Technology. This happens time andy came i t again, whether it be new viral, antivirals, cancers, et cetera. And money came in. The idea wasnt so much on the return. Dr. Anthony fauci is getting an update on potential vaccines for covid19. He is speaking today at an event hosted by the university of Virginia School of medicine. Some zoom webinar housekeeping. Slides at the end of this program provide a resource list, information about continuing education credit for clinicians and a link to our centers website where youll find our speakers biography. The slides also give a link to Medical Center hours youtube channel. Todays program is being recorded and closed captioned and will be posted to youtube within days. Today well handle questions using zooms online q a function. Write your questions there, brief and to the point, please, and well draw from them for our speakers consideration after his presentation. This Medical Center hour joins with Medical Center grand rounds for the lecture where an esteemed science addresses matters in virology and epidemiology. The lectureship honors Professor EmeritusFrederick Hayden and remembers our epidemiologist barry farr. Our 2020 lecture disclosed no conflicts of interest. Here to introduce and welcome todays hayden farr lecturer, dr. Anthony fauci, is dr. Wilkes, dean of the school of medicine. Dr. Wilkes . Thank you very much. To begin, id like to thank dr. Hayden and Margaret Childers for extending the invitation to dr. Fauci, and to dr. Fauci for accepting this invitation during this incredibly busy time period. He is the head of Infectious Diseases at the National Institutes of health and hes held that position since 1984 where he oversees Extensive Research on infectious and immunemediated diseases. As a longtime chief at the laboratory of immunization, dr. Fauci has made several contributions to clinical research. His presentations number in the thousands, and hes one of the worlds most cited by a medical scientist. Recognition for his Outstanding Service includes the u. S. President ial medal of freedom ordered by president george w. Bush. In the medical science arena and the public square, dr. Fauci is lauded for his work in epidemic infectious disease. Two local pandemics bookend his career. In the 1990s, it was hiv aids and now covid19. He was one of the architects for the president s emergency plans for relief, known as pepbar, a program launched in 2003 under president george w. Bush that saved millions of lives throughout the developing world. In 2020, dr. Fauci leads nihs Coronavirus Research effort and is a member of the White House Coronavirus task force. He has become the scientific and legal communitys leading spokesperson on the covid19 pandemic and the critical importance of nonpharmaceutical interventions such as masking and social distancing. As you will see, dr. Fauci is a master communicator on matters of concern and consequence to medicine, health care and society. I must mention on a personal note, i was very fortunate to serve on the niaid National Council in 2006 to 2010 when i got a chance to watch dr. Fauci in person. He was the role model of the scientist, educator and so much more. We are gatefrateful and proud t welcome him to the university of school of medicines 2020 hayden farr lecture. Dr. Fauci . Thank you very much, dr. Wilkes. And thank you to the university of virginia for inviting me to give this hayden farr lecture. Its a great pleasure and an honor to be here with you today. As you can see from this first slide, ive chosen as the title, the Public Health and scientific challenges of covid19. Now, i want to start off by showing the cover of this jama viewpoint which my colleagues and i wrote in january of 2020, literally a couple of weeks after the identification of the novel coronavirus, and i entitled it Coronavirus Infections more than just the common cold, and i did not at all mean to be facetious by this title, but i wanted to bring out to the readers of the viewpoint the fact that for decades and decades weve had experience with coronaviruses. So this was just not something that was totally new to us. This is the coronavirus genetic tree. The human coronaviruses are in red letters, and as you can see, four of them that are shaded in yellow are the four human coronaviruses that are responsible for anywhere from 15 to 30 of the common colds that we experience repetitively each year, usually during the winter months. Now, that was essentially considered really not particularly important series of infections until we got into 2002 and 2012 with the first and then the second pandemic coronavirus with sars, the Severe Acute Respiratory Syndrome, and mers. Some of you might recall that in 2002 would emerge from the quangdung province of china the Severe Acute Respiratory Syndrome which came from a bat, similarly to a cat and then leading to humans with about 780 or so, close to 800, deaths. This was the first of the recognizable coronavirus pandemics. Ten years later, in 2012, another pandemic coronavirus called middle east respiratory syndrome. This was a disease that passed from bats to camels to