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In the Bubble with Andy Slavitt: Our Shot
All Podcasts Dr. Fauci Answers Your Biggest Questions

Dr. Fauci Answers Your Biggest Questions

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Andy and Dr. Fauci cover all the latest questions you have, including boosters, variants beyond Delta, breakthrough infections, and vaccinating the globe. Plus, what Dr. Fauci and the Biden administration are doing to prepare for the next pandemic.

 

Keep up with Andy on Twitter @ASlavitt and Instagram @andyslavitt.

 

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Transcript

SPEAKERS

Andy Slavitt, Dr. Tony Fauci

Dr. Tony Fauci  00:00

I think that a third shot is going to be part of the original vaccine regimen. Just the same way with hepatitis, where you have a prime a boost after a month and then six months later, so that the real proper regimen is a boost, we didn’t have a chance to determine that early on because it was such an emergent situation, we had to get vaccines out to people. So all the tests were on a prime in a single boost. So we really need a boost.

Andy Slavitt

Welcome to IN THE BUBBLE. This is your host, Andy Slavitt. This is a special episode for a couple reasons. One is the guest, and the other is more personal. Dr. Fauci, Anthony Fauci. Tony Fauci back IN THE BUBBLE, Dr. Lisa went out on the street, and collected questions that you most wanted answers to. And it gives us about as good a read, this conversation does as you’re going to get, and what we know and what decisions are likely to get made. And we’re likely to need to make over the next several months, the latest data on the vaccines, how quickly we can vaccinate the globe, booster shots, how the president’s making decisions, the differences between Pfizer and Moderna, many other things that you have on your mind, Tony and I work together as part of a small team, to vaccinate Americans beginning in January. As people know by now he’s served seven presidents. He’s the chief adviser to President Biden, on science, our work together was an immense undertaking. And together, he and I face the cameras twice a week, we’ll talk a little bit about that, joke a little bit about that. And we basically had in front of us the job of trying to tell the public the truth about what’s going on, and our COVID response me sitting in the White House, Tony, over at an age.

Andy Slavitt  02:17

And he’s my source of a lot of things. And I think it’s a pleasure to be able to bring it to you freshly, I want to talk today about the idea of small adjustments and the power that these small adjustments can have, both in our lives. And in the big picture. You know, if you’ve ever been in an uncomfortable position for too long, you often don’t need a radical adjustment in order to fix things. A slight change will sometimes create a big improvement. There’s lots of examples of this in our everyday life, cracking the window a little bit to let in some air, a slight grin that will brighten your mood. A sigh and a deep breath can make you feel like the mountains are shifting in your directions. You don’t need a complete life reset, to feel better about your life. It often when you feel that way. It turns out, it’s the smaller things that can actually free you up. You think about how kind word or a smile has changed your disposition. Your teenager who just hated their new school one day, and the next came and told you it wasn’t that bad. Why? Because a friend invited her over to their house  or to sat with her to have lunch.

Andy Slavitt

Big adjustments are hard, moving to a new city ending a relationship and they’re sometimes scary. But thinking about the power of these small adjustments and thinking about them when facing something even monumental, like the pandemic, or even climate change, things that are existentially scary, and could stop us in our tracks from taking any action. We don’t know what to do. We freeze we may be denied for as long as we can we just hope it isn’t. So we don’t know how to make a dent and so we feel like if we can’t go completely carbon neutral. Or we can’t help end the pandemic. You know, what’s the point and we give up, sometimes. The answer I think, is to think about small adjustments. You know, I can put on a mask, I can install solar panels. If I want to see my aging parent, I can take an instant test. I can just make a modifications in between doing nothing and a radical change. There’s often this small adjustment in the middle that’s often best. We often don’t even know that it’s an option. But of course when the small adjustment becomes a habit, you can consider making other ones and other ones become easy because we know these are things we can do, they just don’t seem so big.

Andy Slavitt  05:07

We’ve adjusted to a lot of radical things. I mean, face it, we used to be hunter gatherers, we can adjust to things as they change on us, like the pandemic. And adjusting is essentially a way of saying that we’re not powerless. You know, we’re gonna face some beautiful things, and it just is I mean, viruses mutate, the climate is changing. Congress is a bunch of jerks, politicians lie, you know, these things are gonna change. But you know, where am I ask, reduce energy consumption exercise, stop watching cable TV, get off Twitter. Well, I can’t even take that advice. These are the small actions that I believe if we take by the 1000s, will drive change across the country, it also just will show respect, and shows people we care about them if we’re willing to make small changes for us that benefit them. And I feel like the theme of some of our prior episodes around what is going on in Florida, in this fight for ground zero is people just unwilling to make the smallest of changes in their life, to make other people’s lives better. And I think if we think about the fact that, you know, these changes aren’t symbolic of us giving up on some American identity, to wear a mask, to get vaccinated for others, to agree to comply with something that we don’t want to that these small changes are very much the things that our country’s been made up of over time.

