NAS COVID19 Update
The National Academy of Sciences in the US holds an annual meeting of its members. This year, the 157th such meeting was held online in response to the COVID19 outbreak, and for the first time ever, the general public was allowed to view the plenary session talks.
The first day included a two-hour panel discussion, with each participant joining remotely, providing an update on the COVID19 outbreak by some of the world’s top scientists. Participants included:
- Dr. Victor Dzau, President of the National Academy of Medicine, moderator;
- Dr. Jeremy Farrar, Director of the Wellcome Trust;
- Dr. Anthony Fauci, Director, NIAID;
- Dr. Sanjay Gupta, Chief Medical Correspondent at CNN;
- Dr. George Gau, Director-General of the Chinese Center for Disease Control and Prevention;
- Dr. Susan Weiss, Professor of Microbiology at the University of Pennsylvania; and
- Dr. Richard Hatchett, CEO of the Coalition for Epidemic Preparedness Innovations.
I watched the whole thing. I thought it interesting enough that I recommend it generally. Here, I’ll provide some annotation in case you want to watch specific parts of the panel without spending the entire two hours on it.
Dr. Dzau opens the session with an overview of the agenda and a summary of the participants. This is pretty skippable.
At about 13:50, Dr. Farrar from Wellcome gives an overview of the current state of the global pandemic. He talks about its zoonotic origin — a bat pathogen, but with an intermediate species between bats and humans that we haven’t figured out yet. He talks about communicability and the viral load in sufferers over time, and then give a summary of infections globally. This section ends with a few cautions: We’re still early in the pandemic and will see subsequent outbreaks in places that have cases now; the global south, and particularly Africa, South America and South Asia have so far not seen the concentrations that China, North America and Europe have, and it’s likely to be very bad there.
At about 22:50, everybody’s favorite White House briefer, Dr. Fauci, starts talking. His session is primarily on the state of the outbreak in the US. He provides a brief history on infections regionally, including the sequencing work that suggest that the New York outbreak originated in Europe, and the West Coast infections came from China. Fauci talks about disparities in cases among different racial and ethnic groups, highlighting the disproportionate share of infections in African American communities.
He spends some time as well on the trials underway for possible treatments, including remdesivir. I was surprised at the large number of clinical trials that are active globally. I think I’m pretty up on the COVID19 news, but wasn’t aware of the many tests of different drugs that are ongoing. I’ll touch more on this later, as it was a recurring theme.
There’s a live document, continually updated, on the National Institutes of Health website, that provides the latest guidelines on COVID19 treatment. It’s an interesting read and just learning about it was reason enough to watch Fauci’s presentation. It’s a good resource since it’s getting revised as we learn more.
Notwithstanding problems in early US response, we’ve made tremendous progress in managing this disease globally. It was just 65 days from determination of the virus’ genetic sequence until we had the first clinical trial underway. That’s much faster than we managed during previous zoonotic outbreaks, and says a lot about the advances in science in the last forty years, and even in the last decade.
Fauci closes with a prescription for opening society back up and letting folks get back to work. He lays out, at a high level, a multi-step process that will take time, and that must be driven by testing, risk assessment, and mitigation strategies.
At about 35:20, Dr. Sanjay Gupta comes on. He spoke primarily about the importance and the difficulty of reporting responsibly on the pandemic. We’re operating with imperfect and missing information. As we learn more, recommendations change. This is a useful session, but if you are tight on time, there’s not a lot of specific COVID19 insight here.
At 47:00, Dr. George Gau comes on. He runs China’s CDC. This was a really interesting part of the panel, to me. I freely confess to bias: I suspect that the Chinese authorities have lied in communicating with the rest of the world over the course of the pandemic, and that infection and fatality rates are higher — maybe much higher — than claimed. But, of course, I have no proof of that.
Dr. Gau clearly aimed to dispute my opinion. Words like “transparency” and “collaboration” appear over and over in his remarks and in his slides. He, alone among the panelists, seemed to make an effort to stick to his assigned time slot, so he absolutely raced through his deck. But even as he did so, you could read a shocking amount of detail on the specific criteria, programs and methods that China used to contain and control the outbreak. No senior US official has presented anything like so thorough a plan, which is why state and local officials have had to step in with inconsistent programs.
This was really good.
At 1:02:02, Dr. Susan Weiss from UPenn takes over. She delivers, essentially, a lecture on coronavirus biology. I’ve done enough lay reading in microbiology to understand most of the words and all of the concepts, but unless you’re in or adjacent to the field, I don’t think you need to spend much time here. The key points I took away: There are plenty of good targets for vaccines against SARS-CoV-2. There are even some good targets for coronaviruses generally, so we might be able to design a vaccine that protects more broadly than just against COVID19.
At 1:16:56, Dr. Richard Hatchett from CEPI begins speaking. He manages a coalition of private companies and research institutes that are collaborating to produce a vaccine against COVID19. His presentation was excellent. I’d never heard of CEPI, so just learning about it was interesting, but more specifically he talks in detail about where we are in the search for a vaccine.
I was shocked to learn that there are 107 vaccine candidates right now, with many clinical trials already underway. I had no idea, and it was heartening to learn.
Even with all that activity, the timeline for vaccine production is long — you really do need to do randomized clinical trials to confirm that the vaccine works, and that it doesn’t have bad side effects. A fifteen- or eighteen-month target, from first formulation to general availability, is realistic.
One thing that CEPI is doing to shorten that is to take some steps in parallel without compromising safety. For example, once you have a candidate vaccine, you need to test it. If it works, then you need to manufacture a whole lot of it, because there are 7.8 billion people in the world. But, if you are willing to risk wasting some money, you could start manufacturing before you knew that the vaccine worked. Best case, you have a lot of it ready as soon as it’s validated; worst case, you have to throw all that inventory away.
And in fact that’s happening. The Gates Foundation has announced it intends to fund the production of the top seven candidates before their clinical trials have completed. This actually makes economic sense. You risk tens of billions of dollars in wasted costs if a vaccine fails, but the economic crisis induced by quarantine is costing the global economy hundreds of billions of dollars a month, so if we can advance availability of just one that works by just a month, we’re ahead.
One key point from Hatchett’s presentation, echoed elsewhere in the session: We are very likely to wind up with multiple effective vaccines, and multiple effective therapies. That’s a good thing: Since we don’t know yet what’s going to work, we need to be trying many different approaches, all at the same time, to increase the likelihood that we succeed. Besides, a diverse set of tools for doctors to prevent and treat this disease will be good for public health.
At just about 1:26:00 into the panel, Dr. Dzau moves to Q&A. That lasts for a little more than half an hour. Honestly it’s not the best part of the panel, but there’s some good back-and-forth on testing, and a little bit of discussion of therapeutics and the progress of the disease over time. Dr. Farrar makes a point on treatment that I hadn’t considered: The disease moves very swiftly in the hospital, and a sick patient may need different treatment regimens at different times. You might want to boost the immune response early, but then suppress it later to manage inflammation, for example. So, again: More tools for treatment is a good thing.
If you’re a public health nerd or COVID19-obsessed, I recommend watching this NAS panel. I think it’s great that the Academy decided to open its annual meeting up like this. No way I’d be able to hang around folks like this otherwise! My personal recommendations are Fauci, Gao and Hatchett; then Farrar and Weiss; with Gupta, though good, most skippable.
