Transcript, Meeting 19, Session 6

Date

November 6, 2014

Location

Salt Lake City, Utah

Presenters

Anthony S. Fauci, M.D.
Director, National Institute of Allergy and Infectious Diseases
National Institutes of Health

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Transcript

SESSION 6: DELIBERATION AND BIOETHICS EDUCATION: CASE STUDY OF PUBLIC HEALTH EMERGENCY RESPONSE (CONTINUED)

DR. GUTMANN: Welcome back, everybody. We  are going to move on to our second speaker for Public  Health Emergency Response, Dr. Anthony Fauci.

Dr. Fauci is the Director of the National  Institute of Allergy and Infectious Disease, the  National Institutes of Health. This is a position  Dr. Fauci has held since 1984. There, he oversees an  extensive research portfolio of basic and applied  research to prevent, diagnose, and treat infectious  diseases such as HIV/AIDS and other sexually  transmitted infections, influenza, tuberculosis,  malaria, and illness from potential agents of  bioterrorism.  

 Dr. Fauci serves as one of the key  advisors to the White House and the Department of  Health and Human Services on global HIV/AIDS issues and  on initiatives to bolster medical and public health  preparedness against emerging infectious disease  threats such as pandemic influenza. He is the  recipient of numerous eminent awards including the  Presidential Medal of Freedom, and 38 honorary doctoral  degrees from universities in the United States and  abroad.

And for our purposes, very importantly, he  is the spouse of our esteemed Commission member,  Dr. Christine Grady.  

Welcome, Tony. Thank you so much for  being with us remotely, but as I said to Larry Gostin,  you are even larger than life for us. So thank you for  being here.

DR. FAUCI: Good to be with you.

So can I start off and give a brief  presentation and then leave it open for questioning?  Is that how we are going to do it?  

DR. GUTMANN: That's how we're going to do  it.

DR. FAUCI: Okay. So I was asked to  discuss some scientific and potential ethical issues  associated with this concept of quarantine that has  been very actively discussed and disputed over the last  couple of weeks. And I think everyone in the room  knows that this concept of quarantine is a very  historic terminology, with the word quaranta, meaning  forty, when it was first used in Florence -- excuse me,  in Venice during the centuries of the plague, where  ships that would come in would have to stay in port for  forty days before the passengers were allowed to  disembark into Venice.   

 Some of the misperceptions about  quarantines is that it is sometimes used to be able to  confine people who are ill or people who are suspected  of being ill. Today, we use two different terminologies.  We use "isolation" for people who are truly ill, and  "quarantine" for people who you suspect are ill. So  the discussion, really, for today is the right balance  between the risk of the American public and the  quarantining of health workers, particularly, and  others who are coming in from West Africa vis-à-vis  their rights, their own essentially human civil rights,  as well as the unintended consequence regarding  outbreak control.  

 One of the important issues is to just lay  out very briefly the scientific evidence for why a  person who does not have any symptoms is not a threat  to transmit Ebola. And we have extraordinary  observational data that argues in that case. I can go  over a lot of it, but I can succinctly outline it for  you in one single case study.  

 Mr. Thomas Eric Duncan, who was infected  in West Africa, came to Dallas, and the only two people  in the United States who have been infected were  people -- nurses who directly put themselves into  harm's way by caring for Mr. Duncan. Whereas  Mr. Duncan's family members and friends with whom he  was in personal contact in the apartment in Dallas,  none of them have been infected nor have any of the  ones who came into contact with the nurses subsequent  to the time that they were infected. So the real  question, and the dilemma, is do you put everyone in  the same bucket who has been exposed or been travelling  in a certain area, or do you match the level of risk  with the level of monitoring and restriction? So the  CDC guidelines, which I had a role in putting together,  tries to balance the stratification of risk with the  monitoring, the public activities, and ultimately the  restriction on travels. Probably you all are aware that there are  four major categories of risk to a healthcare worker.  One is "high risk." And a high risk is a needle stick  or you're taking care of a person in a facility in  which there have been many infections even though you  are using proper personal protective equipment. The next is "some risk." "Some risk"  means you're in close contact with someone who is  symptomatic or you actually were in direct contact with  a patient, but you were wearing proper personal  protective equipment.

The next is "low but not zero risk," is if  you either traveled to the region with no noticeable  contact, or you are in direct contact with the proper  PPE in a United States hospital.  And then there's no risk at all.  Just for the sake of reference, I am "low  but not zero risk" since I took care of Nina Pham,  using proper personal protective equipment. So I'm in  one of those risk categories.