humans. It did not have the capability of spreading rapidly and still smolders somewhat in the middle east. I might add that sars was contained completely through public measures, identification, isolation, Contact Tracing and quarantine. It had a moderately efficient capability of spreading human to human, but good Public Health measures essentially eliminated it. Now lets get to the present time. The third pandemic coronavirus recognized as an unusual pneumonia emanating out of a wet market in the wuhan province in central china, literally within a period of ia couple weeks in early january, the chinese identified this as another strain of coronavirus that was put up on a public database. As you see here, it is, from a genetic standpoint, quite proximal to the original sars, thus the nomenclature was changed where the original sars became sarscov1 and mers became sarscv2. The original sars virus is called covid19 for coronavirus disease 2019 based on its recognition in december of 2019, and as mentioned a moment ago, the virus itself is referred to as sarscov2. So where are we now with that . This virus, as we all sadly know, has exploded upon our planet to be the worst outbreak of a respiratory infection in 102 years, since the 1918 spanish flu. Currently, as of yesterday, there were 56 million cases and over 1. 3 Million Deaths globally. Unfortunately for us in the United States, we are the country that was hit the hardest and continues to be hit the hardest by this outbreak with more than 11 million cases and now over 245,000 deaths. The current cases per 100,000 is shown here on this colorcoded slide with the usual dark being the worst and light being the lightest. Now, if you look at the risk levels in the United States by county, you can see where we are now in the hottest levels. We are in the processes ill get to in a moment of another resurgence as we enter into the much colder months of the late fall and early winter, and people go indoors much more than outdoors, in their gatherings with friends and with families. I want to point something out that i think is worth noting, is the difference in dynamics, response and baseline between the United States and the European Union. If you look at the blue, you recall europe, particularly northern italy, had their peak a week or two before ours. In fact, the new york city metropolitan area was seeded not from china but from europe, particularly northern italy. When they reached their peak with the blue line, they came down to a baseline that was quite low. In contrast, with the United States burst of cases dominated by the new york city metropolitan area, we never got down to a real baseline. Because as things got under control in new york city, we had outbreaks in various parts of the country, keeping the baseline at about 40,000 until we tried to socall reopen the country and reopen the economy. As you can see from june to august, we had a surge up to about 70,000 cases per day, which after a while leveled off and hung around 40,000 a day. A very bad position to be in when you enter into the vulnerable position of the winter months and people going indoors. As you can see right now, we, and European Union is right there with us, in a major surge of cases where we are now breaking all current records that weve had before with over 1,000 deaths per day over 100,000. The last was about 150,000 cases in a day. I testified before the congress a couple months ago when we were at 40,000 and said if we do not do Something Different and contain this, it is conceivable we would get to 100,000 cases a day. I was severely criticized by some members of the congress for being hyperbolic, and now weve been as high as 180,000 cases a day with hospitalizations over 70,000, and the numbers totality of cases i showed you a little bit ago. So why was there this difference of baselines . If you look in the United States and you look at a parameter of movement, namely how much did you actually shut down, well, in the United States, although we were talking about shutting down following the new york city outbreak, in fact, the percentage of people who visited parks and outdoor spaces that decreased looking at italy and spain as representative of the European Union, we did not shut down nearly as much as they did. We in the dark line, italy and spain in the lighter lines. If you look at presence in the workplace, in other words, how many people didnt go to the workplace, look at the shutdown in spain and italy versus the United States. And then if you look at grossry and Pharmacy Store visits, again, what you can see, that spain and italy shut down certainly much more than we did. So thats a glimpse of the epidemiology. Lets take a look at the virology. So what we see here is that something i told you and alluded to a moment ago. Its a beta coronavirus, an rna virus, so you would expect it to mutate somewhat. There were four structural proteins, the most prominent and important of which is the spike protein, whose receptor domain is shown in green there. Binding to the ace receptor, which is the cellular receptor, which is distributed widely in the