Director, National Institute of Allergy and Infectious Diseases, The National Institutes of Health
Assistant Secretary for Preparedness and Response, U.S. Department of Health and Human Services
Executive Vice President, Worldwide Government, Legal and Business Affairs, MacAndrews & Forbes Incorporated; Member, Board of Directors, Council on Foreign Relations; Former Homeland Security and Counterterrorism Advisor to President George W. Bush
Panelists discuss threats to global health and U.S. national security, including the coronavirus outbreak in China and the ongoing Ebola crisis in the Democratic Republic of Congo.
TOWNSEND: Good afternoon, everyone. We have Dr. Fauci and Assistant Secretary Bob Kadlec today to talk about threats to global health and biosecurity could not be more timely. I am pleased to convene the meeting. Welcome to today’s foreign—Council on Foreign Relations meeting. I am Frances Fragos Townsend, executive vice president of worldwide, government, legal, and business affairs at MacAndrews and Forbes Incorporated. And I will be presiding over today’s discussion. I will have the privilege of leading a conversation for thirty minutes, and then I will open it to questions and answers. We will end promptly at 1:30. As you might imagine, these gentlemen are very busy right now dealing with coronavirus.
So let’s just start. Looking back over roughly the past decade, emerging infectious diseases have played a recurring and ominous theme—be it the H1N1, Ebola, Zika, and now the 2019 novel coronavirus. The threat is clearly not dissipating. When it comes to non-disease natural disasters, the Stafford Act provides disaster relief funds to enable immediate response. By comparison, there is a small infectious disease rapid response reserve fund. Do we need a more Stafford Act-like mechanism to enable a quicker response to research these new threats?
KADLEC: So maybe I’ll take the first whack at this, because I think the thing—the feeling in Congress, at least from discussions with both House and Senate members is that clearly there’s a value for having some kind of disaster relief fund-like activity. And CDC has an emergency infectious disease fund which has been enabled and operationalized right now. But the question is, what is the scale? To give you some sense of this, one, is in the last year HHS and, again, with CDC and NIH, have done a crimson contagion scenario exercise which was at the federal government, state, and local level government, that basically established that in a kind of an influenza pandemic scenario, you probably would need some kind of fund that would be on the order of $10 billion. I mean, that’s what that exercise identified. I think probably people would have shock to that part of it.
But I think the other side of it is, is that there has to be some mechanism by which you can rapidly access funds. And again, this is a little bit different scenario than a pandemic influenza setting, but I think it just highlights the idea for speed, agility and, again, mobilization, as Dr. Fauci can maybe elucidate here in a minute, the kinds of things that he has in his box of tricks, if you want to call it that, and what BARDA has to rapidly accelerate products that could be helpful to manage this kind of event.
So, Dr. Fauci.
FAUCI: Yeah. Well, the answer to your question is that we do need some sort of a reserve fund that we can actually both tap into but also backfill when you tap into it. I mean, there are two examples, for better or worse. I’ve been through all of the outbreaks that you’ve mentioned. When we had the original Ebola outbreak we immediately got a lot of money that we put into it. But with Zika, you might recall when President Obama asked for a supplement, it took many, many months before we actually got it. That really messed everything up, because it not only depleted what we were doing, but we had to tap out from other activities. And then finally, we never paid it back.
So if you—like, right now I’m moving resources to respond in a countermeasure way. Fortunately, the things we’re doing are not that expensive. But they’re going to get really expensive really quickly when you go from a phase one trial, which is a one to two million, to a phase two trial, which is twenty, forty, fifty, sixty million. So the answer to your question is we absolutely need it, because when you have to rely on appropriations to go through the appropriations process, that always takes time, and debate. And it doesn’t work.
TOWNSEND: So, Fran, let’s talk about the coronavirus. Let’s set the stage, right? It’s—t he coronavirus outbreak is—has set a number of historic firsts. It’s the largest quarantine in world history, with China locking down over sixty million people. It’s the first mass repatriation of American citizens into a quarantine, climbing over a thousand. Can we level-set kind of the basics? How contagious is it? What’s the morbidity rate? And how does it compare to others, right, with SARS or MERS? Can we kind of—give us the basics.
FAUCI: Sure. OK, so you can judge it by two things: One, its transmissibility, and the other its morbidity and mortality. So as far as transmissibility goes, it highly transmissible. SARS was less transmissible but had a mortality of 9 to 10 percent. MERS was less transmissible with a mortality of 36 percent. Seasonal flu is very transmissible. It has a mortality of 0.1 percent. The pandemics that we, in our lifetime, have experienced—1957, 1968, and 2009—have a mortality of 1.3, 1.4, 1.6 (percent). The catastrophic pandemic of 1918 had a mortality of about—just shy of 2 percent, 1.8, 2 percent. So therefore where do we stand now?
We have a highly transmissible virus that has a calculated mortality, which we call CFR—case fatality rate—of 2 percent. But there’s no doubt it’s lower than that. And the reason it’s lower is because the only things that we’re counting are people who come to the attention of health care providers. Which means as inevitably they’re going to be a lot—maybe multifold more people who have either no symptoms or minimum symptoms. And they don’t get counted in the denominator. So if it’s 2 percent now, with a spuriously small denominator, when the denominator increases by threefold, fivefold, you’re going to probably have a mortality of about 1 percent or less. Which means if it continues to evolve into what we hope it doesn’t, namely a pandemic flu, it will be very much like a really, really bad flu season, or a moderately bad pandemic season.
TOWNSEND: And can you be an asymptomatic carrier of the coronavirus?