It's important that each risk category has  a designation of how you monitor. There are two  major -- well, three major types of monitoring:  Passive, which means I take my temperature, evaluate my  symptoms but don't tell anybody; active monitoring is I  take my temperature, evaluate my symptoms, and report  it to somebody; direct active monitoring is someone  takes my temperature, questions me about my symptoms,  and then records it.

So right now when we look at the different  risks that I mentioned, high, some, low but not zero,  and zero, in fact a high risk has direct active  monitoring and there are already restrictions in that  high risk group. So functionally, if I had a needle  stick or if I was in an Ebola treatment unit in which  several of my colleagues got infected, I would not be  able to freely travel on a plane or in a subway or in a  place where there's a lot of people. I think people don't fully appreciate that; that, short of a bucket of  total quarantine, there are some categories that CDC  categorized that already have the functional equivalent  of a quarantine.

And then you go down the list with less  monitoring, less restriction. So to give you an  example, I am low but not zero risk. Someone watches  me take my temperature every day, they record it, but  since I'm without symptoms, I have absolutely no  restriction on my travel. However, if you were to put  me in the bucket of quarantine, which some states would  do, I would not be able to travel on a plane or on the  metro here in Washington, D.C., which, as you can see,  there really is what I call kind of Draconian one way  or the other; either all in one bucket, no matter what  you quarantine everyone, which some states want to do,  versus letting everybody out on their own, which I  think would be equally inappropriate.

So let me just close by making just an  observation, that I think if you are going to be  talking about ethical issues, if you want to use that  word, or common sense issues about quarantine, you have  to ask yourself are you quarantining a group of  individuals? In this case all healthcare workers and  all people who come from a region. Are you doing it  based on scientific evidence or are you doing it to  alleviate public fear? And my conclusion has been that  a blanket quarantine for all healthcare workers, as  well as people coming from that region, is much more  based on alleviating public fear than it is on  scientific data.

And the unintended consequences, I think,  are real. A good example is that in the American  Society of Tropical Medicine and Hygiene meeting that  is taking place in New Orleans this week, that the  state of New Orleans will not allow any healthcare  workers who have been in West Africa to attend the  meeting. And those are the very people who you want to  attend the meeting to be able to bring back their  experience and share it with their colleagues. So I'll  stop there and be happy to answer any questions.

DR. GUTMANN: Great. Thank you.

Let me start with a question where you  left off to ask you to elaborate a bit. Is there any  evidence, actually, that it alleviates public fear?  Here is my concern about not following the science:  The science doesn't tell you per se what to do. But if  you don't pay attention to the science, you're likely  to do the wrong thing. So here is my concern about  that. If you quarantine, despite what the science  says, then what is it that's guiding public fear?  Anything will create public fear. So I don't even see  how the quarantine quells public fear.

The next thing you need besides a  quarantine is you have to close all the borders. And  the next thing you do is you're afraid of people who  have the wrong color skin, and we are back in the dark  ages. So is there any evidence?

We are all with you on why -- overreaching  on the quarantine. But I'm wondering if you are  actually conceding too much in saying it actually  quells public fear. Because if the public are  amorphously fearful because they don't know what you  need to know about the risks here, I don't see how a  quarantine in itself is going to do the trick.

DR. FAUCI: Well, I agree with you. I  mean, there hasn't been a study to say if we  quarantined all these people would people be less  concerned? The governors who are instituting the  quarantine are saying that they are doing it because  they absolutely want to take no chance whatsoever,  implying that, A, scientifically there really is a  chance and that they are getting to the "is there a  zero risk"? And there is never a zero risk.

I think you can make an assumption that if  people, particularly people who are not particularly  well informed, knew that every healthcare worker that  came back would be quarantined for 21 days, that they  would feel more comfortable getting onto a subway or  onto a plane. That's an assumption on my part. But  again, I'm not yielding that because I don't think  there's any scientific justification whatsoever to do a  blanket quarantine. But I can't --

DR. GUTMANN: Why don't you say, besides  that there's not scientific evidence, what you have  also said, and this is for the public record, of what's  lost when you put a quarantine in. What, that we need  to contain this epidemic, do we lose when we go further  than is necessary?

DR. FAUCI: Well, I have articulated that  many, many times. I mean, what you do is there's a  major disincentive on the part of health workers to go  and volunteer their services if there's an automatic 21  days out of action. And as we have said many times,  the best way to protect Americans is to completely  suppress the epidemic in West Africa. And one of the  ways it is being suppressed is on the basis of our  volunteers going over there. And it looks like even  now, with the decrease of cases in Liberia, that's in  large part on the basis of a lot of volunteers, people  who are going over there.

