Dr. Anthony Fauci on a Covid-19 vaccine & reopening schools this fall | Homeroom with Sal

Hi everyone, welcome to today's homeroom. We have a very exciting special conversation with Dr. Fauci coming in a few seconds. But I will make my standard announcement reminding everyone that Khan Academy is a not-for-profit organization. We can only exist with support from donors like yourself, so if you're in a position to do so, please think about going to khanacademy.org/donate.

I want to give a special shout out to several organizations that stepped up when they realized that we were already running into deficit pre-COVID and in our efforts to support all the schools and learners around the world due to school closures. They have helped to step up to close that gap. Special thanks to Bank of America, google.org, AT&T, Fastly, Novartis, and the Amgen Foundation. But we're still running at a gap, and so anything any of you all can do to help is very much appreciated.

So with that out of the way, I'm super excited to have today Dr. Anthony Fauci, who I think needs no introduction. Thank you so much for joining us, Dr. Fauci.

"Good to be with you. Thank you for having me."

So as you can imagine, and I'm sure you're at the center of this, I've been getting a ton of questions from everyone I know for what they want to go over. But you know, I actually want to start just, you know, on you personally. How are things going for you? How are you—how's the stress level? How are you handling it? You know, how are you dealing with everything that's going on?

"Well, I'm dealing with it, but I think it would not be honest if I say it wasn't very stressful. This is a very difficult situation we're going through, the historic pandemic. The amount of demands for what we need to do—I’m simultaneously running the institute that I direct, which is the National Institute of Allergy and Infectious Diseases, which is responsible for most of the science that goes into COVID, particularly developing a vaccine and developing therapies and diagnostics. I'm also a member of the Coronavirus Task Force, which is, as you well know, charged with the responsibility for trying to provide direction and guidance to the country. We're in a very difficult situation, so yes, it's extremely stressful. But it is what I do. I've been doing this my entire professional life, going back 40 years to the beginning of HIV/AIDS and all the other outbreaks that we had to contend with, so this is part of the job. But it's wearing; it's not easy."

Well, I can only imagine, but I think I speak for all Americans and actually people around the world saying that, you know, you've been a source of comfort throughout. My wife's a physician, and if I've ever felt insecure about my marriage, it's based on how much she's been a fangirl of you. I actually have your "Principles of Internal Medicine" right over here. So this has been—it’s great to talk to you, but you know, getting into I'm sure what you've been really steeped in and been talking about a lot. Before I even start talking about school closures and what might make sense, I'd love to just get our framing and where we are in this journey together.

There's a lot of conversations now about vaccines from Moderna, from AstraZeneca. Where are we in that journey? It looks like we're getting into kind of the Phase Three. If you could explain that and what you think will—how it'll play out over the next few months?

"Well, that's a great question. If the journey is the vaccine journey, then it's very clear where we are. So I think one needs to point out that historically, this is the fastest we've ever launched into a process of developing safe and effective vaccines for an important disease in history. I mean, the speed with which this happened was a combination of the technology which allowed us to do that, with new vaccine platforms that could start on bona fide vaccine development literally within days of knowing what the sequence of a particular pathogen is, as opposed to having to grow it up and getting it isolated and purified. We saved at least a year or more by technological advances alone.

So a number of trials—you know there are dozens of vaccines that are going into different phases of trials, which I'll explain in a moment. About a dozen, or between a half a dozen and a dozen, are the ones that are really getting involved in proceeding in good faith with trials. Take one for example, the Moderna one that you mentioned. We started a Phase One trial only 62 days after we actually started developing the vaccine. Those results were published in the New England Journal of Medicine and they look pretty good in the sense that even though there's a limited number of people—45, 15 per dose, three doses—that the induction of neutralizing antibodies that were comparable to the levels that you would get with convalescent plasma are very promising.

A Phase Two study has also been done, and literally, a couple of days from now, on July 27th, we're going to enter into a Phase Three trial. So for your audience, so that people understand, Phase One looks just at safety and the kind of response that you induce. Is it safe, and does it look like it's inducing the response you'd like to see? Phase Two amplifies that. So Phase One has like 45 individuals, Phase Two has hundreds of individuals. Phase Three is thousands of individuals. So on July 27th, 30,000 people—we're not going to do them all on July 27th, but there will be a trial that will be started with 30,000 people to determine does it really work.