upper and lower airways, the g. I. Tract and other organ systems, including the heart. This structure has been now determined in its prefusion form by Barney Graham and jason mclevin and others at the nih and is now actual the prototype immunogen thats used in some of the vaccines that ill talk about in just a little bit. What about transmission . Now, obviously this is a respiratoryborn virus, transmitted by the classic respiratory droplets which tend to drop to the ground within a few feet, hence, the sixfoot distance discussion that we have. However, recently it has been clear that a certain proportion of the transmission do occur for what we refer to as aerosol, namely particles containing virus that are light enough that they stay suspended over time and through various distances for various periods of time. The virus can be found on contaminated surfaces. The role in transmission is unclear, and the virus is found in multiple body fluids. But here again, the role in transmission is unclear and likely not significant. If you look at the risk of transmission, we know it varies by the type and the duration of exposure as well as the viral load in the upper respiratory tract. Transmissions are common among household contacts and in congregate settings and in those Health Care Settings where ppe is not used. Its reasonably good protection if Health Care Workers have adequate and appropriate ppe. But weve seen outbreaks in closed settings, such as cruise ships, Nursing Homes and prisons. The factors that increase the risk are crowded, enclosed spaces with poor ventilation. And, interestingly, it isnt only coughing and sneezing. But its singing, speaking loudly or breathing heavily. This is a typical example that is well known of an outbreak during choir practice in skagit county, state of washington, last march where a single symptomatic person indicated in red infected 87 of the group who were practicing their choir songs in an indoor space. There are also Community Transmissions at family gatherings. Ill get back to that in a moment as well as Church Events where people crowd together without masks. Right now today, in mid to late november, were finding that innocent occurrences such as groups of friends and family, meeting indoors because of the cold weather for dinner, are becoming a major source of asymptomatic spread to the group in the dinner party or in the social event. That seems to be driving infections much more so now than the more obvious settings of bars and other places, which also, obviously, are important but were having the contribution of these family gatherings. The cdc recently published some of the exposures and the risks that you have in different places. Note restaurants in the top there is very high among it, with gyms and bars and various gatherings such as Church Gatherings for social function, particularly in unmasked indoor situations becomes a high risk for transmission. And, again, as i mentioned a little bit ago, this is particularly relevant as we approach the thanksgiving season of which were in and next week being thanksgiving is the concern that as people travel and friends and family gather together, particularly given the percentage of asymptomatic spread, which well get to in a moment, is something that is a cause of concern and families need to make an individual decision based on those in the family that might be vulnerable, such as elderly and those with underlying conditions, again, all of which ill get into in a moment. The fundamentals to prevent acquisition and transmission are fivefold. The universal wearing of masks and face coverings, maintaining a physical distance that i mentioned a moment ago, the avoiding of crowds in congregate settings, particularly indoors and certainly wearing a mask must be done under those circumstances. Doing things outdoors better than indoors, this becomes a little more difficult now as we get into the colder weather. But frequent washing of hands. As i alluded to a little while ago, one of the most unusual aspects of this disease, this infection, is that about 40 to 45 of infected people are without symptoms. And we know now from modeling studies that a substantial portion of transmissions occur from an asymptomatic person to an uninfected individual, which makes Contact Tracing all the more problematic, particularly when you have a high degree of Community Spread the way we have right now. What about the clinical manifestations . Early on in infection, confusing matters is the fact that the presenting symptoms are often indistinguishable from a flu and a flulike syndrome. One exception, though, in a certain percentage of people, there is a curious loss of smell and taste which precedes the onset of the respiratory symptoms. Now, superimposed upon the 40 to 45 of people who have no symptoms at all, those who do, 80 or so have mild to moderate symptoms that does not require hospitalization or significant medical attention, other than staying home and waiting until the symptoms resolve, as significant as they may be. About 15 to 20 of people will have severe or critical symptoms, of which the state mortality