FAUCI: Oh, without a doubt. The real question that we’re trying to sort out, because we’re getting anecdotal reports, can you transmit it efficiently when you are asymptomatic? We know that there are people who are infected, for sure, who don’t have symptoms, or who have minimal symptoms they don’t even notice. We have anecdotal stories of people who clearly transmitted it when they were asymptomatic. That has implications for things like tracking, or testing, or screening. Because if screening is dependent upon symptoms, then the asymptomatic person throws a glitch into the screening.
TOWNSEND: How efficient, how good, reliable is the diagnostic at point testing right now?
KADLEC: Well, I would just say we don’t have point-of-care testing right now. And the testing that’s going on is in the public health laboratories around the country. CDC has come up with an effective test. There are some issues in terms of some of the reagents. But in terms of having that spread out around the country, there are 190 locations in U.S. labs where they can do this kind of testing. But there’s certainly a lot of development. And that’s a significant concern, about making it available to clinicians so they can do the very things that I think everyone would like to know, is do I have it or does someone I love have it? And what’s the risk of having it to someone else in that family?
TOWNSEND: Are we close to—or are we working on sort of that point of examination, testing?
FAUCI: Yeah. What the CDC did was very soon after the Chinese put the sequence on the public database, we pulled out the gene for the spike protein to make a vaccine. The CDC took the whole sequence to develop a PCR, or preliminary chain reaction, molecular test. They developed it at rocket speed. I mean, it was really amazing, a matter of a couple of weeks. They perfected that. And in answer to your question, Fran, that is a good test. So if you test me, and my test is positive, I am infected. If my test is negative there are a couple of explanations. Either I am uninfected, or the level of virus is still so low in me that you’re missing it. It becomes a matter of sensitivity. PCRs are pretty sensitive.
The point of care test that Bob was mentioning is one that you want to get out there, that you could actually get an answer just like that and it’s both sensitive and specific. We’re not there yet. We have a very good test, but it isn’t yet point of care.
KADLEC: And to your question about timing, we would hope that in a few months that you could basically have a test that would have to undergo FDA evaluation, for the very reasons that Dr. Fauci talked about—sensitivity and specificity of that test, either giving you a true positive, or potentially a false positive or, even worse, a false negative.
TOWNSEND: So I’m getting the sense from both the testing point—the diagnostics point of view and what you saw earlier about the cases that we’re aware of—we’re at the beginning of the beginning, right? We don’t really have a sense of size, or scope, or scale yet of the magnitude of the worldwide infection.
FAUCI: Right. Well, it’s even more disturbing, because not only do we not have an appreciation of the magnitude, even more disturbing is that we don’t have an appreciation of where the magnitude is going. If this was static and we say we don’t know yet what it is, you could do sampling and figure it out. But the critical issue right now is how the countries that have travel-related cases are going to prevent them from being sustained transmissibility. Once you hit sustained transmissibility, then you have a real problem. We have handled travel-related cases very well. We had fifteen cases. We now have fourteen extra because we flew fourteen over from the—from the cruise ship. But we’ve done identification, isolation, and contact tracing.
So to our knowledge, there aren’t individuals in society in the United States that are infected. We don’t think so. We don’t know 100 percent, because they could have kind of come in under the radar screen. So what we’re doing to mitigate that is that we’re taking five cities, representative cities—Los Angeles, San Francisco, New York, Chicago, and Seattle—and going into clinics where people present with flu-like symptoms but don’t have the flu. So why do they have flu-like symptoms? We’re going to test them for coronavirus. And if they do it would indicate we’re missing some. If they don’t, that means we’re in good shape.
But the real question is, what about countries that don’t have the capability of doing that identification, isolation, and contact tracing? Once they cascade into sustained transmission, the more they do that the more they get closer to a classic definition of a pandemic.
TOWNSEND: So let’s talk for a moment, because we are a globally interdependent world. And not all health systems are as capable as the United States. How good a partner have the Chinese been? We know that they closed the wet market where this started on the 1st. We know they sequenced the gene virus on the 9th. They didn’t share it till the 12th. How good and how transparent—maybe that’s a better way to ask it—how transparent have the Chinese been about how they’re handling it, and what they’re doing to cooperate with the United States.
KADLEC: You take the first one. (Laughter.) You can talk about 2003 till today and I can talk about today a little bit, OK?
FAUCI: (Laughs.) OK. So if you compare it to the SARS outbreak, they were egregiously nontransparent. They had a new infection in Guangdong, and that was in November. They didn’t say until February, when it got to Hong Kong, that this was not flu. It was an atypical flu. It was something very different. That put us behind a fair amount. Today, at least from the standpoint of publishing the—in the database, the sequences, you know, that was good, that they did that. But when you talk about transparency, it depends on who you mean by “the Chinese.” We have colleagues that we’ve dealt with for years, if not decades, some of whom—many of whom trained in the United States. They’re very transparent on the phone with us about what’s going on. Official numbers that come out, it’s kind of opaque where that’s coming from. I’m not saying it’s wrong, but I don’t know for sure.
KADLEC: Yeah, I was going to say, and another way to look at it is if you think our bureaucracy’s big, China’s is bigger. And the manner in which by these things are basically kind of handed from the local province or city to province and whatever else. And obviously, at least according to the press, there may have been either confusion or deliberate decisions at very local levels maybe not to report it. You can imagine that something that is kind of novel as this is gets lost of the noise of the regular flu season, it may not become apparent. And so there are a lot of it, I think, reasonable reasons. But to Dr. Fauci’s point, I think we’re getting information. And now that we have a team in Beijing with the WHO and a couple of Americans on there, I think that’s just going to enhance the opportunities to understand better, and really work collaboratively to kind of manage this because, quite frankly, as Dr. Fauci has said, you know, we don’t know what the magnitude of this could be. But we certainly know it’s very disturbing.
