With China taking extreme measures to prevent further spread of COVID-19 and previously quarantined American cruise ship passengers returning to the United States, Dr. Anthony Fauci, America’s point man on infectious diseases, spoke with the USA TODAY Editorial Board on Monday about the latest coronavirus developments. Fauci, 79, has been director of the National Institute of Allergy and Infectious Diseases since 1984. Questions and answers have been edited for length and clarity:
Q. What’s the status of the COVID-19 outbreak?
A. China is in very difficult straits. We have now over 70,000 cases there and (nearly 1,800) deaths. The rest of the world has about 30 countries that have a total of about 500 cases and three deaths. We only have 15 cases in the United States, 13 of which are travel, two of which are spouses of the travelers. As of Monday morning, we now have 14 additional ones, because we flew in the people from the (Diamond Princess) cruise ship.
Q. Was it a mistake to quarantine the passengers aboard the Diamond Princess in Japan?
A. The original statement, which is not unreasonable, was that the best thing to do with these people was to keep them safely quarantined in an infection-control manner on the ship. As it turned out, that was very ineffective in preventing spread on the ship. So the quarantine process failed. I mean, I'd like to sugarcoat it and try to be diplomatic about it, but it failed. I mean, there were people getting infected on that ship. So something went awry in the process of quarantining on that ship. I don't know what it was, but a lot of people got infected on that ship.
Q. Why were the 14 passengers who tested positive, as they were being evacuated, let back into the United States on the charter flights?
A. We had a lot of discussion — intense, difficult, into-the-night discussion — about what's the safest thing to do. Literally every hour there's another four or five people infected. Right now, I think the number is 454 people who were infected on the ship. It got to the point where (we decided) we've got to get them off that ship.
Q. Were they allowed back because they weren’t showing symptoms?
A. No. It was a really, really tough decision made late into the night, which is why if I have bags under my eyes, you'll know why. It was a tough situation. They were thought to be negative. And as they were there on the bus, getting ready to go, the tests came back that they're positive. So you have a choice. What do you do? Do you get them off and have them stay in Japan, or do you put them in a certain compartment on the plane, which was described to us in great detail on this multicontinent conference call, where it would almost be like being in a containment laboratory.
Q. So that was the deciding factor?
A. The critical issue is that they really wanted to get them out of Japan and to our own facility to be treated here, because it was amazingly stressful to them. Many of them were elderly, many of them had underlying conditions. They just wanted to get home. And we felt it was safe enough on the plane to get them home without infecting anybody else.
Q. When you make these tough calls, like the one last night, who is the ultimate decider?
A. The ultimate decider is the State Department. When you're dealing with the disposition of American citizens who are in a foreign country, the ultimate decision is the State Department. They are very good about taking advice from medical authorities. But the ultimate decision is the State Department.
Q. Some Americans are electing to stay on the ship. What do you think about those decisions?
A. We are men and women of free will. People will do what they want to do. I mean, there's a lot of different motivations that people have. I'm not going to be out second-guessing people. Some people are exhausted. They don't want any part of it. Just get me off. I think the ultimate intent of the Japanese is to get everybody off that ship, one way or the other, and figure out what the disposition is going to be.
Q. Do you expect additional cases among the people who were evacuated?
A. We are anticipating that there were people who were negative who would turn positive because they're incubating it. So if you come back and say there were 14 people that were infected and they say oops, there's 16 people, I wouldn't be surprised about that for a second.
Q. What happens next?
A. If you're infected, you're not really, technically quarantined. You are isolated and cared for your infection. If you are exposed and we're trying to find out if you're infected, then you are quarantined. So quarantine is someone who's suspected of being infected, whereas isolation of someone and taking care of them is when they are infected. For 14 days, the whole group is out of action.
Q. How sure are we about the 14 days?
A. Pretty sure. (The incubation period) is two to 14 days. The mean is 5.2. So you've really given an extra cushion to 14.
Q. How deadly is this virus compared with the flu?
A. The mortality rate of seasonal flu is about 0.1%, 0.2% at the most. If you look at the new coronavirus, and you do the math, it's sticking right at 2%. But (the actual rate could be much lower) because there are many, many either asymptomatic or minimally symptomatic people (in China) that don't get counted in the denominator.
Q. Is there any evidence that the Chinese are fudging the numbers?
A. I don't think so. I think that's real. I think that, as I mentioned, I don't think it's 2%. I think it's less because they're not counting a lot of people who are asymptomatic. But the fact that it stays at 2% is just I mean, you just, do the math. I don't think they're fudging the numbers.
