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

MS. ABUTALEB: Good morning. I’m Yasmeen Abutaleb. I’m a health policy reporter with The Washington Post.

This morning, I'm joined by Dr. Anthony Fauci, chief medical advisor to President Biden and the nation's top infectious disease expert.

Dr. Fauci, welcome back to Washington Post Live.

DR. FAUCI: Thank you very much, Yasmeen. Good to be with you.

MS. ABUTALEB: It's great to have you.

I want to start by acknowledging the progress that the country has made in the pandemic. Cases are among the lowest they've been since the start of the pandemic. Vaccinations are rising, but is there a concern about a resurgence in the latter part of the year as the weather gets colder? And how much of this hinges upon what our understanding is of how long these vaccines are effective?

DR. FAUCI: Well, I don't think we should be that concerned right now about how long they're effective. I think they will be effective long enough that we will get to the point where we are not going to be necessarily worrying about a surge.

Let me explain what I mean. The positive wild card in all of this that we didn't have during the previous three surges that our country has experienced, the most profound of which was one at the late fall and early winter of the 2020-2021, where we had cases as high as 300,000 per day and deaths up to 3- to almost 4,000 per day, that was at a point when virtually no one in the country was vaccinated. If we get to the president's goal, which I believe we will attain, of getting 70 percent of the people getting at least one dose, adults, that is, by July 4th, there will be enough protection in the community that I really don't foresee that there being the risk of a surge, provided we continue to get people vaccinated at the rate we have now.

Of course, there are several things that are uncertain when you're dealing with a pandemic. One thing that is quite certain is that when you have a vaccine or a group of vaccines that are as highly effective in the real world--and those data were very clear--highly effective as these vaccines are and you get a substantial proportion of the population vaccinated, the chances of there being a surge are extraordinarily low. I mean quite, quite low. You don't want to declare victory prematurely, and it's for that reason why we're continuing to put the push on of getting as many people vaccinated as we possibly can.

MS. ABUTALEB: One thing that you've talked about is that people might need a booster shot within a year or so of being vaccinated. What is the timeline right now for when people might need to start getting that? Are there people who will need to get it as early as December for the people who are the first among to get vaccinated, and do you think that coronavirus shots will become kind of like an annual flu shot?

DR. FAUCI: Well, Yasmeen, there are several questions there. I think it's first important to point out that we don't really know when we may need a booster. I mean, we're making extrapolations saying that if the level of protection at the correlative immunity starts to wane and come down to below or at a critical level and you may start to see more breakthrough infections, at that point, that would be the trigger.

But I really don't think it's accurate to say that we will need boosters X number of months from now. We may not need it for quite a while. We are preparing for the eventuality that we might need boosters, but I think we better be careful not to let the people know that inevitably X number of months from now, everyone is going to need a booster. That's just not the case.

We're looking at the different potential scenarios and what you follow--and we are following people from the original trial--as to the level of what we call a "correlative immunity." For example, if the cutoff point of protection is a level of 1, let's say, to 100 or 1 to 200 of a titer of an antibody and you're way up at 1 to 2,000, you're in good shape. As the mean of the number of people who are vaccinated start to come down and reach the point where you're getting close to that critical level, then you'll seriously consider the possibility of a booster, but I don't know when that will be. But it would be foolish for us to not at least consider that we may need that.

In that regard, the second question that you asked, which is a reasonable question, which is there is no definitive answer for, but you've got to look at the options. Will this be a situation where over the years, we may need intermittent boosts? Again, you want to be prepared for that, Yasmeen, but you don't know definitely if we'll need it.

Of course, you have to put it into the context as follows. When you have an infectious disease and you want to, in essence, address it appropriately, there are three possibilities. One, you could eradicate it. That's a very high bar because we've only eradicated one human infectious disease in our entire history, and that is smallpox, with a highly successful vaccination campaign.

The next thing is you can eliminate, and you generally do that by having certain countries, usually with good vaccination programs, essentially eliminate the presence of a particular pathogen in society. We've done that with polio in the United States. We've done that with measles in the United States and other developed nations. So, that's called elimination, and the other is control. You have a very, very low level in the community, not enough to be a public health issue but enough to know that you haven't completely eliminated it. We don't know where we're going to be with SARS-CoV-2 and with COVID-19. I would hope it would be much closer to elimination than just control. That's going to depend entirely on the success, which I believe we're going in the right direction, of the vaccine program, and the more and more people that get vaccinated--and that's the reason why we continue to push to get those people who are reluctant to get vaccinated--to, in fact, get vaccinated, because the closer we get to more and more people getting vaccinated, the more likely you'll lean towards elimination rather than just control.