rate varies from a few percent among those to about 20 to 25 for those requiring mechanical ventilation. This becomes so confusing when you have a virus, and ive never seen anything like it, where you go from no symptoms at all of a substantial amount to mild symptoms to situations where individuals, because of age or underlying condition, have a serious risk of highmore bidty and mortality. That is just so unprecedented to see a virus that can kill you and can cause severe morbidity and mortality, and yet so many people have absolutely no symptoms at all. Now, who are at risk for this covid virus . You see a dramatic variation between the discrepancy of hospital rate per 100,000 population of younger individuals on the lefthand part of the slide compared to the elderly as you get to the righthand part of the slide. A profound difference. When you talk about people of any age who have certain underlying medical conditions, there are those that are clearly associated with severity of disease, and that is individuals with the conditions on this slide. As you can see, i put these in alphabetical order. But the ones that dominate are obesity, diabetes and chronic obstruct acti obstructive pulmonary disease, as well as smoking. Obesity looms large in this. There are those who may confer an increased risk, but not as clearly as those on the prior slide, and that is hypertension and overweight and cerebral vascular disease and immunocompromised individuals. Those on chemotherapy, individuals who are immunosuppressed for a variety of reasons. Now, if you look at in our country, what percentage of people have an underlying condition . It is significant. About 40 . About 30 of the individuals are obese by the definition of a bmi equal to greater than 30. Thats important. Now, what about the manifestations of severe covid19 disease . The dominating manifestation is the acute respiratory distress syndrome or ars. However, we do see a significant amount of other organ dysfunction. Cardiac dysfunction manifested by arrhythmias, cardiopathy, and interestingly, a hypercoagulability state, as well as a phenomenon that can lead to a stroke in what otherwise appears to be normal individuals. There is also a multisystem inflammatory syndrome in children that has recently been shown in adults which is strikingly similar in many respects to kawasaki disease that has been well described in children for some time right now. Another important aspect of this particular disease is the profound racial and ethnic dispari disparity. Actually, on two accounts. One, the risk of actually getting infected. Because as a group, though you never want to generalize, but in this case its informative. As a group, africanamerican and latinos and native americans have employment, jobs, which most likely put them out into the essential workers where they do things that put them in contact with others as opposed to having the capability in their employment to be going through a computer and doing things virtually the way were doing right now. And also once they get infected, they have much more predominance of the underlying conditions that i mentioned on a prior slide, much more so than individuals in the general population, and certainly among the white demographic group. This is a very impressive slide, i believe, because using the parameter again of rate of hospitalization per hundred thousand population, take a look at the hispanic, latino, american natives, blacks, asians and whites. Its at least a 100,000 population with reflection of the comorbidities that these individuals have. In addition, there is a syndrome that is now being more widely recognized of individuals who clear the virus, and so theyre virologically free, our cured, as it were, however, of individuals who dont get hospitalized, those who may have been home for a couple weeks, three or more, as well as those hospitalized up through and including people requiring intensive care, in the Recovery Period after clearing of the virus, a certain percent, and were trying to figure out what that is, it looks like it may be somewhere around 25 or so percent, but that awaits further study have persistence and when i say persistence, im talking weeks and months or even longer of extremely bothersome, and in some cases, incapacitating symptoms and signs, such as severe fatigue, shortness of breath such as athletic people who now have difficulty climbing one flight of stairs. Temperature disregulation or disautonomia, they call it, as well as tachycardias that are unexplained, or whats called a brain fog or inability to krons trait or focus ones thoughts. Lets move on to therapeutics. We at the nih have put together a Treatment Guidelines Panel thats constituted by clinicians and people who have experience in treating covid19 from throughout the country and even the world. They produce the living document thats accessible online at the link shown on this slide that truly is a living document, being frequently updated as new Clinical Data come out either in established publication or as personal experience and prepublication information. This has been now accessed