TOWNSEND: You know, it makes clear what you’re saying, that we’re going to depend on information from our foreign partners around the world. Are there obligations in terms of reporting outbreaks around the world? And what are those obligations? And what should we expect from our international partners?
FAUCI: No, it’s explicitly said in the international health regulations that when you get an outbreak you have to—I mean, that’s a responsibility of any nation when you have an outbreak of a new infection, that you are obliged to make it public so that you can let other people know.
TOWNSEND: But I—presumably not all health—countries’ health systems are equal, right? And so we know that there’s a large, for example, expatriate Chinese community in Africa. Do we have the same level of confidence that those health systems will have the ability, the capability, to observe those requirements?
FAUCI: Almost certainly they don’t. I wouldn’t say to observe the requirements. It’s not a question of knowing and not telling the rest of the world. It’s more a question of not even knowing what’s going on in your own country.
KADLEC: But I do think it’s really a good shoutout to say that this global health security agenda, that is a policy initiative both of the Obama and the Trump administration, is an important one, which is: How do we build greater capacity and capabilities around the world, particularly in these areas where they know that they’re not only vulnerable but have less-than-capable systems? And so small investments can mean a lot in those settings.
TOWNSEND: So how does the current outbreak affect our domestic medical supply chain? What does it mean in terms of our domestic supply chain?
KADLEC: Ruh-roh. (Laughter.) No, I think the thing is, is we’re seeing that kind of playing out in real time here. Clearly there is—there’s some good news here, but there’s also some more chilling implications. First of all, for the manufacturers and distributors, typically before lunar new year, when it’s anticipated that the Chinese factories will be closed, they order more and advance, if you will, ship more in terms of making sure that we have an adequate supply. And they factor things in like our flu season, if it’s severe or not. And I just saw something in today’s Post that said, I think, they’ve estimated that we’ve had twenty-two million people with the flu this year, twelve thousand deaths. So the distributors and suppliers feel like right now they’re OK.
How this plays out longer-term is still a matter of concern. So let me give you some—few examples. For things—and so this is a joint team effort that we’re leading at HHS with our FDA colleagues, with Dr. Han, and others, and with our DOD, VHA Veterans Affair colleagues, as well as the private sector, kind of sharing information and understanding where we stand is saying: There are things that we need to—that we could need for this outbreak—things like respirators and N95 masks. And so we know that a lot of—90 percent of the raw materials come from China. We know that a supply—a significant supplier of masks finished products come from China as well. 3M has a factory that has been commandeered by the Chinese government, and they’re not exporting those masks that they made for their own personal use. And that goes with other health care products around that.
So there’s some very significant things. Same thing with antibiotics, that there could be risks in terms of particularly generic products. But a lot of our health care—80-90 percent of our health care products either our source for raw materials, active pharmaceutical ingredients, or finished products from India or China. And India gets its raw materials from China. So there could be some very significant events, depending on how long this lasts and how it affects the Chinese system going forward.
FAUCI: We can’t see them crash. If they crash, we have a real problem.
TOWNSEND: But we should—you know, you make the point that’s a vulnerability whether or not you have coronavirus, right? And that’s a vulnerability we ought to fix with or without this. What’s the fix? What do we need to do? Is that Congress? Is it legislation? Is it budgeting?
KADLEC: It’s a whole of—it’s a whole of government approach. It’s Congress. It’s everybody, quite frankly, and the private sector. I mean, if you haven’t read the book China Rx, it’s probably worth a read, because arguably part of the economic plan, strategic plan of China, is to basically become the source for many of these products. And so there are a variety of issues at hand. So if you believe in domestic capacity and domestic jobs, and having an uninterrupted supply of things, it’s clearly a matter of national policy as well as support by Congress, and involvement from the private sector to be in—to figure out the solution set to do this.
And so there’s intense interest in Congress, particularly in the House, to see how we can address this. There’ll be a hearing with Energy and Commerce. I don’t think you’re the corpus of delicti, but I am one of them—(laughter)—coming up. But it’s the whole notion, though, that we probably need to kind of change the way we do business in these areas because of the significant risks and vulnerabilities that are being highlighted by this event.
TOWNSEND: So over the weekend we saw another fourteen Americans repatriated who were infected. Presumably, if we’re at the beginning of the beginning, we’re going to see more. Do we have the medical infrastructure if the quarantine expands, if there are more Americans repatriated? Do you have the infrastructure that will be required? And how quickly is it likely to be overwhelmed?
FAUCI: You know, I think fourteen Americans repatriated doesn’t stress our system at all. And you could have a lot more and it wouldn’t. But probably buried in the question, Fran, that you’re mentioning is that if we really get a pandemic influenza, that then you’re going to get into what’s called mitigation, which is very different in many respects from containment, where you’re going to have getting people to stay in their own homes, because you’re quickly going to run out of institutional quarantine capabilities, which is I think the question you’re asking.
TOWNSEND: Yeah. Yeah.
FAUCI: And once you do, and you’re in mitigation, then you’re going to require social distancing, keeping people at home, using teleworking, closing schools, things like that.
TOWNSEND: So we looked at that—back when I was in government, we looked at that in the context of pandemic flu. How are we thinking about that now? And had we exercised and are we working with the private sector? How would you—the difficulty with that, of course, is how do you execute against that? How do you implement that?
