Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.
Featured topic and speakers
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 the latest research on COVID-19, including a decline in new cases and deaths across the U.S. that's being attributed to additional public health programs that have been instituted across the country.
Learn more at the AMA COVID-19 resource center.
Speakers
- Howard Bauchner, MD, editor-in-chief, JAMA scientific publications
Transcript
Unger: Hello, this is the American Medical Association's COVID-19 update. Today we're discussing the latest research on COVID-19 with Dr. Howard Bauchner from his vantage point as editor-in-chief of 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, it's been about a month since we last talked and a lot's happened since then. Let's begin by talking about infection control and spread. What are you seeing from the research in certain terms of are we seeing signs of slowing or anything new that we're learning about transmission or drivers?
Dr. Bauchner: Well, it's an interesting question, Todd, because I think if you had interviewed me two weeks ago, the answer would be a little different than it is today. So I think up through mid August, there was a concern that in the United States, that there were about 45 or 50,000 new cases each day with about a thousand deaths. But it's very clear that in the last two weeks, that number seems to have declined from 50,000 to maybe 30-35,000 and more like four or 500 deaths. So there's been a very substantial decline just over the last two weeks. And most people attribute that to additional public health programs that have been instituted in various states around the country. And I think by this time, most of your listeners know what those are, which is social distancing, masking, hand-washing; really limit, dramatically limit, the number of people who can gather indoors, particularly for example, restaurants or bars. So I think answering that question would have been different two weeks ago. Nice progress around the country the last two weeks.
Unger: Well, speaking of gathering indoors, let's talk about school reopenings. With your background as a pediatrician, as well as what you're seeing in the research, what are we seeing in this area and what can we learn from it?
Dr. Bauchner: Yeah. This was probably the fundamental educational question of this generation, if not in the last 50 years, that is whether schools can open for in-place education or whether it will be Zoom. It's clear. It's very clear that these are going to be local decisions governed by many issues, including the amount of disease in that community, as well as in the larger school districts, how are superintendents and mayors working with school boards? I do think everyone now acknowledges, particularly for young children, virtually nothing can replace in-school education. It's very hard to imagine that kindergartners, first graders, second graders, third graders, can learn as well via the internet or Zoom as they can in person. Obviously there's an enormous amount of concern among the teachers and the parents about children being a reservoir of disease. I think the one issue that hasn't been clear is that younger children are very, very different than older children.
Dr. Bauchner: There's still a great deal unknown. And I got a really wonderful scientific report from some friends in Canada, and I thought it'd be helpful for the listeners just to understand how they've looked at the data. They summarize the world's data. So this is children younger than 10, which is fifth grade, probably related to puberty. Are they less likely to get infected with the virus? Uncertain. Once infected, are they less likely to shed the virus? Uncertain. Are they less likely to infect others? Uncertain. So for young children, much uncertain. The good news: much less likely to become symptomatic? Yes. Are they less likely to become seriously ill? Yes. So much less likely to become symptomatic, much less likely to become seriously ill.
Now this changes for people older than 10. Are they less likely to get infected with SARS-CoV-2? No. Once infected, are they less likely to shed the virus? No. Are they less likely to infect others? No. So 10 or older, they're behaving much more like you or I, like young adults or adults. Are they less likely to become symptomatic? Yes. Are they less likely to become seriously ill? Yes. So in that regards, they're different than adults. So for children or young teenagers, some characteristics like adults, other characteristics like young children.
Unger: That is a very clarifying way to look at it. Let's talk about the latest research on vaccine development and treatments. Are we any further along in understanding antibodies and immunity to COVID-19 and what physicians really need to know right now?
Dr. Bauchner: So I think now there have been enough studies published to know that depending on the population, as expected, 85, 90 or 95% of individuals who are infected with the virus, adults--we still have less data in children--are clearly developing an immunologic response. So-called neutralizing antibodies, IgG, and there may be a way in which their immunologic system is prime, so that if they see the organism again, it's not neutralizing antibodies or IgG or IgA, but it may be a T cell response, but 85, 90 or 95% of individuals are clearly developing some form of protection. The great unknown is how long will that last. Is that three months, six months, nine months or 12 months? So that's in response to the immunologic question.
