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What is most surprising about this particular coronavirus is how infectious it is (unlike MERS and SARS) and that people under 50 are disproportionately asymptomatic.
The trajectory of COVID-19 cases has been higher than expected. In addition, antibody testing showed in the spring that the number of infections could be 10 times higher than the number confirmed cases.
This year, it will be even more critical for people to get a flu vaccine. A flu outbreak will stress hospitals that are already battling the COVID-19 pandemic.
Current clinical trials are for people over age 18 and do not exclude those at high risk, including those over 70 and/or with comorbidities such as diabetes.
Now is the time to invest in public health, which we haven't done adequately in the past.
This transcript has been edited for clarity.
John Whyte, MD, MPH: You're watching Coronavirus in Context. I'm Dr John Whyte, chief medical officer at WebMD. Today I'm joined by Dr Robert Redfield, the director of the Centers for Disease Control and Prevention (CDC). Dr Redfield, thanks for joining me.
Robert Redfield, MD: Great to be here. Thanks for having me.
Whyte: You're a virologist by training. What has surprised you about this novel coronavirus?
Redfield: I think that it's important that we don't really know this virus very well. We just got introduced about 7 months ago. The thing that surprised me the most was how infectious this virus is. You know, when we saw that it was a coronavirus, I think we were thinking it was going to be more like SARS or MERS.
Even with the first cases we identified in the US, the first 12 cases that we did contact tracing in over 850 people, we only found two of those contacts, who were infected both by spouses. So we had a view that this virus was probably going to be more like MERS and SARS, but we rapidly understood that this is a highly infectious disease.
I think that's probably the first thing that surprised us. The second thing is that, probably for a majority of individuals under the age of 50, it's disproportionately asymptomatic. I wish we had been invited in early. I had asked my counterpart [in China], George Gao, to have us join in back on January 3, to put CDC in to work alongside him, to try to understand the outbreak as it was unfolding in Wuhan. I think if we had been able to get in at that time, we probably would've learned quicker than we learned here that, in fact, it is highly infectious and that asymptomatic disease is going to be a critical hallmark of this infection.
Whyte: We're at 5 million cases. But as you know, to put it in perspective for our listeners, we were at 4 million cases, roughly, 3 weeks ago. So the trajectory in terms of the number of new cases is higher than we would like. How do you think we got to 5 million? Is it that people aren't doing the safeguards that they need to be doing? Are people not taking it seriously? I was told you're in one of the old war rooms in the Old Executive Office Building. How are we doing in this war against COVID-19?
Redfield: Well, I think you're right. It is a war. I think the first thing that I'd like to say is that we're pretty confident that this virus slowly entered the United States in late January and February. And there wasn't extensive infection throughout February. We have about five different lines of evidence to support that conclusion that we've published.
But clearly, in March, there started to be more introduction, particularly from Europe, and we basically ceded large parts of the United States. When we looked at March, April, and May, we had about 2 million infections that were diagnosed, as you alluded to. What's interesting is that when we went back and did antibody testing during that period, we actually had evidence that for every one case that was diagnosed, there were actually 10 more infections. Probably in those first 3 months, we actually had 20 million people. But if you divide 20 million by 90 days, you can see that we're looking at probably over 200,000 infections a day, even though we were only recognizing 10,000 or 15,000.
Whyte: Dr Redfield, we're over 160,000 deaths in the United States so far. Do you expect COVID to be a leading cause of death by the end of the year?
Redfield: You know, John, I think it's clearly going to be one of them. If you looked back and used our surveillance systems that we have — and we have one that looks at death by pneumonia — we had either pneumonia, influenza-like illness, or COVID-like illness, and they all probably represented COVID.
At one point in time in April, early May, 27% of all deaths in the United States were caused by pneumonia, influenza, or a COVID-like [illness]. I can show you the curve — a huge spike when this outbreak hit New York and then the follow-up deaths. So it's clearly going to be a major cause of death in the United States.
Luckily, the mortality is improving, really for two reasons. One is we're recognizing more infections, so the denominator is different. But also, we really are getting better as physicians at managing these patients: good recognition of the hypercoagulable state, the importance of anticoagulation, the recognition that steroids have a role in advanced disease, the earlier ability to use remdesivir. So the mortality, I think, continues to decline.
Whyte: We've also changed ventilator protocols.
Redfield: Very important, the agent in ventilator protocols, as you know. And I think we've learned a lot as clinicians — I'm an internist too — in how to manage these patients. Hopefully we'll see on the horizon — not too distant — additional new therapeutics come in to add to the armamentarium that clinicians have.
Eventually this virus is going to have its day. It's either going to infect a majority of the global population or we're going to have a biological countermeasure; that's going to be an effective vaccine that's going to prevent it from infecting [the global population].