FAUCI: Right. Well, thank goodness for the pandemic flu plan that we put together. (Laughter.) No, really, because we actually did that in response to pre-pandemic—the H5N1 that you remember, and the H7N9, and things like that. What happens when you have the emergence of a pandemic? Much of that is easily extrapolatable to what we’re doing right now.
KADLEC: And we’re doing that right now as well in terms of—with the interagency, and looking at that, and actually modeling out what it would be for the 0.1 percent mortality rate versus the 1 percent mortality rate, to see what happens. But one thing that’s imbedded in that question too is about the fragility of our health care sector in terms of the ability of hospitals to manage cases, depending on the severity of the situation, in light of what is flu season already. It doesn’t mean—if you superimpose coronavirus on top of the regular flu season, it’s additive not—it doesn’t subtract the flu problem. And so I think that’s one of the issues. In fact, tomorrow we’ll be meeting with senior health care executives across the country to basically talk about what they need to do in preparing for this.
I’ll just highlight one thing that—and, you know, given an audience—a sophisticated audience, is to share one kind of important message. We talked about those masks, those N95 respirators. Well, 50 percent of those respirators, and reduced every year—like, and there are millions of them—if you try to go to Home Depot today you can’t find them. The flew off the shelves. But 50 percent are used by the health care industry, 50 percent by the private sector—if you will, people. For painting, for sanding, whatever else you can imagine. The problem is, is that there’s huge demand. The supply is going to get constrained because of raw materials. And what we need to make people understand is those kinds of masks really don’t need—are not needed by the general public.
In fact, for people buying those things up, you’re depriving the health care industry—the doctors, the nurses, the people who are going to take care of you and your families. And we got to—we got to get people to understand that the run on these kind of products is really going to hamper the ability of the health care industry to basically protect itself so they can treat you and everyone else in our society. So there’s some very simple things and messages we have to get out there. I would say that’s one of them. Dr. Fauci can even say a better one about you don’t need a mask unless you’re sick, right?
FAUCI: (Laughs.) You know, the—well, I don’t want to denigrate people who walk around wearing masks, but—(laughs)—the fact is the mask is probably for someone who’s sick to prevent them from infecting somebody else. So the one thing you want to do during an outbreak, when someone comes in coughing and sneezing, put a mask on them, not on yourself.
TOWNSEND: Right. So folks often paint infectious disease and biodefense in separate categories, as we know. The truth is there’s significant crossover in terms of preparedness and research. Understanding it’s a sensitive topic, Bob, could you talk about how we should approach these risks in a comprehensive manner so that we can achieve public health and national security objectives?
KADLEC: Sure. One thing is that they’re inseparable. Meaning, is public health, security, and national security inseparable. If you just look at what the event in China is going to do to their economy and what it’s going to do to our economy—if you saw, Apple is going to basically have a loss in—you know, a decrease in expectation in the first quarter based on the parts they can get from China. And they’re not unique in their dependency. Is this is going to have enormous impacts on our economy, and if it—if it is unabated and basically goes on a trajectory that it seems to be going on.
And so I think the thing is, is one—and I just make this as an affirmative fact. And it gets back to money, is that the national biodefense strategy that the president signed in in September of ’18 basically shows that we spend about $8 billion a year on the whole kit and caboodle, it you will, subject to our investments to Dr. Fauci’s institute, investments to BARDA, investments in local and state public health. That is about half the cost of an aircraft carrier. We have twelve aircraft carriers. We probably could benefit from some kind of thoughtful investment at all levels of government, state and local, to build capacity, to make sure that we can have a domestic manufacturing capability for a vaccine so we could rapidly—and that’s identified in the president’s pandemic influenza plan—that we need to have domestic manufacturing not only for vaccine but, as you can see, for other vital healthcare components.
So there is a real need to kind of take a different approach to this. Because of the global interdependencies, because of the risk to our—to our livelihoods as well as our social stability, as well as to our national security. Remember, 1918 happened during World War I. And more people, more soldiers, died of the flu than they died of combat actions. So they’re interconnected. You can’t separate them. I just think some of the issues we have to get our head around, and it’s incremental—this is imperfect incrementalism—is we have to somehow understand that we have to kind of engage, particularly now with this on our table, in the long-term fix to this, which was started, I would just say, by Fran and her colleagues back in 2005 and ’(0)6, with Dr. Fauci.
TOWNSEND: So let me take one minute. We were originally going to meet and talk about bioweapons. Let me just ask you, before I open it up, you know, BioShield was written back by you in 2003. We have the strategic national stockpile. One of the things—we worried about sort of the bioweapons, like hemorrhagic fever, smallpox, that sort of thing. And we have a strategic national stockpile that protects us—tries to at least begin to protect us against those sorts of threats. But we’ve seen emerging threats. We’ve seen the North Korean assassination using a weapon. We use Russian assassinations. How do you stay on top of the emerging threats? How do you think about the strategic national stockpile and staying ahead of emerging threats?
KADLEC: So first of all, emerging threats are the next potential bioweapon. So you have to think of it as a continuum. Mother Nature serves up agents that basically we’re susceptible to, and conceivable could be used by someone in a way that could be—to optimize that natural agent into something that could be very significant. So number one. Number two is, is that the stockpile—we have to think of it not as just something that’s static—because the worst thing we can have is a medical Maginot Line, which is basically a stockpile that is not agile, anticipatory, and in one area here—I’ll just antimicrobial resistance as an example—you know, and I—you know, not to air dirty laundry, other than to say is some of the antibiotics we have are the ones that we identified in 2002 to basically identify the anthrax problem.
