Howard Bauchner, MD, JAMA editor, discusses three critical COVID-19 trends

Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.

In this episode of the AMA’s COVID-19 update, Todd Unger, AMA chief experience officer and Howard Bauchner, MD, JAMA editor-in-chief discuss three critical COVID-19 trends, among them the volume of scientific output being produced on the virus and misinformation on social media, vulnerabilities in private and public health systems and the country's response to the pandemic.

Learn more at the AMA COVID-19 resource center.

Speakers

• Howard Bauchner, MD, editor-in-chief, JAMA scientific publications

Unger: Hello, this is the American Medical Association's COVID-19 update. Today we're discussing the latest trends and research on COVID-19 with Dr. Howard Bauchner from his vantage point as editor in chief of JAMA and the JAMA Network in Chicago. Dr. Bauchner prefers that I address him as Howard. I'm Todd Unger, AMA's Chief Experience Officer in Chicago.

Howard, let's start with an editorial recently published in JAMA by you and three coauthors that discusses three critical trends that deserve mention. The first is, the infodemic. Can you talk about what that is?

Dr. Bauchner: Well, there appears to have been almost 100,000 articles published in journals regarding the COVID-19 pandemic. This output is just extraordinary. More specifically, JAMA has had over 10,000 COVID-19 papers submitted since February 1st. And so simply the volume of scientific output has increased dramatically. And it's not clear to me how clinicians, patients, the public can take this all in. And this is in addition to all the media outlets, as well as all the reporting systems like the Hopkins tote board on the number of cases and deaths. So we're being literally inundated, pummeled with information. And I think one of the questions is what's the signal to noise ratio. And I think that remains unclear.

Unger: And a lot of that information is, I would classify it as misinformation. How do we deal with that?

Dr. Bauchner: Yeah. So part of the struggle has been both in social media, as well as the reports, preliminary reports and preprint servers. So those would be the two areas where it would surface. Now, some have argued actually that journals have not been as aggressive as they could be in social media. That is when something goes up that's not factually correct, should journalists be more aggressive in addressing it. Our experience is limited, but that has not been a very effective approach because often those people posting that information are delighted to end up being involved in a discussion with the journal. And somehow it increases the number of followers that they have had or will gather. And so we've been reticent to engage in social media. We're careful about what we say and the information we put out, but some people have said journals and other professional groups need to be more proactive in social media. Preprint servers, different question. I think they serve an important purpose for many articles, but not all.

Unger: Well, one of the other trends that you mentioned is the pandemic has exposed vulnerabilities in both the public and the private health system. What do you mean by this and what can we do about it?

Dr. Bauchner: Well, in the public health system, I think people have for many, many months now have been clear that the public health care system had been underfunded for many years. It's gotten worse under President Trump, but it was not particularly well funded under President Obama. People have for more than a decade, suggested that, particularly the state level, more funding was necessary. And I think we've seen that play out in many statewide attempts to track, trace, and quarantine. It simply has not gone well in virtually any major place in the United States.

Some colleges, interestingly enough, have really mounted an effective tracking, tracing, and quarantine approach, but it's been very difficult that the city and state levels in part, because we simply have inadequate resources in terms of public health. Private resources are a bit different. Obviously, there were struggles early on, particularly in New York, New Jersey and Connecticut. I think as the pandemic has spread more widely around the United States, most health care systems, at least with the initial surges have been able to keep up. Now we're unclear what will happen in the fall, but simultaneously because of the lack of PPE and testing, they have to curtail virtually all elective procedures. And that has enormous clinical and financial implications for hospitals and large health care systems. And I think it's clear going forward once we're through the pandemic, that we're going to have to think about how we develop a more flexible health care system that has surge capacity.

Unger: And how are you thinking about the way that health care is delivered, especially with the lens of health equity that we've seen really at the center of a lot of that just unequal response that folks in certain communities are experiencing right now?

Dr. Bauchner: The death rates clearly in the black and Latinx community is far higher. The most recent data from the Centers for Disease Control suggests they are three and a half times higher, both in the black, as well as the Latinx communities. So this has unveiled what has been a persistent problem in the United States, which is health care disparities. They've always existed, but I think this once again is highlighted the struggles for certain communities. I think people are trying to sort through what the appropriate approaches should be going forward. So for example, when we get to the distribution of vaccines, the question is how will you account for what would be inequity in terms of diseases in certain communities? And so that will be something that both the National Academy of Medicines, as well as the Advisory Committee on Immunization Practices will have to address in terms of their recommendations.

We've had quite a few articles on this, Clyde Yancy's written on it. Lisa Cooper and David Williams have written about it for JAMA. In some regards, I'm most proud of the JAMA article we had by Otis Bradley almost two years ago on entitled Cancer Justice. I think he highlighted that health disparities for breast cancer, prostate cancer, colorectal cancer are well-described, we know what to do. We just have to make that national commitment. But I think this is not a new issue, but it's clear that the COVID-19 pandemic has once again, highlighted health care disparities and inequality across our service lines.