hundreds and hundreds of times for people throughout the world. Now, two of the drugs that have now been recommended by the treatment guidelines are recommend did he say sir a remdesivir and decxamethasonede. Ill get back to that in a moment. The examples of other investigational therapies are antivirals, bloodderived products, monoclonal antibodies looking quite promising, as a matter of fact, then there are a number of immunomodulators and then a variety of anticoagulants for the hyper coagulant state. Lets look at remdesivir. It was recently reported that a study done as an nih study in the United States and other countries in which hospitalized individuals who had pulmonary involvement were in a randomized placebocontrolled trial and showed a significant diminution in time to recovery, leading now to remdesivir becoming the first covid19 treatment to receive fda approval. Another study that came out from the uk was a randomized placebocontrolled trial of dexamethasone in hospitalized patients requiring ventilation or high flow oxygen, and in this study, it was shown to have a significant diminution of the 28day mortality compared to the placebo control. Of note, there was no benefit for early patients, and in fact, it even made them somewhat worse which actually is in accordance of our understanding of the p h pathogenesis of early versus late disease, where early you want to attack the virus to prevent the aberrant, sometimes aberrant vascular response that occurs later, which is the reason why dexamethasone, which is not an antiviral, but blunts a response is beneficial late but not early. Then with regard to treatment, most recently one of several of the monoclonal antibodies in trial were released a few days ago by the fda for treating mild to moderate covid19 disease in patients older than 12 years old. What is going to shake out, i can assure you, is that direct antivirals and monoclonal antibodies will obviously be good early on in the course of disease and much less effective as we go later into the cause of disease. And then finally, there is vaccines. So what we did a bit ago, my colleagues and i, wrote an explanation in science in may of this year, several months ago, of what were referring to as the strategic approach to covid19 research and development. We have been making Major Investments in six vaccines, which ill get to in a moment. But were talking about the harmoniization where you can have common end points and common parameters that can be used for bridging studies between the various vaccine candidates. So this slide, and i want to go through it slowly with you, represents the three platforms on the left, the developers and the stage of clinical study. So we have the nucleic acid platforms which is moderna, chfrs done in collaboration with the Virus Research center, nih, and biontech. The next is viral vector with astrazeneca which is a chimp adeno with the viral gene. Janssen is using a vector for the spike protein. And then merck with its vsv which you might remember was used successfully in ebola. Then theres the protein subunits with novavax and sanofi. Five of them are actually in phase 3 trial. As i mentioned, two of them, the moderna and the pfizer one, results are in. A week ago, this past monday, pfizer announced that in their trial they had a situation where there were, i believe, four infections in the Vaccine Group actually, five infections in the Vaccine Group and 90 in the placebo, now they came out literally today with the announcement that thats a 95 efficacy. In the moderna trial, which was Just Announced a couple of days ago, they again had the same sort of breakdown, five in the vaccine, 90 in the placebo and 94. 5 efficacy. Of note in that trial a question had been asked, does it really protect against severe disease . In that trial, there were zero severe cases in the Vaccine Group and 11 severe cases in the placebo group. So what were dealing with now is a brand new platform that many people had concern about because it was a new platform which clearly has shown a very striking efficacy signal almost identical in two separate studies done by two separate Companies Using the same platfo platform, and of note, both of them showed a very clear difference in severe disease in the Treatment Group or the Vaccine Group versus the placebo group. Now, we dont want to get ahead of ourselves, because the ultimate decision of how it should be distributed is actually going to be made, as usual, by the cdc with input from the Advisory Committee on immunization practices, or acip. Because of the seriousness of the situation, the National Academy of medicine was asked to weigh in on suggestions for what the distribution should be when you have early on not enough doses to give to everyone. This is their breakdown. Be aware that this may not be the final breakdown because the ultimate decision will be with the cdc. But it looks like somewhere around highrisk Health Care Workers and First Responders in the old age groups as well as those with highrisk co morb comorbidity, and after that you go to phase 2, critical people in the essential