番茄社区

In this exclusive video interview, Jeremy Faust, MD, editor-in-chief of 番茄社区, talks to Anthony Fauci, MD, former director of the National Institute of Allergy and Infectious Diseases (NIAID), about his new memoir, .

In this video, Fauci discusses the novelty of COVID and his masking preferences.

Watch Part 1 and Part 2 of this interview here.

The following is a transcript of their remarks:

Faust: It's a fascinating book, but let's talk about some of the chapters, which could be entire books and are entire books by other people.

The real breakthrough in HIV, let's talk about HIV first. We had AZT [zidovudine, or azidothymidine], the first antiviral, but then the real watershed moment is the combination therapy, Atripla [efavirenz, emtricitabine, and tenofovir]. It's a really moving section of your book where you describe the way you understood what that meant.

Do we have a similar opportunity with other pathogens like influenza, like COVID? Because I feel that the antivirals we have there have become less useful, and yet there's not the same motivation or impetus to say, "No, that's not enough. We need something like an Atripla where it really knocks it into less of a life-threatening fatal disease and more into a chronic infection that you can manage."

Not that COVID is a chronic infection, but the point is, Have we stopped innovating? And how do we get around that?

Fauci: Yeah. Well, the answer is probably a little bit more complicated than we'd like.

As you well know, Jeremy -- I'm telling you something you're entirely familiar with -- they are two different viruses that have two different courses. So when you deal with a virus like influenza or even COVID, when the vast majority of people spontaneously recover even if you don't give them an antiviral, the incentive or the compelling need to have a highly effective antiviral, to put the investment in, and to make sure people take it is very different than HIV. [HIV] is a chronic infection, which if you don't get a really good antiviral, the patient is not going to do well at all. Whereas if you get a really good antiviral, you completely transform the life of a person.

So the incentive and the resources that you would want to put into getting a triple combination, including one that you could put into one pill like Atripla, is far greater than whether you get an antiviral that'll make you 24 hours less symptomatic with influenza when you give somebody oseltamivir [Tamiflu]. So, there's a big difference between those two.

I think that's the driving force of the difference that's put into the resources to get antivirals.

Faust: And you just said something subtle to some listeners, which is that oseltamivir, or Tamiflu, really when you look at the meta-analysis and the Cochrane Reviews, it doesn't do as much as we'd like it to do.

What I would like to know is, why don't we have a yearly platform adaptive trial, something like what we were doing early on in COVID, every flu season to say, "Hey, what if we change the dose or the frequency or add this thing?" Because we do know that there are thousands of lives lost to flu every year, you could do tens of thousands if you do the CDC's way of saying secondary causes leading to other things and things we don't catch.

Why don't we do something like these platform adaptive trials every year, or an Operation Warp Speed on flu vaccines 6 months before? We could use Australian data to make our vaccines. I just feel like we are so locked into complacency with flu. Why don't we do what we did with COVID?

Fauci: I don't disagree with you. I think we can and should be doing more with flu, and some of the things you just mentioned are a good start to essentially really trying to get the optimal, best anti-flu virus [antiviral] that we have as well as the vaccine. I mean, if we had an antiviral that was a real knock-it-dead antiviral the way some of the antiretrovirals are with HIV, that would be a big difference.

I mean, look at Paxlovid [nirmatrelvir/ritonavir]. Paxlovid -- even though right now when you have people who've had multiple infections and multiple vaccines and boosters, the effect of Paxlovid is not as dramatic -- in the naïve population, Paxlovid was dramatically lifesaving.

Faust: Talking about COVID -- it seems like you could write a whole book on that. And yet it's really the last quarter, not even quarter of the book, which is an amazing flex, I have to say. I believe the chapter is called "A Disease Like No Other."

I've spent a lot of time thinking about this. The question is, is COVID special, or are we just really unfortunate to be present at the type of event that has been happening since time immemorial? Which is that when there's a species jump of a novel pathogen to which we have no immunity, something like this happens, and all the what we call 'seasonal coronaviruses' that we now live with had their moment like this.

Fauci: It is entirely conceivable that what we call the common cold coronaviruses now, eons ago came out in a pandemic form and did a lot more damage than the seasonal kind of common cold coronaviruses did.

It was a disease like none other because we haven't had this kind of an impact of a respiratory-borne illness in over 100 years. I mean, this is far worse than the pandemic flu of 1957 [and] 1968. 2009 swine flu was trivial; I mean, it spread a lot, but it was a very, very low degree of morbidity and mortality.

