Public health measures, especially physical distancing and wearing face masks, have made a big difference in preventing the spread of COVID-19, but “we’re far from out of the woods” in terms of ending the pandemic, Anthony S. Fauci, MD, Director of the National Institute of Allergy and Infectious Diseases (NIAID), said during an address to attendees of the American Urological Association’s 2020 Live Virtual Experience.
“We know now that the large-scale anti-contagion policies have significantly diminished the number of infections as well as the number of deaths,” Dr Fauci, who is a member of the White House Coronavirus Task Force, told listeners during the June 27 presentation. “It is felt that the shutdown, the wearing of masks, the staying-at-home orders over a 3-month period have averted about 60 million infections in the United States and prevented 3.1 million deaths in 11 countries in Europe.”
The risk of person-to-person transmission is high when people are less than 6 feet apart, Dr Fauci said. The virus spreads via respiratory droplets and infected surfaces, door knobs, and food utensils, he said. In addition to keeping 6 feet away from other people, preventive measures include wearing face masks, avoiding crowds, diligent hand washing, and regular cleaning and disinfecting frequently touched objects, he said.
Dr Fauci cited a systematic review and meta-analysis published recently in The Lancet showing that physical distancing of 1 meter or more was significantly associated with 82% decreased adjusted odds of transmission of SARS-CoV-2, the virus that causes COVID-19, compared with a distance of less than 1 meter.1 The protective effect doubled with each additional meter of distance. Face mask use was significantly associated with 85% decreased odds of transmission. Use of eye protection reduced the odds of infection by 78%.
In a discussion about vaccine development, Dr Fauci noted that multiple candidates are under investigation and that an effort to “harmonize the approach” has been implemented. This includes having a common data and safety monitoring board, trial protocols that ask the same questions, common primary, secondary, and tertiary end points, and common laboratory tests. Phase 3 trials of vaccine candidates are expected to start this summer, he said, adding that “we are cautiously optimistic” that if the trials go well a vaccine will be available by the end of this calendar year and first quarter of 2021 and beyond. One of the vaccines is based on the incorporation into messenger RNA an RNA sequence that encodes for a form of the spike protein. The messenger RNA is injected into muscle tissue, where the protein is expressed and antibodies are produced in response. Study results so far show encouraging titers of antibodies induced by the vaccine, Dr Fauci said.
The COVID-19 pandemic is the third outbreak of severe illnesses due to coronaviruses. The first one was the original SARS (sudden acute respiratory syndrome) outbreak that began in November 2002, when cases of an atypical pneumonia were observed in the Guangdong Province of China. The original SARS cases had a high case mortality rate (10%), but the virus did not transmit easily from person to person. Containment strategies such as isolation of cases, infection control, quarantine, travel advisories and screening at airports were successful in ending transmission, Dr Fauci said. From March 2003 through June 2003, SARS cases peaked, then diminished, and then “literally disappeared, because it had no place to go, no one to infect,” Dr Fauci said. An investigation revealed that the virus jumped from a bat to a civet cat, and civet cats, which are sold in wet markets in China, are consumed.
The second outbreak occurred in 2012, when MERS (Middle East respiratory syndrome) emerged. This time, the virus jumped from a bat to a camel to a person, and then spread from person to person. MERS had a high case fatality rate (37%), but, like the original SARS virus, was poorly transmissible from person to person. “It did not adapt itself as well to humans,” Dr Fauci said.
SAR-CoV-2 is more closely related phylogenetically to the original SARS coronavirus than it is to the MERS coronavirus and others, and “pretty far away” phylogenetically from common cold coronaviruses. To enter cells, the SARS-CoV-2 spike protein binds to ACE2 receptors, which are relatively widely distributed in the upper airway, gastrointestinal tract, lungs, and elsewhere, Dr Fauci explained. Compared with the original SARS and MERS coronaviruses, SARS-CoV-2 is far more contagious.