industries, teachers, staff, et cetera, et cetera. But, again, this is just what the National Academy of medicine came out with. The final decision will be made by the centers of Disease Control and prevention. One thing you have to mention when youre talking about vaccines is that, as you all know in this audience, that what we showed you just a moment ago was vaccine efficacy in a trial. Whether or not a vaccine is going to be effective in the community is going to be whether or not people take the vaccine. So the two elements are whats the degree of efficacy and whats the uptake . That is going to be a challenge, because as shown here in a recent survey published in science, that 50 of americans plan to get the vaccine, but what about the rest . This is particularly true in the minority population. If you look on the bottom of the slide in the yellow, 40 of blacks say they dont want it, and 32 say theyre not sure, and hispanic, its 23 and 37. This is something that we must address by outreach in the community by individuals that the community actually trusts. So weve got to get that done, and weve got to get it done quickly because we would not want to have an efficacious vaccine that at the population level is not effective because of a lack of uptake. So heres an example of the kinds of prevention modalities that weve all been practicing in the absence of a vaccine. When you have a vaccine thats effective like we have right now, what we want to say is that we cannot abandon Public Health measures, even in the presence of a vaccine thats highly efficacious. A, because its going to take a while to get the community completely protected as you would say. By completely, i mean a veil of protection that truly is herd immunity for this particular infection. So we dont want there to be a signal to the community that, ah, we have a vaccine so let down your guard. No, it should actually be an incentive to double down until we get everybody vaccinated. What i mean by that is that if you have a vaccine thats moderately effective, then what you want to do is you want to make sure you continue in an intense way. But we have a vaccine that is really quite effective now, but you still do not want to abandon so many of those other nonvaccine preventive modalities that we know do work. So i want to end by just putting up this cover of cell of a paper that my colleague david morens and i wrote and published this past summer. The title, as you can see, is emerging pandemic diseases how we got to covid19. And it really is an examination, particularly, of the encroachment of the environment, the humananimal interface that has led to the jumping of species and a variety of other factors. What the bottom line of this is is similar to something that we wrote years ago, and that is that outbreaks and pandemics have been with us forever, even prior to recorded history. History shows us theyve been with us for a while within the context of recorded history. Weve experienced outbreaks now and we will continue to. The critical issue is that we cannot prevent the emergence of a new microbe. But what we can do, by our preparedness, prevent that emergence from becoming a pandemic crisis. That will be the challenge for the future as we learn lessons from the past and we make sure we dont lose corporate memory of what were going through right now as we go into the future beyond the control of this outbreak. Ill stop there. Thank you again, and id be happy to answer some questions. Thank you, dr. Fauci. We really appreciate that, and a wonderful and up to the minute talk, a marvelous scope of coverage of the current situation. We have a number of questions that have come in through the q a, and ive been seeing about how these might group so that we might go through some of the things. I know you actually answered a number of the questions in the course of your presentation, and we appreciate that very much. To start, and partly because of whats been in the headlines of late, questions about vaccines and about vaccination. So within Health Systems like this one and others around the country where were very interested in seeing strong compliance with vaccination once vaccines are available, especially compliance on the part of the front line Health Care Workers, you know, how do we go about assuring that level of compliance . And, you know, what percent of a population, even a subset, will need to be vaccinated in order for there to be a herd immunity achieved . So let me answer the second question first. We dont know exactly what percentage, but the estimates are there somewhere north of 75 , that you would need probably close to 75 to 80 to get more, if not really good, herd immunity. With measles, which is probably the most highly transmissible virus youve ever dealt with, and this one is quite transmissible in its efficiency, that if you get below 90 , you get a lot of herd immunity that could lead to outbreaks. So we would like to see almost everybody get vaccinated with this, even though i think we can certainly end it as a pandemic if we get to 75 , 80 . Thats just a guesstimate. I think well have to wait to see how