We know there’s an antimicrobial problem in the world, right? And so somehow we have to use that engine of need, public health, to also support the need for national security. And how do we do that? And so we’re trying—we’re thinking through that, but it does take a very different approach than saying: You know, I got this box of the shelf. Hopefully it won’t expire. But the thing is, we need to keep rotating the stock not only, but also adding new items on the shelf that can address these things. And quite frankly, I think this example of a coronavirus—and Dr. Fauci can talk very eloquently about what happened to his great vaccine for the SARS event—that kind of lost steam.
FAUCI: Right. So there’s another side to the coin of stockpiling things that you know are countermeasures for something you’re anticipating. And that would be to take, which we’re doing in addition to the stockpile—it’s not one or the other—is to take a more generic approach, and to develop what we call platforms of diagnostics, therapeutics, and vaccines. So that when you get a new microbe, a new pathogen that you have not anticipated, therefore you couldn’t stockpile anything you just didn’t anticipate. What you need is the ability to move extremely quickly to get a vaccine for that. And the way you do that is that you don’t rely on having to identify it, grow it, and active it, or attenuate it. But that within a day of sequencing it you can get the gene, stick it in whatever vector you want, and then go for it.
So we have an example of that right now with the coronavirus vaccine that we’re working on. We’re not the only ones working on it. There’s about ten good candidates. But what we’ve done, from the time we got the sequence to the time we’re going to go into phase one trial, is going to be about two and a half months, which is overwhelmingly the world indoor record because that would have been years before you did that. Then you get it into a phase one trial, and you know the platform that you’re using, be it an mRNA, or a vector, or a viral-like particle. And you can move much more quickly with that than you would if you, again, went back to the twentieth century, find the organism, identify it, grow it, et cetera.
So there are two things. You anticipate organism X and you stockpile countermeasures. Or you develop a very, very quick-moving process to make a countermeasure more quickly. You got to have both of those things together. You can’t have one or the other.
TOWNSEND: OK, really last question. The FBI recently arrested a Harvard scientist for accepting undisclosed grant money from China for scientific research. It’s now been reported there are similar investigations at a number of U.S. universities, including Yale and MIT, just to name two, and that the grant monies in question here are in the billions of dollars. What are foreign governments looking for? Why in the U.S.? And clearly there’s a national security risk. Is this a bioweapons concern? Why should we be concerned about this? And what is the foreign government interest, do we think?
KADLEC: Go ahead.
FAUCI: You know, it isn’t a bioweapons issue. It’s really a stealing technology issue. It’s—I mean, it’s very clear. It’s unfortunate, you know, because it has put a taint on all Chinese. And that’s too bad, because it’s a small, small fraction of Chinese scientists who have, in this country, taken fellowships, gone on study sections, and essentially taken confidential issues, brought it back, and developed it in China. That was picked up by people at the NIH and other places. And it’s—you know, it’s an unfortunate situation. Fran, I don’t think it has anything to do with biodefense, to be honest with you.
KADLEC: No, but it does have to do with economic security.
FAUCI: Yeah. Oh, for sure.
KADLEC: And, you know, basically stealing our best ideas and our innovations and translating it overseas so they can do it maybe better, cheaper, faster? I don’t know about better, but certainly cheaper and maybe faster. And I think that’s where the issue of national security comes in.
FAUCI: Right. Yeah, it’s an economic thing more than another threat.
TOWNSEND: OK. At this time I’d like to invite members to join our conversation with their questions. A reminder that this meeting is on the record. Wait for the microphone, speak directly into it, one question not a speech, and please be concise as possible to allow as many members as possible to speak. OK, we’ll start here.
Q: Grace Skou (ph), Josena (ph) Capital.
Thank you for the panel. Diamond Princess has confirmed about 540 cases of infection. That’s out of 2,400 tested. So the concentration of infection is at a 15-25 percent rate, depends on how many remaining to be tested. What does this floating experiment tell you about the virus? And does that help us to understand sort of the prognosis of what’s going to happen to the rest of the world? Thank you.
FAUCI: Well, I think it just confirms the high degree of transmissibility of the virus. And when you create a beautiful setting for the virus—as that people on a large ship all together at the same time, all the time—you couldn’t ask for a better incubator for infection. So it confirms what we already know: That this is a highly transmissible virus. And that’s one of the things that’s of concern. You amplify that when you put it in a closed space. It could also tell us something about maybe some modalities of transmission that we didn’t appreciate before. You know, we had a very interesting experience with SARS in Hong Kong in 2003. An apartment complex, the Amoy Gardens apartment complex, in which we had assumed, correctly, that SARS was spread predominantly by respiratory droplets, the way most respiratory infections are transmitted.
But there was something went on in that apartment where virus actually got aerosolized and it was felt that it was likely due to the plumbing where—you know, because, you know, the virus gets into the stool and feces. That when people were flushing toilets they didn’t see this very invisible aerosolized that vertically transmitted it. So people who were on the second floor were giving it to people who were on the tenth floor, and even a wave that went across to another apartment. That’s rare that that happens. That’s something that could possibly have been going on in the ship. We don’t know. But that vessel was really an incubator for infection.
TOWNSEND: Dr. Fauci, does the virus survive on a surface? And for how long? Do we know?
FAUCI: You know, we’re doing those—the answer is—last week I would have given you the history of, you know, influenza is X number of hours, the coronavirus is X number of hours. Most of the time it survives for hours, not days or weeks. It depends on the medium it’s in. If it’s in a mucus coat, it could survive longer. What we’re actually doing now at our—my institute’s laboratory in Hamilton, Montana, is we’re actually doing the experiments. We’re taking the virus and putting it on stainless steel, wood, cardboard, glass, and trying to find out how long it lasts. So we’ll know soon.