Andy Slavitt  06:44

And together, we’ve just got to make the world better for more people. Now, I also want to, before I get to Tony, send a special word out to someone that, frankly, I’ve been madly in love with for a long time. This person knows that it hasn’t been a secret. In fact, today, Lana has been my wife for 25 years, it’s our anniversary, she’s been my partner in experiencing fundamentally everything in these last 25 years, she’s been the most go to person in my life in good times and bad, and incredibly proud that we’ve hit 25 years today. Now, of course, we’re too young, we’re both too young for that to be possible, but suspend your disbelief. I just want to remark and take the point to say that being joined at the hip with someone, such admiration for who cheers you on and you cheer them on, that we, you know, being at each other.

Andy Slavitt

We draw all of our inspiration purpose from each other. And of course, our boys, you know, you go through a lot in 25 years, if you don’t think about that. It sounds like a long time. When we think about 25 years ahead of us, but 25 years behind us, the birth of two sons, the death of our fathers, some health scares, the early loss of three of our best friends, we move cities, then we move back. We’ve gone on trips by ourselves and with our kids. We’ve done evenings with our friends; we’ve had day times with our work that we each pursue. And I couldn’t be a fraction of the person that I feel like I could be without her. So she’s given me just as she has other people every bit of herself. I just get more of it than other people. And that’s why I’m incredibly lucky. I just love her like crazy. And I just have to say that now, here on the show, but I think she knows. Anyway, thank you for letting me do that. Couldn’t get through the day without it. And now I’m gonna bring it full circle back to Tony Fauci. And listen and enjoy this great conversation. Thanks.

Dr. Tony Fauci  09:24

Hey, Andy, how are you?

Andy Slavitt 

I’m so good. How are you?

Dr. Tony Fauci 

I’m good. We miss you.

Andy Slavitt 

I miss you. I miss you a lot. You know, I don’t miss the work so much. But I miss you guys.

Dr. Tony Fauci

Yeah. Well, we’re doing okay. But it’d be great to have you back. But I’m sure you enjoying life and enjoying work.

Andy Slavitt 

I’m trying to do what I can to help from outside. I mean, I think that is the question most Americans have on their mind is how are you managing without me?

Dr. Tony Fauci

It’s very tough. You know, we talk about that every day. What are we doing here without Andy?

Andy Slavitt  10:00

Oh man. How are you? I mean, you’ve been at this for, this has been a marathon for the country. We started out in the marathon like watching the US Open for 10. You’ve been on the court for like, you know, 18 months straight without a break. How are you? How are you holding up?

Dr. Tony Fauci

It’s true. I’m okay. You know, it’s almost surrealistic, I haven’t had a day off really Andy, literally in 18 months, not a single day off. Not one single day off in 18 months.

Andy Slavitt 

It was a good thing you’re in your 40s.

Dr. Tony Fauci

Yeah, you know, if I was an old guy, it would be tough.

Andy Slavitt 

That’d be tough. How do you manage? I know you walk but you managed to stay mentally very, ahead of all the rest of us. How do you do that?

Dr. Tony Fauci

Well, I don’t know about ahead of you guys. But at least I stay on, you know, on track. You know, I don’t know what it is.

Andy Slavitt 

You’re not allowed to have an off day. That’s your problem. I mean, you literally can’t have a bad game. Because so much it’s run, so much is on line. So much pressure.

Dr. Tony Fauci 

Yeah, yeah, absolutely. But you know, something simple, like trying to exercise every day, if you could. But my wife is an amazing partner in the sense that she’s been through all of this throughout the world, you know, the almost 40 years that we’ve been married. And she, you know, she’s been through the worst of the AIDS epidemic with me and Ebola and Zika. And this is, it’s good to have somebody who understands what you’re going through.

Andy Slavitt  11:29

Yeah. So she understands. And you could tell the audience she understands not just as a spouse, but she’s also a person to sciences. I understand, right?

Dr. Tony Fauci  11:36

Yes. Oh, yeah. She’s the chair of the department of bioethics at the NIH. So she knows about all the sensitive issues and things. So she gets it, which is good.

Andy Slavitt

That’s incredible. Power couple. Yeah. Yeah. And how’s everybody else doing? I mean, you know, what to think about the president, and like the, you know, kind of the mood of the country when cases are dropping? Everybody feels like, oh, we’re doing it right, we’re doing it well, vaccinations are going up. And then, you know, sometimes cases are going up for reasons that have very little to do with anything you can control. Certainly, there’s better responses and worse responses. I’m not suggesting there’s not. But how do you see his mood shifting when things get challenging?