In other words, we're doing the trial in those areas of the country where there's active virus infection, which is not difficult to find because we have pretty widespread active infection, to determine does it really work. How long does that take? It generally takes several months at best. With some vaccines, it might take years. But there's so much virus activity out there that it is likely we'll get a good idea of whether we do have a safe and effective vaccine or not within a period of several months. So you can say somewhere towards the end of this calendar year and the beginning of 2021. That's just with one candidate. There are other candidates that one month later and one month later and one month later will be going into Phase Three trials.

Now, no one can ever guarantee whether you have a safe and effective vaccine. The proof of the pudding is you've got to do the trial, which we're doing. My projection, which is just cautious optimism, is no guarantee that by the end of the year, the beginning of 2021, we'll have a vaccine that we could start distributing to people. So that's the timetable. It's extremely quick, but it's not sacrificing safety, nor is it sacrificing scientific integrity. It's just doing things more quickly by essentially going to the next step and taking a financial risk before you actually get the answer to the previous step."

And there's a lot in there that's really, really interesting. One just to make sure that folks are tracking with us: even in these Phase Ones, one, you're just making sure that the vaccine isn't doing obvious harm—that's, you know, do no harm, first step—and also, to your point, the fact that the antibodies are showing up. These are the things that tag parts of the virus to kind of get cleaned up by our immune system. So in theory, if the antibodies are showing up, they'll be able to tag the virus, and the virus won't be able to spread the way it typically would. And in Phase Two, you go a little bit further with that.

As we go into Phase Three, do you focus this on communities where there's already a lot of spread so that you can really see the difference, whether the vaccine's making a difference? Are you focused on the antibody still, or now are you focused on, hey, three months from now, what percentage of the people in the treatment group got the vaccine, or the severity versus those who didn't get it?

"That's a great, great introduction to a really important question. So what it is, is that in Phase Three, the primary endpoint is whether or not you prevent someone from getting a clinically recognizable infection. That's the primary endpoint. You also are going to be measuring the antibodies because you want to get a correlate of immunity. You want to find out what you induce in a person that is directly associated with protection.

So the bottom line is when you get to Phase Three, you want to know not just what the laboratory data is, you want to know have you protected someone from getting clinically recognizable infection because then later on, you could do correlates and use that immune response to be able to predict whether other vaccines are going to be able to protect.

And you know, one interesting thing you mentioned is that normally—and to give credit to this whole system here—normally a vaccine could take many years, sometimes as long as a decade to develop. To your point, the development started within days of having the sequence of the RNA of the virus. And then what the government is doing is essentially taking these pre-bets. Normally, you would wait for Stage Three to finish to say, 'Oh, it works, now let's start manufacturing.' But the government has already placed orders with these companies so they can start manufacturing just in case, assuming it's good. If it’s not, they lost money. But how does that thinking work? How does the decision tree work?"

"Okay, I'll tell you exactly right, again, good introduction to a very important question. So in general, pharmaceutical companies, although they want to help public health, they are a business. They have got to function like a business, even though many of them are very altruistic in what they do. They cannot lose a lot of money.

So what they generally do is that they wait until one step is proven before they start manufacturing at big scale to get it ready. The good news for them is that they are playing it safe. They're not risking. The bad news is that delays by months and months whether you're going to have a vaccine that you can actually distribute.

What the government has done is, to the tune of billions of dollars, they've invested to do just that at the risk to the government's money. They do advanced purchase agreements to say, 'No matter what happens, we will buy 300 million doses of the vaccine.' Now, if the vaccine doesn’t work, then the company doesn’t really lose much, but we lose money. We feel that the government, to the extent that I represent—I don't really represent it because I'm a scientist who does the research—but we feel it is worth the financial risk to allow us to get that much more of a head start on getting an effective vaccine to the people who need it."

Yeah, and the math—the way it works, it's all probabilistic—but it makes a ton of sense that if there's even a sixty percent chance or seventy percent chance that you can get a vaccine into the world three months faster, four months faster, that's going to save maybe trillions of dollars of savings, and not to mention lives, which seems like a really, really smart calculus.