DR. GUTMANN: Thank you. Questions from  Commission member Dan Sulmasy.

DR. SULMASY: Thanks. It was very  helpful. I wonder, though, if your sort of case report  is a sufficient sort of scientific justification for  the sense that there is no risk. And I know you said  there are data, and I just wondered if you could expand  a little bit for the Commission on what sort of  scientific basis there is for assuring the public that  there is no risk of transmission during the pre-  symptomatic period. What sort of data do we have?  What sort of mechanistic understanding of viral  transmission do we have that would help? If you could go into that.

DR. FAUCI: Good, yes. Let me answer the  first part. I never say "no risk." There is no such  thing as a no-risk society. The risk is vanishingly  small. Probably less than if you walked out on the  street and got hit by a car. But it's not "no risk."  And that's where the CDC, I think, has gotten into  trouble, because they say "no" and they get called on  that. But they are not doing that anymore. They are  getting to the point of saying that the risk is so  small as to be almost unmeasurable.

If you look at the kinetics of virus in a  person, you start to get virus right about the time  where you develop clear symptoms. But the viral level  is so low that it needs multiple cycles of PCR to prove  it's positive.

When you get into the symptomatic stage  where you are vomiting, have diarrhea, and are  prostrate and you can barely get out of bed, that's  when the viral load is so high and healthcare workers  get infected. So the data that it is really very, very  unlikely to be transmissible at a time that the person  is without symptoms, there's a lot of epidemiological  data on that. And I gave a couple of examples of  Duncan's family who was in the same apartment with him.  

If you go back to the 1976 and the 1995  Kikwit epidemics in the Democratic Republic of the  Congo, it was very clear that household members, the  only ones who got infected were those who directly took  care of the person; touched them, changed their  clothes, took care of them. The people who were living  in the house who did not have direct contact did not  get infected. So there's an extraordinary amount of  epidemiological observational data that you don't  transmit unless you are not only symptomatic, but  really symptomatic.

And that gets back to Spencer. Everybody  knows Craig Spencer, who is now a patient at NYU. He  said he felt a little achy, without a temperature.  That's when he went bowling, went to a dinner, et  cetera, et cetera. Even then, his viral load was  likely so low that there would be no way he could  transmit it. And as you are going to see in the people  that he has called that are being followed, it's very  unlikely any of them would get infected except possibly  his fiancé, who would be in a high risk group. But  people that he had dinner with and then bowled with,  there'd be virtually -- I wouldn't say no chance, but  an extremely small chance that they would get infected.

DR. GUTMANN: Thank you. Jim Wagner.

DR. WAGNER: Actually, Dan covered my  question. So I'm happy to yield the floor to someone  else.

DR. GUTMANN: Stephen Hauser.

DR. HAUSER: Hi, Tony.

DR. FAUCI: Hi, Steve.  

            DR. HAUSER: You had mentioned that there  was a declining number of new cases in Liberia. Could  you expand on the trajectory and epidemiology of this  outbreak, whether it has any surprises for us thus far  based on what was known about the virus previously?  Apart, of course, from the size of the outbreak.

DR. FAUCI: Well, it was not a surprise  when you go back retrospectively, Steve, and look at  it, that with the porous borders and the extraordinary  dysfunctionality of the healthcare system, that for a  while we had an exponential increase in cases,  predictably in Liberia.  

 Right now we, the United States, have  focused much of our efforts with the disaster-assisted  relief team of USAID, the CDC, NIH's people and the  Department of Defense have really had a major impact,  particularly in Monrovia, in making the real number of  cases go down. What we are concerned about is that in  the outskirts, towards the borders in Liberia, we may  see a second wave.

Simultaneous with the situation going down  in Liberia, we are starting to see now a sharp rise of  cases in Sierra Leone. That is likely because we are  not putting as much resources, and Sierra Leone is sort  of the purview of the U.K. as opposed to Liberia, which  is the purview of the United States. And that's the  reason why now we probably need to start shifting some  resources to Sierra Leone.  

 DR. GUTMANN: Tony, let me ask you, since  you have such a wealth of knowledge and expertise on  what we did well and not well with regard to the HIV/AIDS  epidemic. This is beyond the quarantine now, I'm  asking you to go. But since we have you, what are  some, for you, of the most striking lessons that we  should learn from what we did well and not so well with  HIV for public health emergencies like Ebola moving --  as we move forward?

DR. FAUCI: Well, I have an observation  but I don't know whether it's what we did so well or  not so well. But I can't help but reflect in the very  early years when I first got involved with HIV,  literally a couple weeks after the first cases, we had  a growing insidious horrible epidemic and very few  people were paying attention to it. Here, we have two  cases in the United States and we have essentially  immobilized everybody, including the president of the  United States, who told me personally he is spending  more time on this than he is on ISIS. So it's really a  very interesting dichotomy of effort and concern.