Whyte: Well, we hope. Let's talk about vaccines. But first I want to talk about the flu vaccine. You've been talking about and cautioning how important it is, especially this year, to get the flu vaccine as we fight COVID. Last year, roughly not even 50% of those that should have gotten the flu vaccine received it. How do you think we're going to do better this year? And remind viewers why it's so important this year.
Redfield: It is really important. I've said that if there's one thing we all can do, besides the importance of wearing a mask, social distancing, handwashing, and being smart about gatherings, is ultimately prepare ourselves for the fall to get the flu vaccine. As you mentioned, about 47% people got the flu vaccine.
Whyte: CDC often recommends the goal to be 60%-70%.
Redfield: That's right. Yes, my goal this year was to get it up to 65%. And I think one of the messages we're trying is to switch it from the "anti-vax" or "vaccine hesitancy" to a campaign of "to vaccinate with confidence," and trying to tell the American public, "Please don't leave this important accomplishment of American medicine on the shelf for yourself, your family, your church, your workforce."
By getting vaccinated, you can protect your children. Clearly, when we look at the mortality that we see with flu, one thing is for certain: The kids who get vaccinated basically get protected against death. It also has an impact on the rest of us in terms of severity of illness and hospitalization. Some people don't realize that in the past 10 years, 360,000 people died in this country from flu. Flu is a major cause of death. We have a biological countermeasure and a vaccine, and we do have treatment. And this is the year I'm asking people to really think deep down about getting the flu vaccine.
We've worked with industry. Industry is plussing up the amount of vaccine they're going to make available — probably over 100 million doses this year, 190 million doses. The CDC and myself, we've purchased an extra 10 million doses. Normally we only purchase about 500,000 doses for uninsured adults to give to the states. This year, I've purchased 10 million doses for uninsured adults in the states to make sure states can get this flu vaccine now.
The real reason is we're going to have COVID in the fall and we're going to have flu in the fall. And either one of those by themselves can stress certain hospital systems. I've seen hospital intensive care units stretched by a severe flu season, and clearly we've all seen it recently with COVID. So by getting that flu vaccine, you may be able to then negate the necessity to have to take up a hospital bed. And then that hospital bed can be more available for those that potentially get hospitalized for COVID.
Whyte: Let's talk about the COVID vaccine. How optimistic are you that we'll see a vaccine early next year? And can you give us a better sense of timeframe? As you know, Russia announced today that Sputnik V, their vaccine, is approved while they're still in phase 2. So how realistic is it that we're going to have something in January or February? Or are we thinking more later first quarter?
Redfield: I'm very cautiously optimistic that we're going to have one or more vaccines deployed before the first of the year. Right now, there is Operation Warp Speed — I'm on the board of it. I've been in vaccine development all my life, in the years I've spent in the military at Walter Reed and then at the University of Maryland. I've never seen vaccine development move like this.
There's actually a very effective private-public partnership with the private sector. And there are six vaccines now that are moving forward extremely rapidly, three of which now are already in phase 3 trials — and I suspect there'll be a fourth. So I'm very optimistic that we're going to have one or more vaccines available.
Since we're going so fast, some people worry that we're cutting corners. There's no scientific integrity to corners being cut; there's no corner cut for safety. The corner that we're cutting is the investment in being able to make the vaccine. So when companies were ready for phase 3 trials, the US government started production of 100 million doses of the vaccine, as if it was going to work.
Whyte: But in fairness in timelines, we're in August. Some of the industry had 5000; they still need 25,000 more participants to reach their phase 3 enrollment. People still have to catch the virus, right? And then we have a control group that we have to compare to. So the timeline is pretty compressed if we're thinking of something by the end of the year. Isn't that right? Early next year, and then it still has to be reviewed.
Redfield: We're moving very quickly. If there's any light to the fact of the sudden surge and the challenge of all the new cases we're having, it's the number of trial sites that are up and running. They started 2 weeks ago. They're enrolling very rapidly. I do think they'll all have their enrollment done between now and the end of September, and then we'll see what the data show.
The other thing I want to say that's so different and so important here is, unlike the trials that you may have been involved with, and I know I was involved with, we're not excluding the elderly.
Whyte: That's right.
Redfield: So you can actually get in the trial if you're 65 or 70 years old. We're not excluding people with diabetes, obesity, and heart disease, who normally don't get in trials. We're not excluding pregnancy. So the high-risk individuals that we're hoping this vaccine is used for are being included in these phase 3 trials, so we can determine whether it's potentially going to have immunogenicity and safety in the population at most risk, because that's really where we want to get this vaccine as quick as possible.
Whyte: My understanding was that there isn't anyone enrolled under age 18. Is that right?
Redfield: You're right. The current trials have not included children. That doesn't mean there are not going to be companion trials. But now all the trials are over 18. But unlike many of them that I've been involved with in the past that don't enroll people over the age of 45, this one's enrolling people all the way up to over 70. Same with multiple medical illnesses.