TOWNSEND: Yes, sir.
KADLEC: It’s in your inbox. (Laughter.)
Q: Peter Trooboff.
Dr. Fauci, could you say something about the treatment of those who are infected? What works? What doesn’t work? We hear that the older succumb more quickly. What have you found out and what do we still need to know about the treatment?
FAUCI: Sure. OK, so let’s start with the second part of your question first. Like influenza, very similar to influenza, individuals who are elderly and with or without—elderly, with or without other conditions, or anybody with an underlying medical condition—and those are usually chronic, obstructive pulmonary disease, congestive heart failure, diabetes, obesity, immunosuppressive therapy for underlying diseases like cancer—they overwhelmingly are overrepresented in the individuals who get serious disease and who ultimately die. With regard to treatment, there is no proven direct antiviral drug for coronavirus.
So treatment is generally symptomatic. And if you get into difficulty with pulmonary problems, it’s supportive therapy. That could mean pulmonary toilet. It could mean oxygen. It could mean intubation—anything that gets somebody through an acute stage of pulmonary decompensation. We are doing, and others are doing, clinical trials of repurposed drugs, drugs that were developed for other viruses, to see if they have some activity against this virus, at the same time as we’re screening small molecules and doing targeted drug development. But the bottom line, right now there’s no known antiviral therapy.
TOWNSEND: Yes, sir.
Q: Hi. Tom Bollyky. I direct the Global Health Program here at the Council.
I wanted to ask about the other cruise ship, the Westerdam. So several hundred passengers disembarked. I gather only twenty on the ship were tested. One passenger has, after the fact, been tested positive as being infected. What is the current strategy for the passengers that did disembark? And how far along as we in executing it?
FAUCI: Well, you asked the right question, because you have the guy who makes that decision. (Laughs.)
KADLEC: Well, thanks. But simply is, is those individuals that are on the ship are being tested. There are a number of people, a couple hundred, in a hotel that are being evaluated. And so the thing is, is that one of the things that’s an important kind of issue to figure out is where did that individual get infected? Was it in Phnom Penh, because the incubation period could be as a short as two days or it could be as long as fourteen days? And so there are a lot of unknowns on that. But I think everybody’s going through it in a deliberate fashion to say: What can we do to basically assure that we just don’t send those people around the world and just say everything’s fine. So State Department is doing an admirable job working with the government of Cambodia to basically work with them in a way that would allow us to evaluate those folks appropriately. So before we kind of send them on their way.
FAUCI: Yeah. it creates a difficult situation when you have an exposure which is low-to-medium risk, and then you have to ask yourself, do you have the resources to go trace everybody? Because—you know, I don’t want to be pejorative against cruise ships, but there’s—if there’s one thing you don’t want to do right now it’s to take a cruise in Asia. (Laughter.)
TOWNSEND: Yes, back here.
Q: Sonya Stokes, Mount Sinai Icahn School of Medicine.
Last week the WHO hosted a meeting with multiple tech companies, including Facebook and Google, to address the issue of medical misinformation impeding the COVID-19 response. What are some of the strategies that are being used to combat disinformation online with respect to public health? Specifically, what’s working, what isn’t, and what else can we be doing to mitigate the impact of infodemics on contemporary outbreaks as well as future outbreaks?
FAUCI: You know, to be honest with you, I’m not sure. I don’t know what is being done to counter that, other than what is being done in the normal things you read about, about how to get disinformation off social media. With all of the problems of reluctance to do that because of freedom of expression and freedom of speech. I think medical information—the only thing that we do, as physicians and scientists the way Bob and I are, is to try and get out the facts as often as you possibly can. In other words, to counter misinformation with correct information, as opposed to yanking out the misinformation.
KADLEC: And I’ll just highlight the fact that having trusted spokespeople doing that, like Dr. Fauci. And I think the key thing here is hopefully people will not kind of follow Facebook, they’ll follow Dr. Fauci, because he ain’t wrong.
TOWNSEND: Yes, sir.
Q: Hi. Tim Wirth from the U.N. Foundation.
Thank you both, by the way. That was a terrific program. Really appreciate your great work. Could you drop away for a minute, and I want you to focus on climate change. As climate change—and are you projecting for the institutions for which you’re responsible very significant changes as a result of climate change? And related to that, are we doing or is there a research agenda? And are we pursing that research agenda as aggressively as we might be?
KADLEC: I’ll defer to you, Dr. Fauci, first, then.
FAUCI: OK. So, you know, climate change is—it’s always problematic to try and relate climate change directly to things you’re doing. So if you look at my responsibility as the director of a research agency that involves infectious diseases, some of the things that we are really interested in is the expansion of vector range and vector capability with even slight increases in global temperature. Things like ticks. Things like mosquitos, things like overwintering. One of the critical issues when you have a mosquito-borne disease in a region in which you get cold enough at one part of the year that the mosquitos can’t overwinter. They essentially go out of action and then they come back the next warm season. If there’s enough change in temperature to allow them to persist even longer, you could have the extension of a season of a vector-borne disease. So that’s just one example of where climate change clearly has a direct impact on the things we do.
TOWNSEND: Way in the back.
Q: Hi. Thank you. Jane Tan (sp) with Radio Free Asia.
Dr. Kadlec, can you just confirm that you said U.S. expert are in China now? Are they among the twelve international expert with WHO team? And according to the Chinese Foreign Affair Office, they say they—the expert team are visiting Beijing, Guangdong and Sichuan, not the epicenter of Wuhan. Do you think we are able to get the full picture of the epidemic?