Dr. Tony Fauci  12:23

You know, it’s very interesting. I mean, I don’t think people fully appreciate how many crises he’s juggling at the same time. You know, you got historic pandemic, you got Afghanistan, you have weathered catastrophes, like hurricanes that are historic in their nature, you know, all occurring at the same time. It’s just amazing. He keeps his composure and he stays on track. It’s truly amazing.

Andy Slavitt 

It always impressed me that he knew, he always seem to know just the question to ask to make sure that the average person who is not able to get a lot of information and who is subject to maybe disinformation, but just maybe even isn’t even paying that much attention to kind of current events, to ask about how to make sure we’re taking care of them and focusing on them. I always found that incredibly grounding.

Dr. Tony Fauci 

Yeah. Yeah. Very insightful and empathetic person.

Andy Slavitt

Well, it’s, it’s great that he has you as his advisor. So we had, we had one of my colleagues, walk the streets with a microphone and said, if you had to have a question for Dr. Fauci, what would it be? And so we got some really great questions. And I hope you don’t mind. There’s only about 5000 of them. So we’re going to try to do our best to get to. Now I boil them down to a few, just a handful, and they’re all kinds of things that are on people’s minds that if you don’t mind, I’ll just, we’ll just run them. Let’s go at it. Okay. So I think a big question on a lot of people’s mind seems to be boosters, and whether or not boosters are effective, and whether they need to get a booster or when to get a booster and so forth. But can you maybe start with what you saw or the data you saw that started to lead you to believe that it probably would be appropriate at this point in time to recommend booster shots?

Dr. Tony Fauci  14:28

Yeah, you know what it was Andy. We were examining the FDA, excuse me, the CDC data. And when you look at the durability of efficacy against infection, as well as efficacy against severe disease, they were clearly showing a mild to moderate diminution of protection over time, against plane infection, mildly symptomatic, moderately symptomatic, and only the very early inklings of a diminution of protection against severe disease, pretty clear, but minimal. So there was saying appropriately, that it looks like protection against severe disease is really holding up. The only difficulty is that we are about a month and a half behind Israel in everything in the sense of the temporal rollout of the outbreak, the number of cases, the vaccinations. So we were able to make connections with our Israeli colleagues. And they shared data with us that was not yet published, which is now published.

Dr. Tony Fauci

And that is that they were seeing a substantial diminution in protection against infection. But clearly a significant diminution against protection against severe disease. So they already started on their booster program. So that made us plan as we came out with that pending approval by the FDA and the ACIP with the CDC, that we were planning on rolling out our booster plan around the week of the 20th of September. Having said that, what I think the reality is going to be Andy, I believe that it isn’t a question of a vaccine regimen that failed that you needed a booster, I think that a third shot is going to be part of the original vaccine regimen. Just the same way with hepatitis, where you have a prime, a boost after a month, and then six months later. So that the real proper regimen is a boost, we didn’t have a chance to determine that early on.

Dr. Tony Fauci  16:45

Because it was such an emergent situation, we had to get vaccines out to people. So all the tests were on a prime in a single boost. So we really need a boost. Because if you look at the Israeli data now being ahead of us, they already have data on what the effect of the boost is. And it’s really impressive. In other words, when you boost someone starting from around 12 days on wood, you reconstitute the protection against infection, and you reconstitute the protection against severe disease. And you do that by about tenfold. So the data have are very, very clear that A you need a booster and B the boosters really work.

Andy Slavitt  18:03

Now, we’re gonna test how good a student I’ve been of yours by whether the questions I asked you make any sense whatsoever. But so let me start with the pre-boost. As you see diminution, as you say, and hospitalizations, it we know that that at least at the outset, we’re talking 98%-99% protection against hospitalization. How much did Israel show hospitalization? How big a decline did they see?

Dr. Tony Fauci 

Yeah, that went down to around 70 ish in the mid-70s. It went from 98-97 down to 77-78.

Andy Slavitt 

Okay, and is there any reason to think that that’s specific to Pfizer and that Moderna might be different? Or is there a reason to think that they’re probably close to the same? I know, there was one study at Mayo that seemed to indicate that it was not peer reviewed I know, but it seemed to indicate that there might be some differences between the two?

Dr. Tony Fauci 

Yeah, I think there’s gonna be a slight difference, probably that the ultimate effect is going to be the same. It might be a little bit later Moderna, as you know, has three times the dose of Pfizer. So there are clearly studies that show that the level of antibody that’s induced with Moderna is about two and a half times the higher than the amount by Pfizer, even though they’re both high enough to give extraordinarily good protection. So what I would imagine though, I don’t know this as a fact, I would imagine you’re going to see the same situation with Moderna, as you’re seeing with Pfizer. Only it’s going to be a little bit later, it’s going to lag a little bit.