MS. ABUTALEB: My colleague, Ariana Cha, wrote an article about people who are immunocompromised for which the vaccines might not be highly or entirely effective, people with autoimmune disorders, transplant patients, people with certain types of blood disorders. How does someone know if they're protected against the vaccine, and how does that inform their day-to-day decisions?

DR. FAUCI: Well, we're doing right now in real time, Yasmeen, those studies right now. In fact, there have been a number of studies looking at the response to the vaccine, particularly among transplant patients who are usually rather severely immunosuppressed to prevent the rejection of their transplant, and those who are on certain drugs and things like mycophenolate and other drugs, the response is really quite low. So, with those individuals, it's likely--and again, this is just being studied right now so that we can get a good handle on it--you might want to try more boost with those people and/or--and likely "and"--making sure that even though those people are vaccinated--and for the general healthy population, you don't have to worry because you can feel quite protected--that individuals such as those may need to take an extra step to protect themselves, which means they may need to continue to wear masks, particularly in indoor settings where there's the possibility if not the likelihood that they may come into contact with an unvaccinated infected individual.

So, the idea of immunosuppressed individuals is an important consideration, and that's the reason why we can't say one size fits all. We have a heterogeneous population in this country and throughout the world. So, a healthy person who gets a good response is clearly different from someone who is on cancer chemotherapy or who is on an immunosuppressive drug for, as you mentioned, an autoimmune disease and especially people who have transplantation together with immunosuppressive therapy.

MS. ABUTALEB: Are there other conditions that we know about that might impede the efficacy of these vaccines?

DR. FAUCI: Well, yeah. There are primary immunodeficiencies. There are a number of individuals who, congenital or otherwise, have primary immunodeficiencies. For the most part, a weakened immune system is either primary, due to an infection as in HIV/AIDS, or iatrogenically induced. Namely, in order to treat another disease out of necessity, you have to immunosuppress individuals.

There are a considerable number of people like that in the country, and those are the people you have to pay special attention and the kinds of recommendations that we've heard from the CDC about what people who are fully vaccinated can and cannot do might not apply directly to the people who are immunosuppressed. Again, that's why I say although we try to get broad guidelines and recommendations, often one size does not fit all.

MS. ABUTALEB: I want to turn to the new CDC guidance that states that vaccinated individuals don't have to wear masks indoors or outdoors anymore unless required. There's obviously been a lot of celebration after this guidance was released but also a lot of concern from various groups of people. Do you feel that this guidance adequately took into account some of the more vulnerable people in our population, whether immunocompromised or people who might not be able to get vaccinations yet, given that it relies mostly on an honor system?

DR. FAUCI: Well, putting the honor system aside for the moment, Yasmeen, you are correct, and it gets back to what I just said about it was given as a broad guideline and recommendation. But there are caveats associated with that, one of which you mentioned, is that not everyone is equally protected when it comes to vaccines particularly individuals such as those who are immunosuppressed.

One of the things that I've mentioned in prior interviews and conversations is that I believe the, perhaps understandable, misunderstanding about the guidelines from the CDC which says that if you are fully vaccinated that you should feel protected and you'd be able to have a high, high degree of effectiveness in avoiding infection not only outdoors without a mask but also indoors without a mask. Somehow or other, it was interpreted by some as meaning no longer do masks be needed for anybody, which is absolutely not the case because the CDC was only speaking of those individuals who are fully vaccinated.

One scenario that has arisen that I bring up as sort of an example of how we've got to be careful about a misinterpretation is that you might have, for example, an establishment, whatever that establishment is, a business or what have you, a store, a department store, whatever you want to call it, and there are individuals who will be walking into that establishment who might be vaccinated and fall under the guideline of the CDC that indoors there's no real problem, you're protected, you don't have to wear a mask. But yet since we have no way, at least at present, of documenting or proving that a person has been vaccinated, and when you have such an establishment, you could have people in there who are not vaccinated and even people in there who are infected who might have the risk of infecting someone else. You can see how the owner or the person who is responsible for that establishment might say, "Understanding the CDC guidelines about what vaccinated people can or cannot do, since I as the responsible person don't know who's vaccinated or not, I'm going to say that if you're going to come into my establishment, you're going to have to wear a mask because I can't be monitoring whether or not you are or are not vaccinated." And we're actually seeing some of that.