And Dr. Fauci, yesterday you say you trust—you don’t think China is fudging the number. But we’ve seen—you’re on the White House force—task force. And we’ve seen them commenting on China lack of transparency. So why do you trust the information China is providing? Thank you.
FAUCI: Well, today I do, for the following reason that what has changed in China is that the Chinese officials have been more than adamant about actually punishing people who are holding back information, whereas early on there was a reluctance and a hesitancy on the part of the scientists to talk about what really is going on there. So there was a phase early on where the people that I knew, people that I’ve dealt with for years who were very concerned about speaking out publicly—they would speak to me over the phone, but they wouldn’t speak publicly. Now they feel that the government is giving them the free rein to be completely transparent. So there really isn’t any discrepancy but what was said at the White House before and now.
With regard to the people in China, we’re very sensitive to the Chinese wanting to be the ones that make the statements where these people are and where they’re doing, because we’re guests in their country. And although it’s an understandable question, tell me who’s there, where they are, and where they’re going, we would prefer to have you hear that from the Chinese. Because you don’t want to get ahead of the Chinese, because what we don’t want to do is for them to pull back on the offer of having our people there.
TOWNSEND: Yes, sir.
Q: Thank you. Dong Hui Yu with China Review News Agency of Hong Kong.
How would you evaluate effectiveness and efficiency of the Chinese approaches to containing the virus, from the standpoint of the expert, not from the, you know, kind of politician? And if the Chinese didn’t take all these measures to continue the virus, would you be more concerned that the virus will spread more quickly around—all around the world? And secondly, now that the new cases are out of Hubei, I mean, the nationwide new cases have declined, what’s your suggestion for the Chinese for the next step? Thank you.
FAUCI: What China has done in response to this outbreak is unprecedented. And one could describe it almost as draconian. I mean, to shut down fifty million people from traveling in and out of an area, essentially shutting down the entire city of Wuhan of eleven million people. One, from a pure public health standpoint, the conventional wisdom would have been that’s overreacting because there are so many potential downsides to that. But as a matter of fact, even though it was unconventional and subject to understandable criticism, it very well may have dramatically slowed down the exodus and export of cases out of China.
So at the same time that we imposed an unprecedented travel ban from China, the Chinese were being even more dramatic in what they were doing in their own self-containment. And since the evolution of a pandemic when you have a single region—and overwhelmingly China is the epicenter—unlike a pandemic flu where, you know, I started off—remember the 2009 in California and Texas and within a week, it was all over the world—where it was fundamentally confined there. So an unusual, unprecedented, dramatic restriction of access in and out, I think at the end of the day saved us from a lot more travel-related cases. And with more travel-related cases, inevitably you would have had secondary and tertiary transmission. So at the end of the day I think they did something that really helped a lot, even though it was really unusual and quite draconian.
KADLEC: I’d just put it in a strategic context like this: So you have an annual flu season, as we do. And superimposed on that is a novel agent that you can’t detect, and you can’t discriminate from what’s happening. And so you could imagine, even if it happened in our country, there would be a moment in time where they would be saying: Why are we having this spike in incidents? And then it becomes the race to be able to diagnose this and identify what even would be the rough framework of an epidemiology to begin what I would think would be the appropriate interventions. Add onto the fact that you don’t have a therapeutic or a vaccine. And so you’re left with really non-pharmaceutical interventions. And so this idea of quarantine, isolation, closing schools—look in Japan today as well, is they’re doing things—they’re trying to address this in a way that kind of addresses the reality of the virus, right? Try to quarantine it, limit the spread.
And I think the thing is, as we would look at in our country today in lieu of maybe a vaccine—and we’re working on therapeutics using the same mechanism that Dr. Fauci identified, taking the gene sequence and basically trying to produce monoclonal antibodies, like we did with Ebola in real time, to basically hopefully have a product that—like the cocktails that mAB114 was from NIH and Regeneron from the other company—is produce something that we could use as a therapeutic, and hopefully repurpose other drugs. So this scenario—and what China did is quite extraordinary, for sure. But to Dr. Fauci’s issue, it’s probably put not the brakes on this, but probably slowed the risk of widespread, rapid spread.
Will it continue to spread? We’re seeing cases every day continue. And so the risk is, if it gets embedded in a place, like we talked about earlier, Africa or other places where health care infrastructure is not very good, that could be the next source of the—of the risk, if you will, even though China has done extraordinary things to basically clamp it down. So it—again, this is—you know, we’re living in historic times, if you want to kind of think about it, in terms of the race to—you know, the race against the microbe. And again, I think the challenge we have is, how do we do?
And I recall a seminal piece of work, Emerging Infectious Disease by Dr. Lederberg and Dr. Shope back in the ’90s, actually, that highlighted the risk of this happening. That was kind of like the piece of work from the National Academy of Sciences that started what I think is the intellectual kind of race to say: How do we address this? And we’re twenty years into that conversation. And now it’s a critical time to do what we got to do to make sure we can limit the spread, as well as prepare for the next one. We know in the 20th century, how many pandemics were there? Three, four?
KADLEC: And the thing is, this is the first one of the—well, maybe the second one of the 21st century, but it won’t be the last one.
TOWNSEND: Bob, something you said triggered a question. Do we know if there are existing therapeutics or drugs that could be repurposed that might work against the coronavirus?
KADLEC: Yeah. We’re testing two of them. Remdesivir, which we developed for a number of other viruses. We used it against Ebola. It was not successful. And interestingly, there’s an anti-HIV drug called Kaletra that has two protease inhibitors that we’re using. Both are being tested in randomized control trials.