But the lesson learned is you've got to  keep educating the public over and over again. I mean,  the idea of the famous doorknob question: Can the  bowling ball that Craig Spencer picked up transmit the  infection to someone who used the bowling ball? I  remember, on Ted Koppel's Nightline, arguing with  someone that a gay waiter in Greenwich Village who has  a cut on his hand and puts a plate in front of you and  you have a cut in your hand and you pick up the plate,  can you get HIV from it? And the answer is  theoretically yes. Will you? Absolutely not. So it's  that kind of education.

DR. GUTMANN: Thank you. And just  speaking of that, we thank you for being out there on  the airwaves and so on, because it is obviously taking  a lot of your time, as well, in the educational  mission. And we joke here that I may have seen you  more often than Christine in recent weeks. We won't  delve into that. But Jim Wagner does have a question.

DR. WAGNER: Tony, thank you again for  spending your time with us. Say a few words, since you  mentioned the obsession with two patients infected in  this country and all of this conversation about how it  is we best protect ourselves, say something about the  balance between defense and offense. If quarantine and  isolation are defensive measures -- and it seems to me  this is a bit different from HIV in that we have a  furnace which is blazing with burning embers that are  flying or potentially could fly around the planet. And  yet I don't know that the American public is as  concerned about that. Another way to ask the question  is between our no, low, some, and high stratification  of risk, what is the best way to get our entire nation  in the lowest rungs of that stratification of risk?  And how do we communicate that?

DR. FAUCI: Well, I mean, I would answer  the question by saying you could absolutely get to the  point of no risk whatsoever for anybody in the United  States merely by turning off the epidemic in West  Africa.

DR. WAGNER: Amen.

DR. FAUCI: And that's it. We just are  looking in the wrong place. So next week I'm going to  be testifying with Secretary Burwell and Tom Freeman  about the President's request for $6.188 billion to be  able to essentially help put out that epidemic in West  Africa. That's the offense in your defense/offense.

DR. WAGNER: Thank you, Tony.  

DR. GUTMANN: Do you want to say something  about a possible rider to that of a travel ban, and how  to respond to that movement which is clearly not only  afoot but running hard in this country?

DR. FAUCI: A travel ban is the easy way  out. It doesn't -- I mean, we have clearly experienced  that when you try and do travel bans, the people that  are going to want to get here wind up getting here  anyway through different means.

One of the problems with a travel ban is  that one of the ways that you can suppress the epidemic  in West Africa is by keeping West Africa economically,  politically, and socially whole so that they don't  collapse. And if we really essentially block all  travel, they have a real hard time maintaining their  own capability of suppressing the epidemic. Because if  we ostracize them, other countries will follow very,  very, very closely, and then we are going to wind up  having a very difficult situation of economic and other  issues there that are going to make it that much more  difficult for them to do that.  

            So travel bans, you know, take a look at  the data. So in the months of September and August,  36,000 people went to the airport in the West African  countries to get out. Seventy-seven of them were not  allowed to get on the plane because of health reasons.  Of those 77, none had Ebola. Most had malaria. So  there isn't a major influx of people who have Ebola  trying to get into the United States. Quite frankly,  Duncan was an unfortunate fluke. But there are not a  lot of people who are trying to get into the United  States who have Ebola. So I don't know what we are  going to be accomplishing by a travel ban.

DR. GUTMANN: Thank you. One final question, Barbara Atkinson. And then I know you have to go, Tony. This will be the final question.  Barbara.

DR. ATKINSON: I thought you might want to say something about influenza and vaccinations, just  for the record, because I think there's a scare of  vaccinations in the country, and that might be more  important.  

DR. FAUCI: Well, I actually think that's  a great question. I try to insert it when I get asked  by others. Look at the numbers. Two people were  infected with Ebola in our country. We don't have a  vaccine. We don't have therapy. Anywhere from four to  30,000 people die each year from influenza; 200,000 get  hospitalized, $27 billion in economic cost. And we  don't -- everybody who should get vaccinated doesn't  get vaccinated. So this is probably a really good  shout out for everybody who needs to, which is  everybody over six months of age should get vaccinated  with influenza vaccine.

DR. GUTMANN: Thank you very much. Our  shout out is to you, and thank you for all you are  doing and for what you have presented. And we may very  well call on you again as we move forward with our  report. Hear, hear.

DR. FAUCI: Okay. Happy to do it. Thank  you. Good to be with you.

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