"There it is; it's a bit, but it's a good bet."

Yeah, and what do you see as a probability? You know, let's say you're already making the bet of the manufacturing. You're already essentially kind of buying the vaccine hoping that it will work. Assuming that the Stage 3 trials go well, and the doses start hitting the market in January, February, how long will it be before we have a critical mass of the vaccine out there that it can really start to affect how much virus is out there in the population?

"That's a good question. You're talking about vaccinating a few hundred million people in the United States, notwithstanding that you also have a global responsibility, all of us, of taking care of countries that don't have the resources to do it logistically alone—that takes time. So you wouldn't be able—it will take months to do that, months to vaccinate that many people. But you know, we've done major vaccination campaigns before. We did it with polio globally; we did it with smallpox. It can be done, but it's not easy because it isn't like you can go into the office and get your shot for this and your shot for that. This is a massive public health campaign.

And what is—there a threshold in epidemiology that if x percent get the vaccine, then we’ve essentially turned the tide? You know, it's called herd immunity. In other words, if you get enough people protected, that means that the rest of the people who are not protected will be protected because there's so much blocking of the virus in the community—an umbrella of protection. The virus has no place to go because it can't find susceptible people because most of them are protected. That critical level varies from pathogen to pathogen, from virus to virus. We don't know exactly what that number is for COVID, but we assume it's somewhere around 70, 75 percent, but we don't know. So we have to be humble and realize we don't know what that is because there's so many moving target factors here."

And what is—is there a sense that the vaccine, if it's effective, that and the antibodies are there, that it's essentially a permanent vaccination, or is there some possibility that there's something unique about COVID that it's something of a temporary immunity?

"Well, there is some somewhat sobering information. If you look now, even though we're only six months into the outbreak, and it's very difficult to give a projection of durability of immunity one, two, three years out, we have no idea because we've only been involved with this infection for six months. But a sobering aspect of the information is that in people who have been infected and recovered and you follow them, and find out how long the antibodies last, it's variable. Some it lasts for as long as you follow them, which would be at the most six months. For others, in several weeks, it goes down significantly, which means that the immunity that’s durable isn’t like measles, which is like for the rest of your life you're protected. The durability of the immunity is so great. So this means that we have to keep an eye out on this. It likely will protect enough for the season, as it were, but then you’ve got to follow people. And if a certain percentage of them fall below a critical level after x number of months or a year or two years, you may have to think about giving them a boost the way we give many things, many pathogens that we have vaccines for, we have to boost them. Tetani, you have to boost every 10 years. Some of the others you have to boost every once in a while."

And, you know, given that this could be, you know, based on this analysis, you know, many months, it could go well through the school year. Obviously, you know, we're an online learning organization. A lot of the interest has been around what to do with schools this coming back to school. Maybe a good place to start is, what do we know about how well or not so well kids can be vectors for the virus? I've seen some research that ten and under there doesn’t seem to be a lot of evidence that the kids are spreading it. What do you know about that? What's the latest there?

"Well, that's the same Korean study that you're referring to that everybody's quoting now. It came out last week, and it showed exactly what you said, Saul, that children up to 10 don’t seem to be transmitting to adults as efficiently as adults transmit to adults, whereas 10 to 19 it appears that children transmit to adults as well as adults transmit to adults. Well, we really don't know because there are so many studies, and the percentage varies from country to country. Is it that children get as easily infected as adults? The way you know that is that you look at the percent of infection in children compared to the percent of infection in the general population. If it's significantly less, that means children don't get infected that much. If it's more or the same, that means they easily get infected.

What we're doing here at the NIH, we're doing a study. It's called HEROES—Human Epidemiology of COVID Infection—and what it does is, it started on May 1st, and we'll get significant data by December 2020. And what it is, it's a study of 6,000 people in 2,000 families looking at the rate and the prevalence and the incidence of infection in children and whether or not they transmitted to adults or do adults transmit it to them. We should know the answer to that in a good study by the end of December of 2020."

And so, given that, if you were a district superintendent or school principal, how would you be thinking about that? I've seen guidelines from folks like the Harvard Global Health Initiative, where they essentially have kind of a colored ranking based on the prevalence of new cases in a geography. And if it's red, you're at full distance, if it's green, full, somewhat normal, see what social distancing in between. Maybe you open for the kindergartners or for the, you know, the 10 and under, and then you kind of play it by year for middle school students. How would you be thinking about it as a district official right now?

