhat uncomfortable, but I think people can get used to them. When I wear it with patients, David, I have it on like maybe for 40 minutes at a time or half an hour at a time, but to wear it all day could be a bit uncomfortable as opposed to the much more smooth type of either cloth or surgical masks.

MR. IGNATIUS: Do you think on the subject of masks that the CDC is likely to move toward a double masking recommendation, a cloth mask outside of a surgical or other mask, or KN95 mask recommendation? Do you see that coming?

DR. FAUCI: That’s possible, David. In fact, just discussions with my CDC colleagues yesterday, we were talking about the CDC is looking at doing a study of seeing whether or not two masks might be better than one. It makes common sense that you would think, and the reason they don’t recommend it right now, it’s a science-based organization, the CDC. They make recommendations based on data and science. So that’s the reason why they’re going to look at that particular issue.

But the reason why many people are using double masking–and in fact, you probably have seen me wearing a double mask–is that you can make a general commonsense extrapolation. If one masks serves as a physical barrier, if you put two on, if you’re looking for enhancing the physical barrier, it makes common sense that it certainly can’t hurt and might help, but it doesn’t yet reach the point of an official recommendation from the CDC because of the lack of data.

But when people tell me or ask me should I be wearing two masks, I say, “You know, if it makes you feel better to do two masks, the chances are you’re going to get an enhanced protection, so why not go ahead and do it?”

MR. IGNATIUS: Let’s talk for a minute about challenges in the distribution of vaccines. As of Sunday, the CDC said that about 25.2 million people have received at least one dose of a COVID-19 vaccine, about 5.7 million have been fully vaccinated. I’d be curious. As a scientist, as a researcher, what kind of grade would you give our performance in getting these vaccines into people’s arms? Are we doing a B job, a C job, an A job? What do you think?

DR. FAUCI: Well, I would take it one step earlier to get the big picture, David. I think when you talk about developing the vaccine and getting a successful vaccine, that’s an A triple plus on that. I mean, that is record-breaking, 11 months to do.

DR. FAUCI: Getting them produced, obviously, that’s good.

But you’re right. Getting them into people thus far early on when it was tried at the end of December got a bit of a shaky start in the sense of the logistics of that, something new in essence taking on a task that has not been done before. You’re right. It has not been perfect, and one of the things that President Biden has made very, very clear, if that things are not working well, don’t deny it, don’t run away from it, try and fix it. And that’s exactly what we’re trying to do.

If you look at the National Strategy for COVID-19, part of that is try to expedite the distribution, and that would be in the mind of all of us on the team, a much better collaboration between the federal government and the locals, particularly the states and the cities. The federal government is not going to fix this alone, nor are the states going to do it if you just leave them on their own without any help. What that’s going to be is a cooperation and a collaboration and a synergy between the feds and the states, but also the rolling out of community vaccine centers to make it easier to get it done en masse; number two, to get the pharmacies much more involved; number three, to use mobile units to get out into relatively inaccessible areas, particularly concentrating on the concept of equity, to get particularly minority populations who may not have as easy access to the vaccine to get that done. All of that is being implemented now, and I believe, David, that you will see in the next few weeks, a much bigger escalation of the capability of getting vaccine into people’s arms.

MR. IGNATIUS: And I take it, this will be federal government led. You’ll be working through state and local authorities–

MR. IGNATIUS: –state and local pharmacies, et cetera, but this is going to be led now from the center, from Washington.

DR. FAUCI: Right. Exactly. You’re going to see much more involvement of the federal government in assisting than we saw in previous months, where the states in so many respects were left on their own. We got to get a synergy between the feds and the states, particularly some leadership by the federal government.

MR. IGNATIUS: Let me ask you briefly about the priorities for who gets vaccines. In the closing days of the previous administration, an order went out that people 65 and over should be in the next trance of eligible people after health care workers. That’s been implemented in some states, some counties, not in others. It’s a little bit of a hodgepodge, but in terms of the basic science and medicine, do you think that makes sense now to have 65 and older be the next benchmark across the country?

DR. FAUCI: Well, it depends on where you’re starting from. The first benchmark, David, was people who are the health care providers and those in nursing homes and those taking care of them, and then you went to 65–or 75 and older was the first one, and then individuals who are having essential jobs in society such as teachers. I think that’s reasonable to bring it down to 65 and older–I think is a reasonable adjustment of that.

What we’re looking for right now, as you get into the groups that have a much, much larger proportion of the population of the United States, that would hopefully be at a time when you get much more higher numbers of vaccines available, and as we get out of February into March and April, you’re going to see a major escalation of the number of doses that will be available. So, I think we’re going to be able to accommodate them.

When you get into a group where the demand within a group exceeds the supply, that’s when you have to be very organized in how you roll that out so that you don’t have people expecting that they’re going to show up and get vaccinated and you run out of vaccine or you have inordinate lines and people waiting. If it’s done in an organized way so that people can get a good prediction of when their dose would be available, that’s what we’re striving for.