So this was indeed a historic event. We happened to be living through a once-in-a-century historic event. That's what I meant by a disease like none other.

Faust: And do you think that the characteristics of this pathogen are unique in any particular biological way? Or is it more likely that what we learn about this virus -- the most studied virus ever, probably, already -- will teach us about these other ones that we just haven't really figured out?

Fauci: I'm not so sure. I just think what became very clear is that the pathogenic potential for this virus, particularly in susceptible individuals like the elderly and those with underlying conditions, is very, very much different than influenza. It clearly has a higher degree of morbidity and mortality than influenza does and its spread, it has that deadly combination.

Jeremy, I have said to people over the decades -- 10 years ago, 20 years ago, 30 years ago -- [people] would ask me, what's your worst nightmare? What keeps you up at night? I have always said -- in fact, I challenge people go to YouTube and look at what I said 15 years ago -- is that the thing that keeps me up at night is the emergence of a new infection, likely from an animal reservoir, that's respiratory-borne, that is highly, highly transmissible, and has a degree of morbidity and mortality.

Unfortunately, we've just been living through my worst nightmare. It's not a nightmare now, even though COVID is still around, because most of the population in the world -- certainly the overwhelming population, 90-plus percent in the United States -- has either been previously infected more than once or has been vaccinated and boosted so that even though you get infected, the degree of your severity is infinitely less than it was.

I mean, I got infected about 2 weeks ago. It was my third infection, and I had been vaccinated and boosted a total of six times. It was a very, very mild infection. I'm 83 years old. I would think that if I were naïve immunologically, this thing could have killed me. But it didn't even make me significantly ill. A little sniffles, a little sinusitis, and a fever, and then it was over.

Faust: And yet there is a contingent, a lot of readers of my newsletter, who feel left behind, who feel that for them, the risk is still there. And they feel like the changes that the government made in 2022 and ending the pandemic in 2023, the official public health emergency, left them behind. And the only plan that we're left with is a once a year or once every few months booster and let it rip.

What is your message to them, the people who feel like we've forgotten them?

Fauci: The message is that if you are in a risk category, that you have got to take this seriously.

You don't have to immobilize what you do and just cut yourself off from society. But regardless of what the current recommendations are, when you are in a crowded, closed space and you are an 85-year-old person with chronic lung disease or a 55-year-old person who's morbidly obese with diabetes and hypertension, then you should be wearing a mask when you're in closed indoor spaces.

Certainly when you get out on an airplane, you should do that. And you should be careful to avoid crowded places where you don't know the status of other people. And you should get vaccinated and boosted on a regular basis. And for goodness' sake, regardless of what you're hearing about Paxlovid, if you get infected, take Paxlovid.

Faust: I mean, I've written a lot about who I think Paxlovid is a great drug for -- the immune naive and high-risk people. It's a little expensive these days for the risk-benefit, but people are patients, they're not economists. I see your point.

One question people wanted me to ask is what do you do other than whatever booster schedule you happen to be on to avoid this infection? I just spoke to Vivek Murthy who doesn't do a lot of masking, and I previously interviewed his predecessor Jerome Adams, who does a lot of masking because as he is very public and he talks about, he has an immune-compromised spouse. What do you do these days other than keep up with your boosters?

Fauci: I keep up with my boosters, and under certain circumstances I wear a mask.

I mean, I always wear a mask when I'm on a plane, particularly if I'm doing a 5 hour flight to San Francisco or Los Angeles or -- God forbid -- going across the Atlantic on a 8 hour flight or a 9 hour flight. I just wear a mask because, despite what people say about the ventilation and the HEPA filters or whatever on an airplane, you're in a closed tube for 8 hours with people. And to me, I just don't take the chance.

So I wear a mask under certain circumstances. I avoid as much as possible crowded spaces, and I get regularly boosted.

Faust: Yeah. And for me, I'm similar. I pop on the mask when I went to a huge conference and there was a lot of ventilation, and so I wore the mask intermittently, but whenever I go into the restroom, the mask goes on. It has a lot of benefits I've noticed for that. It's lovely. I don't have to smell anything, and don't have to pick up COVID. And the elevators, as you say, even though the air on planes is very, very good, a lot of epidemiologic data tells us that the row behind you or people walking by you or the lavatories are high-risk spaces.

So the answer it sounds like is, you pick your spots.

Fauci: Exactly.

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