Andy Slavitt 

Got it. And so, as I understand it, mostly from listening to you, there are three types of responses that the vaccine creates in our bodies. There’s of course, the antibody increase which we’ve just been talking about. There’s also the memory B-cells, and of course, the T-cells. And so when we talk about what we see going on with the vaccine, beginning to wane over time, I want to see I can pick apart and understand both those three components as well as this confounding factor of during the period of time when things started to wane, Delta emerged. And so I know that the CDC was trying to take a look at how to pull some of these things apart. But are you able to tell how much of that is due to Delta? How much of it is due to waning? And then what the effects are on those three different and the cellular forms of immunization?

Dr. Tony Fauci  20:43

Okay, so let’s unpack that one at a time. There’s no doubt in my mind, Andy, that it is both waning, and Delta. I don’t, I mean, it isn’t just waning. Because before Delta came, you saw the diminution was already going down. So clearly, it’s waning. When Delta came, given its increased the ability to transmit, you saw an even more profound drop, because there’s a lot more transmissibility. So that’s the answer to your first question. The answer to your second question. It’s complicated, but it’s sort of elegant immunology in the following way. The thing you usually measure is antibody levels, which are going to be the things that immediately will be there to stop the infection, for example, in the upper airway, they also get involved in the lungs. But the lungs also have innate immunity, they have T-cell involvement, and they will require the generation of a memory B-cell from the memory B-cell response, because the memory B-cells when you trigger them, they’re ultimately going to make antibodies.

Dr. Tony Fauci 

So what you’re seeing is that the memory B cells require getting stimulated and getting an animistic response. So it is very likely that what you will see is you will see a diminution of protection, when the level of antibody is very low, because protection against infection is an immediate phenomenon, it gets into the nose, it starts to replicate. It takes a while before it gets into the lung. And by that time, we believe that we haven’t proven if we believe you’ve given the B cells, enough time to generate a memory response. That’s the reason why protection against severe disease is in many respects, easier to maintain, than protection against infection.

Andy Slavitt  22:47

I guess that’s why it’s surprised me to hear you say that in Israel. We saw hospitalizations go from the 90s to the 70s. does that imply some sort of failure in the response of the memory B-cells or the T-cells?

Dr. Tony Fauci

No, I think it in some respects, yes. Because you never you never got them stimulated enough to quantitatively have enough. And that’s the reason why I believe, Andy, that the correct regimen is going to be three doses. It isn’t as if two doses failed. Let’s try for three, it’s like three is the right combination

Andy Slavitt 

Three, or is it possible two, six months apart?

Dr. Tony Fauci 

Good point. We’re going to give you a degree in immunology. No, absolutely. Because we know that if you give the immune system time to mature and get a higher affinity, that if you give the second dose a little bit later. And as a matter of fact, it’s really interesting, Andy, that the Brits did that, because they didn’t have enough doses. So they were trying to stretch out. So they because of a shortage of doses gave up to 12 weeks or more between the first dose and the second dose. And they’ve done much better in two doses than those who did the two doses close together. Got it. So they probably almost inadvertently did the right experiment, namely giving it time to mature.

Andy Slavitt  24:27

Right. Got it. Do we believe, is one of the implications of what you’re suggesting that with this third dose in the regimen, that if the antibody counts stay boosted, stay higher, that that will not only reduce symptomatic disease, but will bring us to a place where vaccinated people are much less likely to be infectious.

Dr. Tony Fauci 

Yes, and let me tell you why. Not only do I conceptually think that’s true, but if you go into the Israeli data, simultaneously, with their dramatically increasing the protection against infection and serious disease, the […], in their cohort diminished from 1.33 to 1.11, which means they clearly, were preventing transmission.

Andy Slavitt

This is with the boost?

Dr. Tony Fauci

This is only with the boost. Absolutely.

Andy Slavitt

So there’s something in the 10% to 15% improvement, which, since it’s only given a part of the population, that sounds quite significant. I mean, I can’t quite do the math in my head. But it sounds quite significant. Yeah. So based on what we’ve seen in Israel, and based on what we’ve seen in I guess we’re down the road in Germany as well. We are seeing that the boost is having the kind of effect they were hoping with?

Dr. Tony Fauci

Yes, yes, indeed. And I was very impressed. And the Israelis are coming out now and preprint servers with their work. And I think when the rest of the world sees it old, it’ll be very impressed.

Andy Slavitt  26:07

What could I mean, that this feels like an optimistic assessment. It doesn’t mean you’re being you’re being optimistic, I mean, relative to what we could be hoping for in the booster. You know, if things play out the way you describe them, then you know, we’re going to both improve our chances at reducing the spread as well as keeping people alive, which are obviously two twin goals here. Is there a pessimistic case? I mean, is there a scenario YOU worry about where things don’t work Quite as you hope?