So there will have to be follow-up trials for children under the age of 18, but clearly there's a comprehensive trial right now that will accommodate the people who are most at risk because of comorbidities and age or because of their jobs; there are physicians, nurses, intensivists, etc.
Whyte: What does Thanksgiving look like this year, Dr Redfield?
Redfield: Well, I pray it is a moment of thanksgiving. You know, this whole thing started for me on New Year's Eve. And I can say that it's been all hands on deck since then, when I got my first call about the new mysterious pneumonia in China on December 31.
Clearly it's almost a tale of two cities. If the American public will really take to heart what I've asked — wear a mask, social distance, use great hand hygiene, and be smart about crowds — and we all do that... I keep telling people, I'm not asking some of America to do it; we've all got to do it. This is one of those interventions that's got to be 95%, 96%, 97%, 98%, 99% if it's going to work for us.
Whyte: Why can't we get people to wear masks? It seems like a small price.
Redfield: We've got to keep trying. We've got to keep trying. It's interesting; it's very different in different cities. I was recently in an area where 3, 4, 5-year-olds were all wearing their masks. All the parents. I didn't see anybody without a mask. But I've been in other areas where it's the opposite. We really do need to get [out the message that the] mask really does work. It's really important. So when you ask me what Thanksgiving's going to be like, I think it's just dependent upon how the American people choose to respond. We're going to continue to try to do what we can to be effective.
As I've said before, when John Kennedy said, "Ask not what your country can do for you; ask what you can do for your country" — to paraphrase that, for your country right now and for the war that we're in against COVID, I'm asking you to do four simple things: Wear a mask, social distance, wash your hands, and be smart about crowds.
If you do those four things, it will bring this outbreak down. But if we don't do that, as I said last April, this could be the worst fall from a public health perspective that we've ever had.
Whyte: Tell us what you miss, Dr Redfield. Is it traveling? How has this impacted you personally?
Redfield: When I decided to accept the opportunity to be the CDC director, I had to give up something that I really love dearly, and that's the practice of medicine. I've cared for some of my patients with HIV for more than 25 years. In a way, I'm looking forward to, when my tour of duty is over, getting back to the practice of medicine because I truly love practicing medicine.
At CDC, I think it's really the intensity of what we're doing. I would love someone like yourself to get into the agency and see how much is going on. I mean, there are thousands and thousands of people working 24/7 on this pandemic. And the fact is that all of our focus is on this pandemic right now.
I have other important initiatives: ending the AIDS epidemic in America, that the president started, that we're still committed to. But obviously, some of that effort gets sidetracked. Getting rid of tobacco use in children — all the progress we've made with e-cigarettes. I want to get that back on. Making progress on maternal mortality. There's no reason why 700-800 mothers have to die in this country every year giving birth to babies.
Whyte: Women of color, particularly.
Redfield: That's right. And the progress that we're trying to make in getting people treated for hepatitis C, the progress with diabetes. So there's a lot of programs. And when you look at the collateral damage of COVID, it is that we've all had to turn our focus disproportionately.
I tell my colleagues at CDC, "Please, do the extra effort to keep the main programs you're doing moving forward. This is not a time to lose ground." I think the past 7 months have been, as you said before, we're in a war. And I hope people realize — and one of the things I recognized when I became the director — we really haven't invested, in this nation, in the core capabilities of public health. It's always been something we left for leftovers. I've tried to make the argument that now is the time to invest in public health, data, data analytics, predictive data analysis, laboratory resilience in our public health labs, public health workforce. We have some states where we're down to less than 40, 30, 20 contact tracers. And then, of course, we need to have the emergency resources to operationalize that with a global footprint and hopefully pick these things up where they start, and to put them out before they come here.
That's one of my hopes that we'll take from this — that people now realize that public health matters. This nation is going to spend somewhere between $3 trillion and $7 trillion in responding to this pandemic. If we could make that investment in those core capabilities — data, lab people — and make sure we do it for the whole nation...
I think many people may not realize that CDC is the backbone funding for the public health infrastructure of every city and every state in this nation. We need to overinvest. Get overprepared. I will say that in four or five decades of investment, when the big one came — and this is not a minor one, this is the greatest public health crisis to hit this nation in a century —we were underprepared. And we owe it to our children and grandchildren that this nation is never underprepared again for a public health crisis.
Whyte: Dr Redfield, I want to thank you and all of your colleagues at CDC for working tirelessly to protect us during this time of the pandemic. And I hope we can check in with you to discuss some of those other priorities that CDC is working on to protect and advance the health of Americans and, as you said, really refocus and invest in public health and public health strategies. Thank you.
Redfield: Thank you very much. We look forward to that. God bless.
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Cite this: CDC Director Outlines Next Steps in the War on COVID-19 - Medscape - Aug 12, 2020.