In late October, healthcare professionals in infectious disease, healthcare epidemiology and prevention gathered virtually for IDWeek 2020, perhaps one of the most consequential conferences in the Infectious Diseases Society of America's 57-year history.
Day one began with a global event, "Chasing the Sun," as IDSA joined with partners around the world for 24 hours of global perspectives and data on COVID-19 - from clinical presentation, diagnostics and therapeutics to infection control, mitigation strategies and vaccine development. Kicking off the special event, Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases for the National Institutes of Health, discussed the current understanding of COVID-19 and where the United States stands in the fight against a virus that had killed more than 230,000 Americans at press time.
Coronavirus & SARS-CoV-2
Fauci began his presentation by noting the scientific community has long experience with coronavirus in humans and in bats and other intermediate hosts. In 2002, he said the world had its first experience with the pandemic coronavirus SARS with another pandemic potential coronavirus in 2012 with MERS.
The current pandemic coronavirus was recognized at the end of December 2019 as a disease and was confirmed by the Chinese in the first week of January 2020 as yet another strain of coronavirus. As the current strain is proximal to the original SARS coronavirus, it has led to a change in nomenclature with the 2002 outbreak being called SARS-CoV-1 and the current strain as SARS-CoV-2.
"As of two days ago, the numbers throughout the globe have been stunning, making this already the most disastrous pandemic that we have experienced in our civilization in over 102 years," said Fauci. At the time of his talk in the third week of October, there had been more than 40 million cases and over 1.1 million deaths globally.
COVID-19 in the US
"Unfortunately for the United States, we have been hit harder than virtually any other country on the planet," he said.
Comparing the United States to the European Union, which has a larger population than the US, Fauci noted tracking shows the EU peaking a little before the US in March, driven by the outbreak in northern Italy, but then coming back down to a baseline under 10,000 new cases for the seven-day rolling average. "The situation in the United States was a bit more complicated," he said.
"We had a major peak slightly after the European Union driven by the outbreak in the New York metropolitan area, which at one point early on accounted for about 40 percent of all the cases, hospitalizations and deaths in the United States." However, he noted, as the New York area went back down to a low baseline, the rest of the country did not. "We began seeing outbreaks throughout the country, as you might expect with a pandemic."
Unlike the EU, the US never saw the baseline dip below 10,000 cases. Fauci said between April and June, the country's lowest mark was at 20,000 cases for the seven-day rolling average before the country began seeing increases as operational restrictions were lifted from businesses.
Although cases did come down for several weeks, the US trajectory is on the rise again, much like the EU, which began sharply spiking in mid-October, surpassing new cases in the United States. However, by the end of the month, the US was seeing record-breaking numbers of new cases entering the winter, as well.
Transmissibility & Severity
COVID-19 is spread by respiratory droplets from person to person. Recent evidence points to aerosols that remain in the air over considerable time and distance as a component of the transmission equation. Similarly, contaminated services do occur, but Fauci said the role is likely not nearly as much as person-to-person transmission.
"There are five major principles that I talk about all the time in preventing acquisition and transmission of SARS-Coronavirus-2," Fauci stated. "The universal wearing of masks or cloth face coverings; maintaining physical distance where possible; importantly, avoiding crowds and congregate settings, particularly indoors; trying to do things outdoors much more preferentially than indoors; and frequent washing of hands."
He continued, "These five public health interventions alone have been shown in multiple setting to have a major impact in preventing surges and diminishing surges after they've occurred."
For those who do test positive for COVID-19, Fauci said 40-45 percent of people exhibit no symptoms at all. "But those that do, about 81 percent are mild to moderate where about 15 to 20 percent are either severe or critical with a case fatality rate that varies from a few percent to up to 20 to 25 percent for people requiring mechanical ventilation," Fauci explained.
Fauci said the scientific community is learning more about manifestations of severe disease and lingering effects. While the most common is acute respiratory distress syndrome (ARDS), he said clinicians are seeing cardiac dysfunction, neurological disorders, hyperinflammation, hypercoagulability, acute kidney injury and multisystem inflammatory syndrome in children (MIS-C).
Fauci added another critical part of the current pandemic is the "extraordinary racial and ethnic disparity" of COVID-19. He said the problem is two-fold with incidence of infection being linked to the front line work done by many in minority communities that increases exposure to the virus, as well as the prevalence of underlying comorbid conditions that predispose these populations to more severe disease.
Therapeutics & Vaccines
"The NIH has formed an expert US Treatment Guidelines Panel, which meets regularly and forms a living document online," said Fauci. The information is available online at covid19treatmentguidelines.nih.gov and includes expert insights from clinicians around the country and a look at the latest literature.
As for therapeutics, Fauci noted, "Some of the recommended ones you know are remdesivir and dexamethasone. Remdesivir is shown to have been effective in diminishing the time to recovery in hospitalized patients who have lung involvement," he said. A randomized, placebo-controlled dexamethasone trial showed patients hospitalized with very advanced disease requiring mechanical ventilation, as well as those with high-flow oxygen, saw significantly diminished 28-day mortality.
"However," he continued, "there are a number of other investigational therapies aimed at early disease." While more research is required, he said there have been some encouraging results with a number of interventions including convalescent plasma, hyperimmune globulin, monoclonal antibodies and immunomodulators such as those that block inflammation and cytokine inhibitors.
"We here in the United States have taken a strategic approach to COVID vaccine research and development, which means that we've made major investments in six companies either in facilitating the development of clinical trial or of buying a product to be ready after the clinical trials are over," Fauci explained.
The three major platforms being pursued are nucleic acid, viral vectors and protein subunit. With five already in Phase 3 trials, Fauci said, "We feel confident that we'll have an answer likely in mid-November to the beginning of December as to whether we have a safe and effective vaccine."
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