“It has exploded throughout the planet in a way that is really unprecedented within a period of just a couple of months,” said Dr Fauci, noting that close to 10 million cases and half a million deaths have occurred worldwide.
To date, about 2.5 million cases of SARS-CoV-2 infection and 125,000 related deaths have been reported in the United States, he said.
“We are experiencing an historic outbreak right now comparable in some respects to the 1918 pandemic flu, and it isn’t over yet,” Dr Fauci said.
A perplexing aspect of COVID-19 is the wide spectrum of manifestations, he said. Anywhere from 20% to 45% of cases are completely asymptomatic, which makes contact tracing extremely difficult and confounds attempts to control the spread of the virus, he said. Some patients experience mild illness, whereas others are bedridden for weeks or require hospitalization, usually for respiratory problems that may require oxygen, intubation and ventilation. Some progress to acute respiratory distress syndrome (ARDS), sepsis, and death. That a single pathogen can cause such a wide variation of illness is unprecedented, according to Dr Fauci.
Fever is present in the overwhelming majority of cases. Cough, anorexia, fatigue, muscle aches, and shortness of breath are common. An interesting novel finding, he said, is the loss of smell and taste that precedes development of disease. Risk factors for severe illness include older age, hypertension, diabetes, and obesity. Young, healthy patients with COVID-19 have a low likelihood of requiring hospitalization.
Severe disease develops in about 14% to 15% of patients, Dr Fauci said. The case fatality rate among those with severe disease ranges from 2.3% to 15% depending on patient age and underlying conditions.
Dr Fauci spoke about promising findings from 2 recently published randomized, placebo-controlled studies of potential treatments for COVID-19. One study of about 1100 patients with COVID-19 hospitalized with pulmonary disease found that treatment with the antiviral agent remdesivir was associated with a 32% reduction in time to recovery compared with placebo. The other study examined the effect of dexamethasone in hospitalized patients with COVID-19. The cohort include patients who required ventilation or oxygen and those who did not require respiratory support. Dexamethasone therapy was significantly associated with a decrease in death rate among patients requiring ventilation or oxygen, but not among those who did not require respiratory support. The difference in effect makes sense, according to Dr Fauci. Earlier in the course of disease, immune suppression of virus is important. With more advanced disease, such as ARDS requiring ventilation, “it’s less the virus than it is the overwhelming inflammatory response—the cytokine storm—that damages tissue.”
Commenting on Dr Fauci’s talk, Adam Feldman, MD, MPH, a urologist and urologic oncologist at Massachusetts General Hospital in Boston, said the NIAID director touched on key points that greatly impact the urologic community. One is that physical distancing and use of face masks are the cornerstone of prevention, and another is the recognition that at-risk patients are typically older with comorbidities, including hypertension, diabetes and obesity. These patients are common in a busy urologic practice, Dr Feldman said.
“Given the nature of what we do, there comes a risk of infection, and we have to continue with precautionary measures in order to protect patients and all providers,” Dr Feldman told Renal & Urology News. “At Massachusetts General Hospital Department of Urology, we’ve implemented measures, such as severely limiting in-person visits and relying heavily on virtual care, maximizing efficiency for necessary in-office procedures, and, during the height of the pandemic, conducting office procedures for the practice in a shift-work manner.” All surgical patients are tested for COVID-19 48 to 72 hours ahead of surgery, he said.
Dr Feldman noted that continuing virtual care, whenever possible, is critical for both patient and provider safety and to maintain social distancing until a vaccine is ready.
“As we look at the road ahead, the urological community will have to continue sharing best practices and institution guidelines for patient/surgical procedure selection process in order to come up with the best care for all of our respective patients,” Dr Feldman said.
Chu DK, Akl EA, Duda S, et al. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: A systematic review and meta-analysis. Lancet. 2020;395(10242):1973-1987. doi: 10.1016/S0140-6736(20)31142-9