Then you asked secondly about vaccines. There's probably a dozen vaccines now that are in so-called phase three trials. An mRNA vaccine, a DNA inspired vaccine, a traditional heat killed virus vaccine. Those studies are being conducted around the world. China, South America, the United States. Four or five of these studies are in to phase three trials, meaning they will enroll upwards of 30,000 patients and then accumulate data, and then eventually, hopefully if there's evidence of effectiveness and safety, apply for broader approval from the FDA. When that will happen, October, November, or December, and then how quickly the FDA would make a decision about that specific vaccine is unknown.
Unger: There's been some talk about an emergency use authorization. Any comments on that?
Dr. Bauchner: Yeah, it's become increasingly controversial that the FDA may utilize an EUA for approval of a vaccine. Commissioner Hahn, Steve Hahn, who I've interviewed on my show, indicated over the weekend that he would be open to such an approach to vaccine approval. I think following the hydroxychloroquine and Remdesivir EUAs, people are concerned about this and whether or not the FDA potentially is being influenced by the executive branch. That remains unclear.
There's been a great deal of concern amongst many individuals who are familiar with vaccines and the EUA process that it not be used. I would say we need to see the data. Before we broadly indicate that an EUA absolutely shouldn't be used, I think it's incumbent upon us given the dramatic impact of the pandemic on life that we see the data. I would be reassured if ACIP, the Advisory Committee on Immunization Practices, and the FDA advisory panel on vaccines would make public their recommendation to the FDA after they get a chance to see the data. I'm very concerned that if the FDA approves a vaccine based upon an EUA, but ACIP and the FDA advisory panel disagree, that will create havoc. And so I think it will really be important for the public to understand what does ACIP and this advisory panel believe about vaccine approval.
Unger: Well, thank you. One issue I've seen recently is the question about the after effects of COVID-19 for people who survive. What is the science telling us in terms of lingering symptoms and issues and long-lasting effects? What would physicians need to know about caring for these patients?
Dr. Bauchner: Right. So the early reports are really from people who were infected months ago. And so those have tended to be the frail elderly. So it becomes very, very difficult to know whether or not an infection with COVID-19 that resulted in admission to an intensive care unit and the use of mechanical ventilation when a machine breathes for you, whether or not it really is any different than just general sepsis that wasn't attributable to COVID-19. We know for those patients, and we've had a research letter as well as two opinion pieces about it, that rehabilitation, physical and mental rehabilitation, can take months for those individuals. In symptom reporting data, it seems like people who were infected early on are reporting symptoms out at two, three and four months, but it's likely that the individuals who were frail and infected are going to need far more rehabilitation from this disease than perhaps they have needed from other diseases, given that the course of the intensive care unit has been so long, but whether it's fundamentally different is a little unclear at this point.
Unger: All right. Well, last question. Let's think about what we're just about to enter. The fall, actually. What about public health preparedness and any guidance for the fall?
Dr. Bauchner: Yeah, I think everyone is uncertain. All the experts are uncertain, but they express the same concern. And why do they express the same concern? Firstly, it's clear that the disease waxes and wanes, at least in the United States, and even countries that have done far better than we have had had additional outbreaks. And, and so we know that disease still lasts or resides in the community. The great concern of the fall is two or threefold. First people move inside and we know somehow the disease appears to spread far more effectively inside than outside, which is traditional for respiratory viruses. So that's the first great concern. The second is the flu season will be upon us in the fall. And so you potentially would have flu on top of COVID-19. Now, when COVID-19 became prominent in the U.S. in February and March, it was towards the end of the flu season.
So even though some of the health care systems were overwhelmed, they were seeing the tail end of flu. If in October, there was a tremendous surge in COVID-19 indoors, more spread, people back to college, back to school, not adhering to masks, social distancing, hand-washing, and that was combined with flu. That's the great concern. And so it's just uncertainty. And so people have really asked, experts have really asked, please get your flu vaccine this year, and then try to continue to practice good public health measures, which will be social distancing, masking, and hand washing. It is complicated by schools and colleges.
Now some people have argued we don't know what percent of the U.S. population has been infected. There's about 330 million Americans. I think the minimal number that people say is 10%. So that would be 35 million people. If it's 20% at 60 or 65 million people, it means that number of people by the fall should still be protected so they can't get infected and they can't spread disease. So the only glimmer of hope that I have for the fall is that because maybe 50 or 60 million people have been infected, maybe the fall will not be as bad as people potentially fear, but really people have to get their flu vaccine.
Unger: Good advice. Howard, it is always a pleasure to be able to hear your perspectives. Thanks for being with us here today. 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.
Dr. Bauchner: Thanks Todd. Bye everybody.
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.