Dr. Tony Fauci 

Yeah, I mean, my pessimistic case, Andy is that if we don’t get the virus under control globally, which is going to be much, much more of a challenge, I think, than getting it on the control in the United States, so the UK, that will continue to have such a level of virus replication and dynamics in the global community that we’re going to ultimately select for a variant that’s not going to be well controlled, even with a high level of antibodies. The good news about Delta is that even though the boost is against the original prototype virus, it’s not against Delta, that when you increase the levels of antibodies so high, it crosses over and protects against all variants. Because we’ve seen, for example, that in Israel, the Delta variant is overwhelmingly dominant. But when you give the third boost, even though you’re boosting against the prototype, the protection of the vaccine reconstitutes, and goes above what it was with two doses.

Andy Slavitt 

Got it. Well, let’s talk about the globe, then for a second, because, you know, I agree with you that it is co-equal the top challenge and priority that we have, along with keeping people in our country safe and vaccinating the pockets in the US where we haven’t vaccinated yet. My understanding is we’ve done about 5 billion shots globally, which has actually, you know, feels like quite a bit of good progress. And we were doing about a billion shots a month around the globe. Still, I think, as we get through it, we will have done a nice job in Europe, North America, East Asia. But I have a lot of work to do in South Asia and Africa. And by the math that I’ve done, and you can correct me if you seen differently, we should have enough vaccines to vaccinate the globe, sometime in the first part of 2022.

Andy Slavitt  28:48

And why I’m a little less specific is because I don’t know if we’re talking two shots, three shots, one shot, you know one shot, adults only, etc. but you know, very strict math is that you can get one shot into 70% of the globe will have enough vaccines to do that, kind of by February, or March, the challenge, of course, seems to be the same challenge we had in the US only more large at large, which is it takes a lot of logistics. It takes a lot of coal transport, it takes a lot of conversations with clinicians, it takes a lot of infrastructure. And those things are easier in some countries than others. Do you think it’s a realistic goal to say that we can vaccinate the globe in the first quarter to the first half of next year?

Dr. Tony Fauci 

No, I don’t think that’s going to happen. I think from a pure just like you said, from all the logistic constraints, and even from the production. I think we’re talking more like end of 2022 beginning of 2023.

Andy Slavitt 

To get to what portion of the globe?

Dr. Tony Fauci 

You know, what do you said 70% this year? I think it’s probably going to be well into 2022. The middle to end of 2022 into the beginning of 2023.

Andy Slavitt  30:02

That seems really concerning. Right? It seems like the opportunity if that’s the fact, if that’s the fat, I don’t dispute that. That’s the way things maybe without any changes headed to playing out. But it seems to me that that gives the virus an awful lot of opportunities to mutate that if we were able to do it in the beginning of 2022. We’d be in a lot better off. Does that concern you, too?

Dr. Tony Fauci

Yeah, it does. It does. I mean, that’s the reason why we’ve got to do as best as we possibly can. But I don’t think it’s going to be the beginning of 2022. Remember, it’s, you know, September, October, November, December, it’s like five months away the beginning of 2022. That’s the problem. Yeah.

Andy Slavitt 

I don’t say January, but I’d say the first or second quarter, because if we’ve done 5 billion vaccines, and there’s 8 billion people on the globe, yet 16 billion, 70% of them is, you know, you’re talking 12. Again, now, this is a two-dose regimen. You know, so that’s another six and a half 7 billion doses. And we’re producing a billion a month. And so we’re in September, October, November, December, January and February, we’re talking about to get one vaccine in 70% of the of the globe. Based on manufacturing capacity, it feels like you could do that by February.

Dr. Tony Fauci

And the question is, are you going to get it into people’s arms? That’s the issue.

Andy Slavitt 

I know you’re our representative at the WHO, what appear to be the issues, because it feels like if you could somehow compress, if those numbers are roughly right, if you could somehow, if it takes another eight to nine months after February to get vaccines in people’s arms. And you could do that more quickly. And again, we’re talking mostly about Africa, South Asia, certainly pockets of South America, Central America feels like if that’s the most important thing, with kind of full G7, G20 leadership, it feels like that is that would be a priority to try to accelerate it.

Dr. Tony Fauci  32:34

I agree with you completely. And that’s the reason why I would hope that we use the infrastructure that’s already in place, that actually is not being fully utilized. I mean, I’ve spoken to my colleagues who are involved in the PEPFAR program, you know, with PEPFAR with HIV AIDS, we set up this extraordinary infrastructure to be able to distribute drugs for HIV, we can utilize that in a vaccine campaign. That’s what I’d like to say.