Q. How does COVID-19 compare with severe acute respiratory syndrome and Middle East respiratory syndrome?
A. SARS, which we all remember from 2002, was not nearly as transmissible as this. SARS had 8,000 cases in over a year. Right now, in two months, we have almost 10 times as many cases as SARS. But the SARS mortality was 9% to 10%, and the MERS was about 36%. It isn't always this way, but with respiratory-borne viruses, usually the more transmissible you are, the less the mortality, and the higher the mortality, the less transmissible.
Q. Is this a pandemic?
A. The World Health Organization is not declaring this a global pandemic, because there isn't a lot of sustained transmission throughout the world. We're really kind of at that brink. If China can contain their outbreak much better than they are and prevent wide distribution, we could avoid a global pandemic. If they don't, we're gonna have a global pandemic. We're teetering right on the line of what's going to happen.
Q. Is there a hard definition of a pandemic?
A. It really is soft. There's no number. It really is open to some interpretation. The general interpretation is that when you have a new pathogen that's spreading widely throughout multiple regions of the world in which there is substantial, sustained transmission (then you have a pandemic).
Q. Could there be a lot of cases in the U.S. that we don’t know about?
A. The CDC (Centers for Disease Control and Prevention) is trying to find this out. Are there under-the-radar infections in this country that have gotten in before we did the airport funneling and things? They're doing a sort of a sentinel surveillance in five cities —- New York, Los Angeles, San Francisco, Seattle and Chicago — of people who come into clinics with flu-like symptoms but who don't test positive for the flu.
Q. How reliable are these tests? Are there lots of false positives or false negatives?
A. They're actually pretty good. The tests that the CDC has developed and that we're starting to amplify to be able to send out to the different health clinics, if you're positive, you're positive. It could be if that you don't quite have enough virus to show, it could be negative. But that isn't really a false negative because the virus isn't high enough. It's pretty good sensitivity and specificity. There was a lot of misinformation that the test isn't really very good. But if I walk in and (the test shows I’m positive), I'm infected.
Q. Can you catch COVID-19 from someone who doesn’t have symptoms?
A. In respiratory-borne illnesses, the driver of outbreaks are usually the people who have symptoms. I'm sick. I'm in the subway. I sneeze on you. I cough on you. There is asymptomatic transmission in other infections. The extent to which that is impacting the coronavirus epidemic, we don't know. But we're having early case reports which are now making it pretty clear that some degree of asymptomatic transmission occurs.
Q. What else don’t we know?
A. Another thing that we don't know is why, with a respiratory-borne illness, are there virtually no children getting infected. I mean, there are no cases of kids less than 15 years old. Does that mean for some strange reason they're not getting infected, or the illness is so mild in children that we're not noticing it? It's very clear the median age is 56 or 59.
Q. Who is at greatest risk?
A. It's almost identical to what we're seeing with influenza. If you're elderly, have chronic lung disease, congestive heart failure, diabetes, obesity — all of that makes you much more likely to have complications, if not death.
Q. So why do some relatively young and healthy people like Li Wenliang, the 34-year-old Chinese doctor who tried to sound the alarm, die from COVID-19?
A. Every once in a while, you're going to get an outlier, someone who otherwise looks perfectly healthy. Most likely, their genetic makeup doesn't allow them to respond adequately to flu.
Q. How confident are you that the Chinese are doing what needs to be done?
A. They're doing things that have completely broken the paradigm of how you respond. They have been, in a draconian way, shutting down everything. They have locked down 50 million people, including the entire 11 million-person city of Wuhan. They will not allow anyone into Beijing unless they have a 14-day quarantine. They're essentially locking people who test positive in their houses. I mean, they're doing things that are almost unheard of in the annals of public health.
Q. Will it work?
A. As unusual and extreme as it is, it might actually, ultimately, have an effect. There's this report that the number of new cases for the last couple of days in China has gone down. I don't put much strength in that unless I see it really start to come down and down and down. A few days of going down doesn't mean anything to me. But if it continues to go down, that might be a signal that they're having an effect of what otherwise would be extreme means.
Q. That would never happen here, would it? Locking down 50 million people?
A. No, not a chance. It would never happen.
Q. Are you getting the information you need from the Chinese?
A. When you talk to the scientists, the people that I've known for years if not decades, you get what you want. But the numbers in the official proclamations don't come from them. They come from higher authorities. Right now, they are saying that they're going to severely punish anyone who doesn't act in a completely transparent way. So if you're holding things back, you're going to be disgraced. You're gonna go to jail. Now, if that's true, then we're getting what we want.
Q. Why is the mortality so much higher in China?
A. We think it is that when you're infected outside of China, we know much more the scope of who's infected. When a travel-related case comes in, it's an index case and you track their contacts. So you get a much more accurate account of the numbers. Whereas in China, there are probably so many more people who are infected that are either minimally symptomatic or asymptomatic that they don't know it.