What we're going to be seeing also--and I think this is very clear because we're already seeing examples of it--there are going to be certain organizations, certain institutions that no matter what are going to require proof of vaccination before you can enter into whatever establishment it is.

For example, we already know there are certain colleges and universities which are saying if you want to come on campus for in-person learning, you have to have proof that you're vaccinated. There are going to be cruise ships that are doing the same things, and it is likely that certain airlines might also do that. So, notwithstanding guidelines from the CDC, there is going to be a situation where are going to be requirements. It's not going to be centrally mandated from the federal government, but almost certainly, individual organizations are going to want to require proof of vaccination before they allow people to come into their establishment without having to wear a mask.

MS. ABUTALEB: Well, to that point, I understand not all of this will come from the federal government, but are there discussions right now about putting out additional guidances that clarify what you do and several of the situations you outlined, a grocery store where there's a mix of vaccinated and unvaccinated people, an airport, other public spaces where there's no way to know, when other discussions with the CDC and the broader administration about how you clarify some of that for these businesses that are struggling?

DR. FAUCI: Yes, Yasmeen. I think you are going to be seeing that because the CDC has already indicated that they are considering right now rolling out further fine-tuning, in a more granular way, recommendations related to the original guideline of not requiring masks not only outdoors but indoors. So, we should be hearing within a reasonable period of time a bit more granularity about the recommendation.

MS. ABUTALEB: I want to go back to just one question on the efficacy and longevity of the vaccines. Will doctors start testing for immunization levels, and will that help us understand how long these might be effective for?

DR. FAUCI: I don't think you're going to be seeing private physicians individually doing that. What is happening is that--you recall, Yasmeen, the original phase 2 studies and phase 2a and 2b that were done on several of these vaccines? We're still following those individuals, because even though it was a vaccine trial, it was really research being done in the context of those trials, and what will be followed will be the durability of the level of antibodies, of neutralizing antibodies, which I referred to sometime ago.

You would expect on the natural course of events that you will have a diminution of the level over a period of time. The steepness of that slope is unclear right now. That's the reason why I was unable to definitively answer your question of when we might require a booster. I mean, one assumes that sooner or later, you might, but we don't know how long that would be. And until we get the information, as a group, how long it generally takes for that level to come down--and it will be manifested by a laboratory manifestation, namely the level of antibodies, but also be clinical observation, if you start to see more breakthrough infections than we're seeing right now, which are still a very, very low proportion of infections or breakthrough infections.

MS. ABUTALEB: Is there a way people will be able to know if their vaccines are still working or still effective?

DR. FAUCI: As an individual basis, like I said, I don't think that that's what's going to happen, like doctors are going to come in and say, "Okay. I'm going to measure your antibody and tell you you're okay." It's going to be more as a cohort where it will be said, in general, people who have gotten this vaccine have a degree of protection that lasts X amount of time, and we don't know what that is.

Practically speaking, if you wanted to go into your physician's office and say, "Could you send out an assay of the level of my antibody? I guess you could do that and say, "Well, it's still very high. I'm okay," but I don't really see that of tens of thousands of people going in to get their level. I just see more of a broad general guideline than individual people doing that.

MS. ABUTALEB: President Biden outlined a few weeks ago that the administration's goal was to have 70 percent of adults have at least one shot by July 4th. I know you've been asked this question a lot, but what will our new normal start to look like, and is there a risk of a tiered recovery if you have regions of the country with very high vaccination rates and others with much lower ones?

DR. FAUCI: Yes. That's one of the issues when you're dealing with a large, wonderful country that we have, but a large heterogeneous country, where you're going to see certain states, certain regions, certain cities that have a much lower level of vaccine. Unfortunately, what likely would happen is that you're going to see a much higher risk of outbreaks of some sort or of sustained level of infection in those areas that are not fully vaccinated or at least not vaccinated to a high percentage.