that shakes out in reality. Now, the question of how do you get people to be convinced to get vaccinated . It depends, really, on what the reason is they dont want to get vaccinated. If its lack of access to the vaccine, youre going to want to give them better access. If its skepticism about the process, like was this rushed, and often we hear and i never liked the terminology that was used, operation warp speed, was something that the designated process that we have now, which has actually been quite successful as tests assessed the vaccines that have now shown high degree of efficacy. But the speed is really because of the extraordinary technology, the success of a novel platform like mrna, the enormous investment in resources to the tune of billions of dollars by the federal government to prepurchase doses so that when the trial showed efficacy, you had the doses essentially ready there for you. That is the reason why it goes so quickly. But to impress upon the public the process as an independent decision, independent evaluation of the data by the data and safety monitoring board, the career scientists at the fda, the scientists like myself that would look at the data, the verpack and the vaccine at the virology advisement committee that the fda grant an emergency authorization or an eua, as well as moving on to a bla, a biological license application, all of that is transparent. And yet, because of all of the noise that comes out of washington, in this divisive time that were living in, some people say, i dont really trust, are they rushing this out to look good. Not at all. I can tell you as a colleague of all of us on this group, this has been an independent decision, and it has been done in the classic way that decisions are made about vaccine safety and efficacy. So, i think if we can educate not only the Health Care Providers who you want to get vaccinated right away, but the general public that youre dealing with a process thats both independent and transparent. Hopefully, we can get a very high uptake of the vaccine, as opposed to that somewhat disturbing slide that i showed you towards the end of the talk. One other vaccinerelated question. Is the vaccine do you know if either one of these vaccines is effective with asymptomatic carriers . Well, what the primary study of the study was symptomatic disease, even if its mild. What were going to be getting by further analysis of the data is whether it actually prevents infection itself. When you see if it prevents infection itself, you can get a better feel for what impact is might have on asymptomatic disease. What it will do, if you look at the imprints on the protocol as its written, if it prevents symptomatic disease but not infection, then what it is, its going to make more asymptomatic carriers. Which is one of the reasons why we say, and have to know whether it prevents true infection is why, when you get vaccinated, that maybe you should still do some of the Public Health measures. Because you may not be symptomatic, but you might be infected. Should we be continuing or even beefing up Contact Tracing in this context, once vaccination is available, also . Well, you know, Contact Tracing got hit badly, when you have in the community, in the community, when you have such communitybased spread which we have like yesterday was 160,000 new cases. That degree of Community Spread makes it very problematic to do Contact Tracing. In fact, you might as well not do Contact Tracing when you have that many infections. However, if a vaccine becomes utilized broadly, the level of background infections is going to be very, very low. Which means Contact Tracing becomes much easier and muff more effective. So if you bring down that baseline, then all of a sudden, Contact Tracing reenters the picture as a very effective Public Health modality. Again, back to Health Systems, should Health Systems be testing their workforce regularly . Including people who are returning to work postcovid, or who are asymptomatic, but positive . And how long is an asymptomatic carrier how long does it take them to clear the virus, do we know that . We dont know the answer to the second question. But we feel it is very, very likely, you know, around 10 to 12 days or so. But, again, thats difficult because we dont know the true scope of the asymptomatic individuals. Be careful when you say clear virus, you want to talk about clearing replication virus, were finding people when you do pcr, they have a high level psychothreshold in the 30s, 35, 36, which is essentially the functional a equivalent of negative in that, theyre not transmitting even though you do pick up by pcr. But getting back to the first part of your question, i strongly believe that we should do surveillance testing intermittently in various groups, that we want to get a handle of whether or not were having silent spread. And i would think that would be true of Health Care Workers. You know, i still see patients at the nih clinical center. And i get tested frequently. Every time i walk into the building, really, i go up and get a quick test. So, i so far now have been tested for covid 54 