MR. IGNATIUS: And what about the problem of vaccine hesitancy or resistance? There are folks who just don’t want to take that shot. Other countries have got pretty aggressive programs to deal with that problem. What about here? Are you and your colleagues thinking about some way to speak more directly to the public and say you need to do this?

DR. FAUCI: You know, David, we’re not only thinking about it. We’re investing an awful lot of time in that.

I would say without hyperbole that a day does not go by when I am not out there in some form of outreach as well as so many of my colleagues, particularly in underserved populations, spending a lot of time with Black churches, Black religious group, brown and Black leadership groups, to be able to talk to them and explain to them why it’s so important for them and their families to get vaccinated not only for their own safety, but the safety of their community. So, there is a concerted effort, which is considerable, in the sense of individuals as well as a group.

So that’s something we take very seriously because, as I mentioned early on in our discussion, if you want to prevent the evolution of mutations, you’ve got to get as many people vaccinated as quickly as possible, and if you have vaccine hesitancy or reluctance to get vaccinated, you’re never going to get to that overwhelming majority of the population, which I’ve estimated should be at least 70 to 85 percent before you get that blanket or umbrella of what we refer to as “herd immunity,” which if we do get that, there will be very few mutations because the virus is not going to mutate if it doesn’t have a playing field to replicate. So, vaccine hesitancy is critical, and we are addressing it.

MR. IGNATIUS: So, Dr. Fauci, given some of the issues we’ve been talking about this morning, including delay and distributing vaccine in the U.S., we haven’t talked about abroad, but the problems are the same there. Do we need to begin to revise our timetables for when this problem is going to behind us?

The Wall Street Journal just ran a story with a headline “Vaccination Delays Put Global Rebound at Risk” and noted that one of the Swiss banks has said only 10 percent of the world will be vaccinated by the end of this year and only 21 percent by the end of 2022.

Let me just ask you in conclusion to address this question we all have, which is, when do you think for us here in America, life is going to get back to something like normal? Is that September, November? Is it next year? What do you think?

DR. FAUCI: You know, David, it’s a great question. Everyone asks it, but they have to be estimates that have contingencies. You cannot give a definite answer when you have so many moving parts. So, let me explain what I mean because I think it’s important for the American public to appreciate that, because when you give a definitive time and it doesn’t work out, they say, “Oh, the scientists were wrong. They gave us wrong information.”

It depends on so many factors. If you have the overwhelming population, let’s say up to 85 percent, get vaccinated in a very efficient way, so that as you get into the summer, you’ve essentially vaccinated most of the people you need to vaccinate, be that 280 million or 300 million, by the time you get to the end of the summer, you have them vaccinated. You’re going to approach some degree of normality as you get into the fall.

But you got to say “however,” and I want to underline “however” about five times, David, because there are a lot of things that could get in that way of that. For example, we were talking about several of them. If we get a real problem with the mutations and the vaccine is not as effective and we don’t address it by upgrading the vaccine, that timetable could change dramatically.

Number two, if you have a degree of vaccine efficacy–excuse me–of vaccine hesitancy, then you have another problem because if you’re striving to get 85 percent of the people vaccinated and you only get 50 percent of them vaccinated, then all of a sudden, the timetable goes out the window. So, you get mutations you got to deal with. You get vaccine hesitancy you’ve got to deal with. All of those things are going to determine.

So, anybody can make a reasonable prediction of when we’re going to get back to some form of normality, but I think the American public has to realize that that’s always contingent on certain things going right, and if they do go right, then the numbers and the dates that I mentioned will be okay.

One final thing that you alluded to just a moment ago is that we live in a global community, and if we really want to talk about true approaching normality, then we’ve got to attack this at the global level, which is the reason why programs like COVAX, which is a consortium of countries which we’ve recently joined now as President Biden became president, which means we’re going to help out with other developed nations and other organizations like Gavi and CEPI and others, to try and get as many people in the globe vaccinated as quickly as possible, because whenever there is transmission and viral outbreaks throughout the world, the United States will always be in danger, no matter what we do.

So again, all of these things are contingencies, David, that will then get us to normal, but they’ve all got to fall into place. Otherwise, it would be really unpredictable when we’re going to get back to what we all want is what it was like before this happened, namely normal existence.

MR. IGNATIUS: That’s a good point to end it on: The more people get vaccinated at home and abroad, the safer everybody is going to be.

I want to thank Dr. Anthony Fauci for being with us for this half hour. It was so informative, so helpful to all of us. Thank you, Dr. Fauci.

DR. FAUCI: Thank you, David. I appreciate you having me on.

MR. IGNATIUS: So, live this afternoon, please join us for Congresswoman Val Demings. She was a presidential candidate and an impeachment manager last year when President Trump was first impeached.

I’ll be back tomorrow for an interview at 1:30 with UN Secretary-General Antonio Guterres, which will be an interesting chance to look at the world from the eyes of the person running the United Nations.

Thanks so much for joining Washington Post Live.

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