Fauci and Panel Discuss Ongoing Challenges of the COVID-19 Pandemic, and Lessons Learned

Until the 21st century, coronaviruses have largely been “inconsequential pathogens” because they cause the common cold and the world had been dealing with them for decades and decades, wrote Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, and colleagues in JAMA back in January 23, 2020.¹

However, since the start of the 21st century, there have been 3 highly pathogenic coronaviruses: severe acute respiratory syndrome coronavirus (SARS-CoV), which circulated from 2002 to 2003; Middle East respiratory syndrome coronavirus (MERS-CoV), which first surfaced in 2012 and continues to circulate; and now, SARS-CoV-2, which causes coronavirus disease 2019 (COVID-19).

During his keynote presentation at the virtual CHEST Annual Meeting, Fauci discussed both the public health and scientific challenges associated with the current COVID-19 pandemic. The first SARS-CoV, which has since been renamed to SARS-CoV-1, spontaneously disappeared “because of the very aggressive and successful public health measures, such as isolation, identification, quarantine, etc,” Fauci pointed out.

COVID-19 first appeared in Wuhan, China, at the end of 2019 as an outbreak of unusual pneumonia cases, Fauci reminded the audience. However, by January, the Chinese had identified it as yet another pandemic coronavirus.

“So, fast forward to where we are today: We are now in the middle of an explosive pandemic of historic proportions, the likes of which we have not experienced in the last 102 years, with over a million deaths worldwide and 38 million cases, and the end is not in sight,” Fauci said.

The United States, he quickly pointed out, has been the hardest hit country. When comparing the United States with the European Union (EU), Fauci noted that the spread of the virus happened very differently. For instance, data has shown that the EU had its peak slightly before the United States, but the EU got its cases under control with country shutdowns. As a result, the daily case rate dropped to a low baseline level, well below 10,000 new cases per day.

In comparison, the United States was hit very hard in the Northeast first, and once that part of the country got its cases under control, the rest of the country began to spike. And the United States never got back below the level of the EU. For a few months, the United States had new daily case counts of about 20,000, and once states started trying to reopen in the summer, there was a surge to about 70,000 new cases per day. While there was a decline and new cases were averaging between 40,000 and 50,000 per day for a few weeks, that number has recently climbed back above 60,000 new cases per day in just the last few days.

We are in a situation “we do not want to be in as we approach the cooler months of the fall and the colder months of the winter,” Fauci said.

He reiterated what we know about transmission and protection. We know the virus is transmitted by exposure to respiratory droplets and that it is less commonly transmitted through coming into contact with contaminated surfaces. The role of animals in human infection seems to be minimal, he added.

We know that situations where people congregate in enclosed spaces for extended periods of time, such as gyms, restaurants, bars, or religious gatherings, present a high risk of disease transmission, Fauci said. Since about 40% to 45% of people infected are without symptoms, transmission frequently occurs from an asymptomatic person to an uninfected person, which makes the use of masks, physical distancing, and frequent hand washing crucial for slowing or stopping the spread of the virus.

In addition to the symptoms that are already well documented, such as flu-like symptoms, loss of taste or smell, and other disease manifestations, such as kidney and cardiac injuries, there is post–COVID-19 syndrome. Patients who recover virologically, or who no longer have the virus in them, have persistent symptoms, such as shortness of breath, fatigue, fever, and in some cases, what is now being called “brain fog,” or an inability to concentrate or focus.

At this time, the only recommended treatments for COVID-19 are remdesivir and dexamethasone. For remdesivir, patients recovered about quicker than patients on placebo, and dexamethasone, reduced 28-day mortality by about 36% in patients requiring mechanical ventilation or oxygen.

Fauci also spent some time discussing data for treatments and vaccines being studied. Clinical trials for monoclonal antibodies are being conducted on an outpatient and inpatient basis, as well as for family prophylaxis, in which the family of an infected individual are given the treatment as a prophylaxis, and as a broad prophylaxis in nursing homes. The vaccines being studied fall into 3 platforms: nucleic acid, viral vectors, and protein subunits. Currently 5 vaccines are in phase 3 trials, and Fauci projects that we will know if we have a safe and effective vaccine by November or December.

“We're cautiously optimistic that we will have a vaccine that would be safe and effective by the end of this year,” he said. “And we'll be able to distribute doses at the end of this year and throughout the beginning and middle of 2021.”

Fauci’s keynote was followed by a short panel discussion on a variety of topics, including what we learned from the early surge in cases back in the spring and how the upcoming influenza season might interact with COVID-19s

Mangala Narasimhan, DO, FCCP, a New York-based physician, noted that the mini-surge seen in New York now is very different from what happened in March and April, when over 900 patients were intubated in her health system at one time during the peak of the virus cases. Now, they have about 30 patients intubated. Other differences include that during the peak, all of the patients were extremely sick, and physicians were faced with caregiver challenges, supply chain issues, and a lack of knowledge of how to treat these patients.

“We didn't really know [in March and April] what we were doing to treat these patients; we really were guessing and discussing and trying to come up with treatment plans on our own as a division,” Narasimhan said.

Now, they know there are noninvasive options to treat the patients and in general, there are more tools available in the toolbox.

Ryan Maves, MD, FCCP, the chair of the American College of Chest Physicians COVID-19 Task Force, was involved with the ACTT-1 trial studying remdesivir for the treatment of COVID-19, and he noted that while that trial evaluate 1000 patients and found a reduction in time of recovery and a trend toward decreased mortality, the new Solidarity Trial of 10,000 patients from the World Health Organization reported no benefit compared with placebo.

He noted that while Solidarity was a big trial, there were some differences between the 2 trials that might account for differences. For one, Solidarity was an unblinded trial. Maves admitted he might be biased, but he also thought that the ACTT-1 trial was better conducted: it was a more rigorous trial with more heterogeneity.

“If we've learned anything in COVID times, it's that, you know, the rigor of our data is so very important,” Maves said. “And having a vigorous, randomized blinded study with high-fidelity data really is going to be the distinction—that it's not just the size of the study that makes a difference, but also the quality.”

He also discussed the concerns about flu season and COVID-19 occurring at the same time, and he put some minds to ease by pointing to data from the Southern hemisphere, where Australia, Chile, and other countries already had their flu season during North America’s summer months. Those countries showed it’s possible we could have a mild flu season. However, he noted that there are a lot of variables to consider, and a key one is how well Americans will adhere to the guidelines on face masks and social distancing.

However, if these guidelines are not followed, it is very possible “we could have a double hit from standard seasonal influenza superimposed on the COVID pandemic, which is the thing we're all fearful of,” Maves said.

Reference

Paules CI, Marston HD, Fauci AS. Coronavirus infections—more than just the common cold. JAMA. 2020;323(8):707-708. doi: 10.1001/jama.2020.0757