"The same way. I think the critical issue—and you know you could break it down into green, yellow, and red—but what the officials need to do is to look at the level of activity of virus in the community. Because what we get confused at is we make the United States a unidimensional phenomenon. It's not; it's very much different geographically, demographically, in the level of infection. So there will be some states, cities, districts, counties where the level of infection is so low that you don't have to worry about anything regarding bringing your children back to school—just bring them back to school, no problem.

But there are some in which you have a level of activity where you’ve got to balance: if you are going to bring the children back, what do you need to worry about? What should you do? And it's a whole set of recommendations that come from the CDC. They are things like alternating classes: morning/afternoon, alternating days, Monday-Wednesday-Friday, Tuesday-Thursday, what have you. Physical separation in class seating, people six feet apart, having children who can tolerate it wear a mask all the time, having the teachers wear a mask. There are so many things you could do: alternate between online and in-person. Those are the things you need to do, and then you can make a decision."

As you said, if I were a superintendent, I would look at where my district was, what the risk is, and I'd fashion the process of getting kids back to school based on that estimation.

"And would you say that, you know, I think what a lot of district officials are looking for is some type of a threshold to be confident that they're doing the right thing? Because they're feeling like these are life-and-death situations. I know the Harvard Global Health Initiative—they're the one that I looked at. They have thresholds like, you know, 10 new cases per 100,000 per day. This is the scenario that you should think about. 25 new cases per 100,000. Do you think those are the right types of things that district officials should anchor on?"

"Yeah, absolutely. Take a look at what the percent positivity is. And from a teacher's point of view, you know, I think we've all heard in the press teacher fears, especially if some of them are in high-risk groups. I have this question from Facebook: Diane Newman’s asking if people over 60 are more likely to get this and have severe symptoms, should they be forced to go back to school? Do you recommend they go back? And then it says, currently, many districts are requiring all their employees to come back to school unless they have a doctor's note. How do you think about that?"

"You know, you asked about three or four questions there. So what I think is that obviously you've got to pay attention to the concerns of teachers who are entering into the elderly demographic bracket, particularly those who have underlying conditions. You know, you talk about the elderly—there aren’t a lot, I think at least the elderly people that I know, there aren’t a lot of elderly people that don’t have at least one underlying condition besides old age. They are either hypertensive; they have mild cardiovascular disease, a little chronic lung disease, maybe diabetes. There are a lot of people with underlying conditions out there. So I think when you talk about forcing teachers to come back to school, you better be careful about that and make sure you pay attention to keeping them safe and keeping them healthy."

And in terms of the actual implementation of that, you know, a lot of questions—I’ll just try to group them together—that I'm getting off of YouTube and Facebook right now is questions about, you know, you mentioned things like social distancing. How do you do that within a physical environment? I am curious—a lot of people are asking questions about outdoor school. You know, there's previous epidemics, tuberculosis, where even in fairly cold places, they seemingly effectively did school outdoors.

Well, is that something that you would recommend folks go in that direction, or it's really, you know, district by district?

"No, I think district by district. But I can tell you as a public health man, a paradigm outdoors is always better than indoors when it comes to COVID or any other respiratory infection because when you get recirculating air indoors, you've got to be careful. So if there's anything that you could do outdoors as opposed to indoors, I would do it. That could be school; certainly, it could be restaurants. I mean, restaurants, if they possibly have the capability of having outdoor seating as opposed to indoor seating, I would stress that."

And from Facebook, we have this question from Aaron Elizabeth: "We live in a state where cases are on the rise and schools are starting to formulate plans. The latest is that they may not mandate masks. Can you share your opinion on masks in schools?"

"Yes, I believe that if you're dealing with a situation, which is almost everywhere in the United States, where there's viral activity, that you wear masks, that children who can tolerate it, because I mean, I've—I have three girls, they're adults now, but I remember them lovingly very well when they were young kids. I don't think I could keep a mask on them. You don’t want a kid who's really young, but to the extent that you can, I would. And certainly teachers."