TOWNSEND: That’s great. Questions? Yes, all the way in the back.
Q: Dr. Fauci, Fran Kritz, NPR.
Do you have the capacity or the scientific sort of capability to not only address the current coronavirus outbreak, but also anticipate others that come ahead—looking back a MERS and SARS. Could anything that you do now help with prevention, with treatment, so that you’re not just addressing COVID-19, but also what might emerge in a year, in five years, in ten years—so that if it emerges you’re a little bit ahead of the curve. Is that scientifically and capacity tenable?
FAUCI: Yeah. It’s tenable, it’s there, but it’s very unpredictable because, you know, 75 percent of all the new infections that afflict mankind are zoonotics. They come from an animal to a human, which is exactly what this coronavirus did. So if you look at SARS, it took a while but we showed definitively that it went from a bat to a civet cat, which is used at ceremonial dinners. They sacrifice them and eat them. And that’s how it jumped into the Chinese population. MERS went from a bat to a camel, and that’s how it got into Saudi Arabia. And MERS is the Middle East respiratory syndrome. This virus, if you look at the evolutionary biology of viruses, coronaviruses really like bats. So if you collect a thousand different bats, you will find coronaviruses in them. And you’re able to trace the evolution of the mutations till it reaches a point where it can bind to a human receptor.
I don’t want to get—(coughs)—excuse me—in the weeds with you, but the human respiratory tract has a receptor called ACE2. And the spike protein of the coronavirus binds to that receptor, which allows it to infect a human. Now, the ones that don’t, don’t have the right confirmation or the right molecular confirmation. When you evolve evolutionarily through bats and other animals, all of a sudden you get the right mutation and the right circumstance. It jumps species and then, boom. Sometimes it dead-ends into the human and you’ll infect one or two humans, and it will stop. Sometimes it, for reasons that are unfortunate for mankind, it adapts itself very quickly to transmitting from human, to human, to human. That’s exactly what his coronavirus did. So we do know, you know, the route to that. How you can prevent it is to merely be able to have good surveillance, good diagnostics, and good response capabilities.
KADLEC: And to your point about capacity, it does relate to, I think, the bottom line, which is: You really need to take what Tony said, develop these platforms that allow you to rapidly respond. As well as, there’s another approach, which is can you look for broad-spectrum therapies, potentially anti-microbial or in this case antiviral, that would have activities against coronaviruses? I mean, again, there’s a huge challenge here in terms of how do you do it? You can’t just do one approach or the other but try multiple prongs to see what can give you the best coverage. But it’s got to be fast, right?
You’d like to think that we can, as Tony said, broke the indoor record. But we’re going to have to beat it again in terms of how do we—how do we position ourselves not only for this one, but for the next one. And what can we do? And, again, platforms are a very significant advantage that we can take too, because not only do they allow you to rapidly insert and test something, but also allows for the regulatory pathway if the FDA is familiar with these things, there’s a broad science behind it, you have data in other—in the safety and efficacy of these products. So it’s complicated for sure, but the answer is we—that’s what we need to do, and we’re doing it, and we need to do it really fast for this one.
TOWNSEND: Dr. Fauci, you mentioned one of the keys here is surveillance. Is our domestic surveillance capability up to this challenge? And internationally, is the surveillance capability there that we need?
FAUCI: Domestically, the CDC has a pretty good system that partners with state and local health authorities. In fact, that’s the great strength of the CDC, because not only are they a great organization but they’re really connected to the state and local health authorities. Globally it’s spotty, Fran. Like, I can’t say it’s homogenous throughout the world. There are some places that really have very good surveillance. And the global health surveillance that we have right now I think is much, much better than it was fifteen to twenty years ago.
TOWNSEND: Yes, sir
Q: Jon Andrus, George Washington University and the University of Colorado.
My point is related to what was just mentioned. I convene—I chair the Pan American Health Organization regional commission for measles rubella elimination. And last week we heard presentations from both Colombia and Venezuela. Venezuela has lost its measles-free status. But the two countries would not talk to each other. And I think the role of the Pan American Health Organization in tackling the international relatedness of infectious disease is crucial. So my point is partnerships, could you comment more on the partnerships required, because in our own backyard there are opportunities to at least maintain the current level of collaboration.
FAUCI: No, I think you hit the nail right on the head. I mean, if you don’t have partnerships and collaboration, you’ve essentially destroyed the continuity of the system, which is what happened in South America, unfortunately. You’re right. It’s tragic that that happened, but it did.
TOWNSEND: Yes, sir.
Q: Hi. Andy Weber, Council on Strategic Risks.
Thanks for a great talk. How are we postured to conduct clinical trials in China of these candidate antivirals and vaccines that you’ve mentioned?
FAUCI: Good. Thank you for the question. It’s happening. So the Chinese have agreed to do a randomized control trial of remdesivir, plus standard of care, versus standard of care alone. Ethically sound, scientifically sound, in two separate groups of 500 people apiece, one group of people with advanced disease, other people with moderate to light disease, to see if in fact you have any. So I think—I’m pretty sure that we are going to have an answer to whether this particular compound works. They’re planning and will likely do also one with Kaletra, which is ritonavir plus lopinavir, two antiretroviral drugs. So we’ll know that. As a matter of fact, Bob and I were just exchanging emails last night and this morning about trying to get that trial, which is a master protocol, for the people in the United States who are infected and have been shipped to Nebraska. So hopefully we’ll get that going.
TOWNSEND: That concludes our meeting. I’d like to thank Dr. Fauci and Dr. Kadlec for taking time out of their busy day. (Applause.) Thank you very much. Thank you for your service.