Unger: Howard, the final trend that you mentioned has to do with our country's pandemic response. What are we seeing there as it continues to develop?

Dr. Bauchner: Yeah, I think that the data from the last week or 10 days are once again, concerning. I think July was concerning where we were having 40,000 [to] 50,000 cases a day and anywhere between 500 and occasionally it dropped, it was above a thousand deaths. Then in August and through early September declined a bit, but it's began to increase again where we're beginning to have 45,000 - 50,000 cases a day. Again, deaths are less than they have been in March. And I think we know that some of these cases are coming from colleges. That's very, very clear. We know that the number of cases on college campuses is dramatic, but we're also moving into the winter months and people for many, many days now, many months have expressed tremendous concern about the twin diseases of COVID-19 and influenza. And I think people just can't predict what will happen come October, November and December when people move inside where we know that the rate of transmission is generally higher.

Unger: Any other kind of key drivers to be expected as we move into the fall?

Dr. Bauchner: Yeah. Bob Redfield and a couple of his colleagues describe influenza vaccination rates in the United States. They remain quite low, somewhere around 50% in the adult population, a little lower in at-risk communities, particularly the black community. And so there's a huge push to try to get the influenza vaccination rates well up into the 60, 70, 80% range. That will help because the vaccine, regardless of how effective it is, is going to prevent flu in a certain number of cases. There's two other lurking issues that have yet to be supported or yet to be accounted for. When people get ill in November and December and they seek care, it will be really important to try to distinguish COVID-19 disease from flu disease, because the courses may be very different, and the treatment may be very different and we don't yet have the capacity to do co-testing.

The second is at whatever time we do have a vaccine, let's say sometime in the first quarter of next year, again, it's likely that a substantial percent of individuals who are vaccinated are going to develop a fever or minor illness and may seek care. And again, it's going to be critically important for one, those people who've been recently vaccinated to tell their health care clinician, whoever is providing the care, but also for us to develop a way to distinguish whatever illness they're presenting with from COVID-19 or flu. And so these are evolving issues. The only other comment I would make is that both Regeneron and Lilly are working on new approaches to prevention and treatment generally in the monoclonal antibody realm. And we're just beginning to see some data emerge on those studies, but nothing is definitive yet and there remains no definitive report around convalescent plasma.

Unger: Any other updates in the world of vaccines and treatments?

Dr. Bauchner: No, I think people have largely probably heard all of the different reports about vaccines. I think the general prevailing view is very late this year, first quarter of next year. Rollout will be complicated. The good news is that there won't be a sufficient amount initially. So that's likely to go to hospitals for health care workers. And hospitals generally are good at storage and distribution and tracking of vaccines. When the larger community needs to be vaccinated, we don't yet have a really high-quality infrastructure. And that goes back to your first question about public health infrastructure.

So, I think people are working in parallel, both not only to develop the vaccine, but to figure out a way to distribute it. And this will be important if people need second shots and then we need to follow them. So, I think there's two issues with vaccines, when it will actually be available and then secondly, the infrastructure, the infrastructure to distribute it. Both the National Academy of Medicine, as well as the Advisory Committee on Immunization Practices, NAM, just late last week released its recommendations in terms of who gets vaccinated when. And ACIP is likely, in the next week or so, to outline their approach to that question. And those will be the two most carefully watched documents around who should get vaccinated first.

Unger: Last question is about, the question about how COVID affects different people so differently. What's the latest research in this area and what's it telling us?

Dr. Bauchner: Well, we've known from early on that individuals who are older and frail are at highest risk for serious disease and death. It's complicated by individuals who are obese or who have asthma or who smoke. There's been a handful of reports, one was in JAMA, a couple have been in other journals, about certain genetic changes that individuals have. It may make them at greater risk for disease regardless of age, but those are still very preliminary reports. There was just a report indicating that obese individuals don't respond very well to certain immunologic challenges. And that may be in part why they do particularly poorly with COVID-19, but there could be other reasons. I think there's not a precise answer yet to your question, Todd, there's been dramatic advances in certain aspects of the science of the pandemic, but not in other areas. And this variable response is still yet unclear.

One of the things that will be interesting, JAMA Internal Medicine published a very positive report indicating that elderly, who had been infected, develop neutralizing antibodies similarly to non-elderly individuals. That suggests that when elderly are vaccinated, they may also be just as likely to develop a high-quality immunologic response. People are very, very interested in those data that will emerge from the vaccine trials, because if indeed the vaccine isn't effective in the elderly, that will have an enormous impact on the type of prevention we can do. So, I think people are guardedly optimistic that in fact, the elderly will respond to the vaccine.

Unger: Well, thank you so much, Howard. It's been a pleasure to have you today and I appreciate your perspectives. That's it for today's COVID-19 update. We'll be back soon with another segment. For updated resources on COVID-19, visit ama-assn.org/covid-19. Thanks for joining us and please take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.