Yeah, our five-and-a-half-year-old, we've had to just make him play like he's a ninja, and then it becomes that much better.

"So this is a question, actually, this is one I've been wondering myself. From Facebook, Anne Marie Byron asks: 'Dear Dr. Fauci, is it okay to wear a face shield instead of a mask in the classroom, or I guess you could say even in general? I think students need to see their teachers' faces. So much of encouragement and engagement comes from a teacher's smile.' Well, this is a face shield; it’s not a mask. It’s cloth. I wear this all the time. I usually rotate; I usually wear a Washington Nationals face mask to cheer on my team. But these are fine; these types of things are fine. And I see there are some new things coming out that have where the mouth part is clear, so that I guess people can see you're smiling. What do you think about the kind of plastic full shields? Do those provide any protection?"

"Yeah, yeah, they do. So you see, the only trouble is that someone will bring up the possibility that they're OK. My staff just brought this in. There you go; that's exciting. Yeah, so this is good. Yeah, this is good for droplets because it'll block it. The only trouble is if you have any degree of aerosol, what happens is that all of this—see, it can go right in like that. That's the problem, you see. So these are good for droplets, but you have to be careful if there's a degree of aerosolization."

And do those—because part of the mask or the shield, it's protecting yourself, but part of it is also protecting other people. Does the shield help at all with protecting other people?

"I guess, you know, things won't get projected as far around; they would go around. See, I think people need to understand—and this may be a good rationale because you really want to get people to rationally go along with why you should wear a mask—is that we became really bullish on masks when it became clear that a substantial proportion of people, 20 to 45 percent, are asymptomatic. They don't even know they're infected. And we know that someone who is asymptomatic can pass the virus on to another person, which is innocent and inadvertent. Nobody's trying to infect anybody; you just don't know you're infected.

So what we do know is that a face covering or a mask can prevent me, if I were inadvertently and unknowingly infected, it would prevent me from infecting you. So it's almost like a responsibility. You wear a mask to protect me, and I wear a mask to protect you. So we're all in this together. And when people realize that, that may be more of a motivation for them to do that, that it's almost like your societal responsibility to not be part of the problem of propagating an outbreak as opposed to saying, 'Oh, I'm a young person; I don't care if I get infected. It doesn’t make any difference.' It does because even if you don't get any symptoms and you're infected and don’t know it, the chances are you're going to pass your infection onto someone else who then passes it on to someone else, and then you'll pass it on to someone who could be someone's mother who's undergoing chemotherapy for cancer, or an immune-deficient child, or someone who has another condition, diabetes, a very common condition, and then that person is at high risk for a bad outcome."

That's super important. And I know we're almost out of time. You know, first of all, Dr. Fauci, I just—I genuinely want to thank you, and I think I'm speaking on behalf of tens of millions of people around the world—that you are a source of grounding and comfort in this very, very tough time. And I can only imagine the weight you feel on your shoulders. Are there any parting messages that you'd like to share? I mean, you just shared a few, you know, just things that people haven't fully grokked or digested that you just really want to doubly underline?

"Yeah, I think what you start to see, Saul, is fatigue on people. No one likes to be isolated, relatively speaking, from society. I certainly miss it. I know everyone that I come into contact feels that way. Just keep in mind, this will end. We will end this terrible scourge that we're under, so hang in there. Don’t get discouraged. Throw up your hands and say, 'Oh, I'm just tired of it. I'm just gonna do things; I don't care if I wind up getting infected.' Hold tight; hang in there; we're all in it together, and it will end, and we will get back to our normal lives within a reasonable period of time."

That's a message I'd like people to hear.

"Definitely appreciate that. I think a lot of people need to hear that. Thank you so much, Dr. Fauci. This was super valuable."

"Thank you, and I appreciate you giving me the opportunity to be on your show."

So, thanks everyone for joining. Once again, another incredible conversation. You know, I think Dr. Fauci, for those of you who don't know, he's obviously been catapulted into fame because of this unfortunate situation we're in. But my wife's a physician, and she's been following him for a while. He's one of the top physicians in the field for many decades now, so we're very lucky to have him, and we're frankly very lucky to have him in this position of leadership right now.

But thanks everyone for joining this live stream, and I look forward to more conversations like this in the weeks ahead.