Andy Slavitt 

Yeah, I’ve been talking to the PEPFAR folk, hearing the very same thing you are, let me ask you kind of a, it’s a sort of a tough question. But it feels to me like if the US could say to the globe, we could commit to participating and leading the way to vaccinating the globe at the levels we’re talking about roughly, in the first part of next year, that it’s not so controversial for us to for not just the US, but for the first world nations, the 10 largest, wealthiest nations to take their third shot. It feels to me like if we say, no, it’s not going to happen until the latter half of 2022, or 2023. And it may be I’m picking arbitrary times here, that, that it is a little more challenging to say, to other countries, let us take our third shot. Before we put a first shot at the arms of other people in the globe. I hope we could be able to do both. I would like to think that we could say if there’s ever a time for us to call it the big guns, and do both using the PEPFAR assets as exactly as you say, would be that would be a great time to do that.

Dr. Tony Fauci  34:10

I totally agree, Andy, totally.

Andy Slavitt 

So let’s talk about variants. I think that’s really helpful to people on boosters, it tells me that, you know, we need to get boosted in that there’s an optimistic scenario under which getting boosted will be part of this first regimen and that is you say, like a flu booster and a year later. And of course, that what we have to be watching for are what comes after Delta. Let me give you a good my laypersons understanding. And again, we’ll see how well you’ve taught me. That in evolutionary biology, the virus basically struggles to survive. And there’s kind of two basic ways that can do that. It can struggle to survive by overcoming the vaccine and therefore surviving that way or spreading far and wide so it can’t be caught i.e. being more contagious, right? Delta as a variant is the latter. The vaccines can defeat it by and large, but it’s awfully hard to catch. It’s a fast runner, it runs fast, it runs quick, Beta and other things we’ve seen they’ve been a little tougher on the vaccine, but thankfully have been out competed by things that are running faster like Delta. So it seems like if that’s the right formulation, that the big fear is you get a future variant that is both more contagious, and also more invasive. Is that what we worried about?

Dr. Tony Fauci 

You hit the nail right on the head. That’s exactly what you worry about. You worry about high transmissibility, and a refractoriness to vaccine and high pathogenesis. He knows 351, the South African one way back that we were worried about. Yeah, that’s the more worrisome virus from a pathogenesis standpoint, in some respects than delta. But Delta knocked it right off the chart. Right. So, you know, in some respects, it’s bad news that we got Delta. But in some respects, it’s good news, that Delta isn’t particularly more, you know, evasive as it were from the vaccine than the others.

Andy Slavitt  36:17

Right. So when we look at, you know, Lambda, Mu, and some of these other things we’re seeing in South America, to any of those have the properties that concern you that they are combination of Beta and Delta, that they have both of those elements together?

Dr. Tony Fauci 

You know, I don’t think we could say that, Andy, they have the constellation, of via of a mutations, that say they could likely spread more readily, because they have just the right receptor binding domain mutations, but they don’t have the capability. As you said, they’re not sprinters. They’re not the fast runners, at least in the presence of Delta, they haven’t knocked Delta off. I mean, Mu, everybody’s talking about Mu, because it has a few extra, more mutations. And in Vitro, it’s worrisome. But we have Mu here, and it’s getting suppressed by Delta, Delta is 99 plus percent in the United States.

Andy Slavitt 

So we don’t see a path where mu is going to be able to overtake Delta, at least right now.

Dr. Tony Fauci 

At least right now. I don’t see that. But again, you know, you don’t ever put anything past viruses.

Andy Slavitt 

Is there a reason why we haven’t seen a virus that has both characteristics? Or is it just randomness that we haven’t? And we’re very likely to?

Dr. Tony Fauci 

It’s random. It really is random. I think we’re fortunate that we haven’t seen both. So let me give you an example of random, you know, people over the over the decades, and they used to ask me all the time, what is your worst nightmare, what keeps you up at night, and I, if you go back on the record of my recorded remarks, it’s always, you know, you have a virus like the 2009, Swine flu, which was extremely efficient and transmission, but was a wimpy virus. When it came to pathogenesis, the deaths that year were very, very low, then you had the H5N1, H7N9 the one that jumped from chickens to humans. It was ferocious in its morbidity and mortality, like 30% 35% mortality. But it was horrible in its efficiency from going to human-human. So my worst nightmare, I used to say, was a virus that has both, that has the extraordinary capability of transmitting from human to human. And that has the capability of a high degree of morbidity and mortality, particularly in selected populations. And that’s exactly what happened with COVID. And that’s the why COVID, historically, is the worst respiratory borne pandemic that we’ve had in 102 years. And it gets right back to what you just asked. It’s just random, that you happen to have a virus that has a combination of characteristics that makes it very formidable.

Andy Slavitt 

One of the things that you, you may not recall this, but you were on the show last year before, not that long before I came and joined you in the administration. And one of the things you taught all of us was that you tend to be able to be more optimistic about vaccines, if the body itself can produce a response in response to a virus. And that one of the reasons why you weren’t surprised that we were having such success and why you were so hopeful that we would, we would ultimately had vaccines that would be effective, is because the body could recognize the virus. Abadi could respond to the virus. It made it an easier target for the vaccine. I know I’m paraphrasing. So you please correct me if I didn’t get that right.