Q. Some people are afraid they can catch the virus from goods made in China.
A. Whenever you have the threat of a transmissible infection, there are varying degrees, from understandable to outlandish, of fear. Inanimate things, like something somebody puts in a container and goes by ship across the Pacific Ocean — no, you're not going to get coronavirus from that.
Q. Bottom line, how worried should people in America be?
A. The risk of coronavirus in this country is still relatively low, but, as I said about the possibility of emerging into a pandemic, this could change. As of today, on the 17th of February, the risk is really relatively low. But we, the public health officials, have to take this seriously enough to be prepared for it changing and there being a pandemic.
Q. Is the seasonal flu a bigger concern?
A. We are right now in the middle of an influenza outbreak, which is having its second wave. We have more kids dying of flu this year, at this time, than in the last decade or more. Then it went down, and now we're having a second wave of H1N1 flu again, which is particularly serious in children. So right now, at the same time people are worrying about going to a Chinese restaurant, the threat is that what we have in this country, we're having a pretty bad influenza season, particularly dangerous for our children.
Q. How can you protect yourself against both flu and coronavirus?
A. Do what we tell you to do all the time. Wash your hands as frequently as you can. Stay away from crowded places where people are coughing and sneezing. If, in fact you are coughing and sneezing, cover your cough. All the things that we say each year. That's the thing we should be doing right now. But the danger of getting coronavirus now is just minusculely low.
Q. Do you subscribe to the theory that COVID-19 originated at a food market in Wuhan?
A. The original cases, reported on December the 31st, about 27 cases, were epidemiologically linked to a specific Wuhan fish market. However, when you went back and did the tracing and the sequencing of the evolution of the virus, it almost certainly did the same thing as SARS did. SARS went from a bat to a civet, which was served at festive meals in China in 2002, to a human. This is fundamentally a virus that likes bats.
Q. So it didn’t start in the market?
A. Almost certainly, somewhere, somehow a bat infected an intermediate host who infected a human. What epidemiologists feel is that the market was an amplifier of something that was already going on. So it didn't necessarily start in the market, but when people congregated in the market they got infected from each other as opposed to all of them getting infected from whatever animal there was in the market.
Q. What about the conspiracy theories involving a bioweapons lab near Wuhan?
A. There isn't a bioweapons lab in Wuhan. There's a biological containment that's studying countermeasures against natural outbreak. Whenever you have a virus that you know has been studied in a lab, and virtually every virus is studied in a lab, and there's an outbreak of a new virus, there's always the suspicion that something either accidentally or deliberately was released. So, I mean, I can't say absolutely that's not the case. It is extremely unlikely that that's the case, but you can find out if it is or not. And there are people who are actually looking at that right now. So I think we're going to get some sort of an answer about that.
Q. How bad is this going to get?
A. I think we are going to know in the next month or so what direction this is going in China. As the weather gets warmer, it is conceivable that the dynamics will shift. It's never going to disappear, because it's 80 degrees in Singapore and they're having infection there. But the dynamics can shift. Instead of accelerating it might start to go down. If that's the case, it may be by the time the fall comes that it'll be just like being in the United States.
Q. Do you see any risk to the Summer Olympics in Japan?
A. Gee, I don't think so, but I don't know. That would be a stretch of a guess for me to figure out. I mean, if we're in a global pandemic ... I don't know.
Q. How close are we to a vaccine?
A. We already started on the development of a vaccine. We're going to have a Phase 1 trial to determine safety and whether it induces the kind of response that you would predict would be protective in about two months. It usually takes about three months. That would be the fastest in the history of vaccinology of ever going from knowing what the sequence is to going into a Phase 1 trial.
Q. After that?
A. It takes about three months to determine if it's safe and if it induces the kind of response that you would predict would be protective. So now you're six months out. Then you go into a Phase 2 trial. Phase 2 trials, instead of involving 10s and 20s of people, involves hundreds and thousands of people. That usually takes, if the outbreak is still ongoing in a roaring way, at least six to seven months. If the outbreak peters out, it may take a year to determine if it works. So from today, the earliest you could possibly say you even have a candidate that you could start revving up to make enough to give will be at least a year to a year-and-a-half. The solution to the containment of this current outbreak will not be a vaccine. A vaccine will be important if this goes away and then comes back next season.
Q. We see everyone walking around in masks. Do they work?
A. A mask is much more appropriate for someone who is infected and you're trying to prevent them from infecting other people than it is in protecting you against infection. If you look at the masks that you buy in a drug store, the leakage around that doesn't really do much to protect you. And for example, people start saying, should I start wearing a mask? Now, in the United States, there is absolutely no reason whatsoever to wear a mask.
This article originally appeared on USA TODAY: New coronavirus: What don't we know? Dr. Anthony Fauci has the answers