times. So, some questions, too. Im glad that you emphasized that even with availability of vaccine, once those are in the works the continuation of some of the nonpharmaceutical interventions. So about masks, and one practical question, if a speaker, a creature or somebody talking in congress is unmasked, but 20 feet away, but indoors, is that okay . Or should we be expecting to see them masked our our protection . You know, thats really a great question that, you know, theres not a Scientific Study that shows that. But if you believe, which i do, that aerosol is a component of transmissibility. What i dont know is how much of a component. But if that being the case, when you are indoors, even if youre 20 feet away in a closed space with poor ventilation, it is conceivable with aerosolized spread that you could have an aerosol a virus thats aerosolized that can go that 20 feet. Its probably unlikely. You know, we havent seen outbreaks of situations that was indoors, where everyone was masked. That when they went to the microphone, when they took the mask off, that there was any spread under those s circumstances. So if it does occur, it is likely rare and unusual. Though, if you really want to be careful when you have the kind of hot transmission like were having now in the country and youre indoors, then it might be the better part of hour, even though when youre speaking in a smaller room, maybe not such good ventilation, that you might want to keep that mask on because of the aerosol. So, weve also had a cluster of questions that look forward, particularly, into the transition to the next administration. You know, questions about will covid policy and things change with that change. But i think, also, theres a question about what about federal versus statebystate protocols for precautions, but also now, also for the protocols for vaccination . And distribution of vaccination. Yeah, a bunch of questions in there. Let me just, i think, focus on the important one. Is that i have always been in favor of recognizing the individual differences from state to state. But there are some times when you have a situation like were in now, where strong recommendations from centrally to the state should be made. States dont like to be mandated for anything nationally. But you can make a strong recommendation about anything from Public Health measures to the distribution of vaccines. Even though, at the local level, thats the final decision to do. I think we should try and give some pretty clear guidance about everything from the Public Health components of it, to how you distribute the vaccine, according to the recommendations of the cdc. So, you want to give some flexibility to the states. But they often even ask for some significant guidance. So, were coming to the close of our hour, and ill just understanding that this is a topic thats going to continue for a while. Your thoughts on what we have learned thus far from covid and its management that will help us not only now, but in the next pandemic, because as you said, there will be more . Yeah, i think what we learned is something that we learned with every outbreak, and that is, pandemics occur. They take you by surprise. Hopefully, not by surprise with regard to preparation, but theyre unpredictable. And they evolve. I mean, i think we need to realize that when an outbreak occurs of a brandnew infection, weve got to be humble and weve got to be monitoring things really carefully and flexible, in that what you think you might know on day one, two, three, four, five may not be what actually is happening two or three months later. I refer to, for example, our fully not realizing the extent asymptomatic spread early on. Thinking it was classic sick person transmits it to an uninfected individual. As opposed to the degree of silent Community Spread. We didnt know that in the beginning. We know it now. But i think one of the lessons is, keep an open mind, be flexible and be humble in that you dont know everything, literally, in the beginning of an outbreak. Youve got to learn as you go along. Sounds like wisdom for now and the future. Dr. Fauci, we thank you so much. We are so grateful for your time with us and for the very good work youre doing. Many of our questions began with an enormous thanks for your great public service. As a scientist and as a spokesperson. For this. So, with this, we close not only this Medical Center hour, but the Medical Center hour series for the fall semester. Medical center hour will return in the new year february 3rd, 2021. Thank you, all, for joining us today. And thank you, again, to dr. Anthony fauci. Thank you, marcia, appreciate you being with us. Cspan3 is live with an update from covid19 officials with a report from the health and Human Services department. Were joining this in progress. These to be analyzed on a daily or by daily basis, as soon as signals appear, they will be analyzed exactly in Clinical Trial and conclusions drawn. And it is important that were able to accelerate the vaccines to the extent we have done. Because, as you know, unfortunately, we have 150,000 people infected every day, and