Dr. Tony Fauci  40:01

You’re relating it correctly.

Andy Slavitt

Okay, good. So what does that let let’s play this out. And let’s say we have a Greek alphabet letter from something that emerges in some country that has those two random properties that we don’t like. In other words, it mutates in a way that the current vaccine even boosted, can’t handle well. And it is highly contagious than Delta. So marked age is a Delta means it’s got it’s approaching kind of measles like contagiousness, just kind of crazy. From a science perspective, where does that leave us? And how quickly do you think we’ll be able to respond and create a vaccine that can defeat it?

Dr. Tony Fauci 

You know, as strange as it may sound? It doesn’t bother me. Well, it does bother me because I don’t like to see suffering and death. But from a scientific standpoint, the fact that something is really contagious, and really, pathogenesis is less relevant regarding a vaccine than whether or not the body makes a good immune response. So you take HIV, HIV, the body does not naturally make a good immune response against HIV. So here we are 40 years into the outbreak, and we don’t have a good vaccine. But if you told me, Tony, we have a COVID strain that’s highly transmissible, and very, very pathogenic, I would say, well, that’s bad news. But, get a group of people infected by it. And if a certain proportion of them, ultimately clear the virus, they may get sick, but their immune system ultimately clears the virus. I will tell you, Andy, that tells me we can make a vaccine against this, no matter how transmissible it is, no matter how pathogenic it is, because she got to go with the body’s ability to do something naturally, that’s what would dictate whether or not we’re going to be successful or not.

Andy Slavitt  42:02

And so we had Albert Bourla on the show. And he said that he thinks that they can be roughly I can’t remember if he said 90 days or 100 days cycles, in order to create a new vaccine that respond to a new variant. Because of the work that’s already done. That’s what his team tells him. Now that doesn’t account for manufacturing time and distribution and so forth. But does that sound right to you that if we saw something, let’s say in March of next year, that by June, July, we’d be in a place where we had something that could get through FDA and effect? Obviously, this is a theoretical question, not a question about what the agency is doing. But does that sound like the right timeframe? Or do you think it’s longer than that?

Dr. Tony Fauci 

No, no, I agree with Albert, I think, given the technology and the flexibility of the mRNA technology, which is one of the reasons why it’s such a favorable technology. But as you said, that doesn’t take into account manufacturing capability. But we can get one ready to go. So I think that if we stick by that, in fact, Andy, you know, because before you left, we were talking about pandemic preparedness plans, broad plans. Remember what we were saying, you remember, one of the goals were to be able to get a vaccine within 100 days and get it distributed within the next 100 days, you know, with manufacturing. So if we build up the capability with these new platforms like mRNA, I think what Albert says is entirely feasible.

Andy Slavitt

So we could have a bad couple of months. I mean, we could have a few months, three months, five months, six months, where it feels like we’re in real danger, but not the kind of danger that we can’t recover from. And again, we haven’t talked about it on this show. But you and I just now but obviously all of this puts lots of pressure on, NPIs and public awareness and public consistency. And that’s something we’ve had a much tougher time of than the science, unfortunately. But that could be that if we’re going to think about preparing for a scenario that might be difficult. Thinking about a five- or six-month period where we’re reconstituting the fight against a variant might be one of those.

Dr. Tony Fauci  44:27

A really good example of another element that’s important, Andy, the idea of surveillance. So let’s say a virus emerges in China again, okay. And we know like, on day one, that it is really transmitting very, very well and it’s killing people. If we set the clock at day one, and it takes 100 days to get something that you could get into clinical trials. And then maybe just another additional time you’re talking about remember when COVID-19 came, it didn’t really hit us badly in the country until you know, the end of the first quarter right of 2020. So if we add that amount of time you realize that even though it’s hurting people in other countries, because it’s exploding by the time it gets around the world, you got a pretty good head start if you got the technology to get you there.

Andy Slavitt 

Got it. So we’re just gonna need to be nimble. And I think that’s, you’re exactly right. That’s a lot of the preparation, or you and others and David, have been doing, I want to close on two quick questions, and I so appreciate you taking the time to talk to us. The first is about an oral antiviral, because in any scenario, it feels like something that is Tamiflu, like something that is easily accessible, doesn’t need to be injected, or infused, but that if someone gets COVID, that they can take it essentially, will keep them out of the hospital and keep a severe disease from rolling would be yet another great tool in our arsenal. I know there’s trials going on right now, can you give us a sense of is A is that right? And B, is that something that you can, do you think we can conceive of having in the near future?