When the president said 70 percent of the adult population to have at least one dose by July 4th, he was talking about the overall country. You may have certain cities, certain towns, certain counties where you have a much higher percentage, and then there are going to be those which are going to be lower. And you're right. It's not going to be a homogeneous unidimensional issue when it comes to this, and that's the reason why we continue, are out there, trying to explain to people why it's so important for your own protection, for that of your family, as well as for your community responsibility, because if you get vaccinated and you prevent or block the chain of transmission, you are doing that in your own community. What you're doing is you're preventing the virus from continuing its dynamics of spreading from person to person, because when it gets to you, it will be a dead end if you're vaccinated.

So, again, there's more than just protecting your own health, and that's the reason why we continue to come back to trying to get people to appreciate why it's so important for as many people to be vaccinated as they possibly can, as quickly as they possibly can.

MS. ABUTALEB: The European Union announced that fully vaccinated Americans will be able to travel in time for summer. Are there any discussions within the administration about whether you have to require proof of vaccination or some sort of vaccine passport for travel? Just because I think there are a lot of anxieties about traveling on airplanes.

DR. FAUCI: Well, I believe that airlines are going to do that on their own. As I mentioned, there are no plans right now for the federal central government to be making any mandates about the requirements for vaccine proof, but there's no doubt in my mind or many of my public health colleagues that we're already starting to see steps in that direction where independent entities will likely be requiring proof of vaccination before you can either get on a plane or step into a university campus.

MS. ABUTALEB: I think one question, as we see the outbreak spreading uncontrollably in India right now, how big of a threat is the India coronavirus variant in the U.S. We know it's spreading in the U.K., and what do we know about how effective the vaccines are against that variant right now?

DR. FAUCI: Yes. Good question, Yasmeen. I, in fact, addressed that at this week's White House press conference, but let me just very briefly outline it. There have been a number of studies literally published over the last week or so which have looked at antibodies induced by several of the vaccines that we are currently using, particularly the Moderna mRNA and the Pfizer RNA, and as we had seen with the 351 variant in South Africa, that the efficacy of the vaccine-induced antibodies is diminished somewhat by a fewfold but not enough to essentially obliterate the efficacy of the vaccine. You would project on the basis of the extrapolation of the level of antibodies that are required for protection and how much you diminish it when you're dealing, for example, with the 617 Indian variant. It is projected that we would have adequate protection against that, maybe not against initial infection but almost certainly protection against severe disease leading to hospitalization and deaths.

So, you don't want to be too cavalier about it. You want to continue to monitor the evolution of new variants, continue to determine whether they're dominant or not, just like the B117 is now dominant, about 70 percent, in the United States. Fortunately for us, the vaccines that we have distributed in this country do extremely well against the 117.

The other variants that you mentioned that are minor, a very small percentage of the infections, we have the 526 in New York, the 427/429 in California. We do have a few P1s and a few 617s, but they're really at a very, very low level and are really not players, as it were, in the spread of virus throughout the country.

MS. ABUTALEB: I want to ask you just one last question before we let you go. What are the implications for the rest of the world if rich countries get vaccinated much faster and also if poorer countries are using less effective vaccines?

DR. FAUCI: Well, I think you have to step back, Yasmeen, and look at the bigger picture that a global pandemic requires a global response, and it would be very difficult if you had countries that have a good vaccination program like we are on our way to as well as other developed nations, and you really have virtually nothing or very, very little capability of vaccinating the rest of the low- and middle-income part of the world, which is the reason why I have said and some of my colleagues also that it really is the responsibility, in my mind, of the rich countries of the world to very quickly work out a program where you can get doses to the rest of the world in an equitable and I think expeditious manner because you can't wait a few years to do that, because if you do, not only will there be avoidable suffering and death in other countries, but you will have the constant threat of the emergence of variants that would come back and be detrimental to the program of those countries who do have a good vaccine program.

We need to do whatever we can as a global community to either get doses directly to them or provide to them the technology transfer to allow them to make the vaccines themselves, be it in countries in Africa or in South America or in Asia or where have you. We've got to have equitable production and distribution of vaccines throughout the world.

MS. ABUTALEB: Well, unfortunately, I'm going to have to leave you there because we are out of time. Dr. Fauci, thank you so much for your time, as always.

DR. FAUCI: Thank you very much, Yasmeen. It's been a pleasure being with you. Thank you for having me.

MS. ABUTALEB: Come back and join Washington Post Live right here at noon Eastern. My colleague, Ann Hornaday, will be interviewing Nicole Kidman and Hugh Grant about their highly successful new series, "The Undoing."

I'm Yasmeen Abutaleb. Thank you for watching.

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