Dr. Tony Fauci  46:17

The answer is yes, it is a correct concept. And I’m thinking of an orally administered, hopefully one pill a day that you give anywhere from 7 to 10 days, upon the acquisition of knowledge that you’re infected with SARS-CoV-2, to prevent the virus from going from the upper airway into the lung. And if it gets into the lung, to suppress it in the lung, we have at least three and maybe five candidates that were already involved in clinical testing, polymerase inhibitors, […] inhibitors, I believe, that is going to be the answer, complementing vaccines of getting us out of this, because there will be people who get infected, either because they get breakthrough infections being vaccinated, or they don’t make a good response to begin with, who you’re going to want to treat. So I consider that a major pillar of the response together with vaccines. And I think it’s doable. We did it with HIV, Andy, you know, we went from nothing to antivirals that totally transformed the lives of HIV of persons with HIV.

Andy Slavitt 

And what do you think roughly? I mean, I know we’re in the middle of trials, we’ve got candidates, is the outlook look like before the end of the year, early next year, or really too early to say, and probably later than that.

Dr. Tony Fauci

I think we could get at least one of the candidates that are being tested right now, knowing whether they work by the end of the year. And I think as we get into the first quarter, second quarter of 2022, we’ll likely have more than one candidate.

Andy Slavitt

That’s great. The last question I want to ask you is about long, COVID. And about the research. There’s funding within the NIH. I don’t know of any that grant funding has gone out to this point. But it feels like for all the attention that we give vaccines, that in addition to and in antiviral treatments, and understanding what’s going on with long COVID are is another part I know it’s a priority of yours. Someone if you can update us and how.

Dr. Tony Fauci  48:32

Well. We’ve been given $1.15 billion to look at that. And we have already because you asked a good question, has money gone out yet? We have already now developed cohorts and the money has gone out the door to develop the first cohorts to be able to study it for its incidents, you know, its prevalence, its pathogenesis, and is there any interventions that we could do because it’s a real phenomenon. It’s not maybe, there are a considerable number of people ranging from you know, 10% to up to 30%, who have variable periods of time measured, sometimes in weeks and sometimes in many months of symptoms and signs that could be incapacitating, profound fatigue, muscle ache, temperature dysregulation, sleep disturbances, concentration, difficulties. Yeah, it’s real. And we’re taking it very seriously.

Andy Slavitt 

Got it? So you have to answer this honestly, were these the best questions you’ve ever been asked? And I’ve done a lot of interviews.

Dr. Tony Fauci 

Unbelievable. I mean, you’ve knocked it. You knocked it out of the park. It’s gonna embarrass all the others who’ve interviewed me.

Andy Slavitt 

Apologies to Wolf and everyone that had to do this, but you’ve given us an extraordinary tip. You’re incredibly generous and what I think people don’t everyone knows you for your grace and your knowledge. And, but what I tell people is just what a wonderful human being you are personally and on top of all that stuff. And, so I’m grateful for clearly, to them some of the things you’ve taught the country and how you stick in there and I don’t know how you do it, but I’m really grateful to you.

Dr. Tony Fauci  50:22

Alright, thanks a lot, Andy. It’s great to see you again. And it’s I appreciate being on with you. It was really a pleasure. Take care.

Andy Slavitt 

Let’s go do some dating apps now. Okay?

Dr. Tony Fauci

Take care. Thanks a lot, Andy. Bye, bye.

Andy Slavitt 

Thanks to Tony. Does his personality just shine through? When you listen to him talk, I think he just brings so much of the spirit of kind of what we admire in people. Courage, Grace, humility, knowledge, intellect. And I can tell you just an absolute, as I said, great human being a pleasure to work with. Funny guy, funny guy to let me tell you what’s coming up in the next two shows because they’re gonna be just as good. Laurie Garrett, the Pulitzer Prize winning science journalist. Boy, she is amazing. She’s a firecracker. It is a fun, fun and intense conversation to be followed by the other person that won the Pulitzer Prize for journalism around the pandemic Ed Yong. So two of the best writers, describers thinkers, communicators about the pandemic, following up on this episode with Fauci incredibly, fortunate to have them here. I’m incredibly fortunate to have you all listening in. I’m incredibly fortunate to have made my 25th anniversary today with Lana. Okay, we’ll talk to you in the coming week.

CREDITS  52:11

Thanks for listening to IN THE BUBBLE. Hope you rate us highly. We’re a production of Lemonada Media. Kryssy Pease and Alex McOwen produced the show. Our mix is by Ivan Kuraev. Jessica Cordova Kramer and Stephanie Wittels Wachs still rule our lives and executive produced the show. And our theme was composed by Dan Molad and Oliver Hill, and additional music by Ivan Kuraev. You can find out more about our show on social media at @LemonadaMedia. And you can find me at @ASlavitt on Twitter or at @AndySlavitt on Instagram. If you like what you heard today, most importantly, please tell your friends to come listen and please stay safe, share some joy and we will get through this together.

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