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Medical News & Perspectives
JAMA Live Highlights
August 5, 2020

Experts Discuss COVID-19—Remdesivir, Vaccines, and More

JAMA. 2020;324(8):730-731. doi:10.1001/jama.2020.15067
Conversations with Dr Bauchner (36:46)
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Conversations with Dr Bauchner (42:42)
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JAMA Live Highlights features comments from livestream interviews by JAMA Network Editor in Chief Howard Bauchner, MD. His discussions with experts in clinical care, public health, and health policy focus on critical issues related to the coronavirus disease 2019 (COVID-19) pandemic. Comments have been edited for clarity.

Rochelle Walensky, MD, MPH

Chief of the Division of Infectious Diseases, Massachusetts General Hospital

On aerosols vs droplets: So the real issue is the size of the particle—droplets being 5 to 10 microns; aerosols being anything less than 5 microns. And we believe that severe acute respiratory syndrome coronavirus 2 is droplets. However, there've been enough studies now and enough cases that demonstrated that there's probably some aerosol in there as well, that it's not just big particles. It's some small particles too. I want to make the important point with regard to this that when we in health care think about droplets vs aerosols, we think surgical mask vs N95 respirator. I just want to be clear that this does not mean we all need to walk around in N95s. And that, I think, is a really important point to make. In the July 6 letter about airborne transmission, even the World Health Organization did not ask for N95s. It asked for more ventilation, air filtration, and decreased crowding.

On the antiviral drug remdesivir: It is kind of, I think to quote Dr Anthony Fauci, a solid single but not a home run. But right now, it’s one of the best things that we have for people who are not quite as sick as meriting dexamethasone. So this is sort of a continuum. You come to the hospital because you need oxygen. That's kind of the time to use the antiviral, before you have all the inflammation and probably less of the time to use dexamethasone. If you progress to a place where you're really super sick, you have the inflammatory immunity responses that land you in the intensive care unit (ICU), that's probably the time to use dexamethasone. And, in fact, that has demonstrated a mortality benefit that we haven't yet seen with remdesivir. One thing that's important to me is the access and cost of these drugs. So, dexamethasone is cheap. It's probably less than $50 for the 10-day course. It's accessible; everybody can get it. Remdesivir, less so.

Michael Osterholm, PhD, MPH

Director of the Center for Infectious Disease Research and Policy, University of Minnesota

On the lack of preparedness: The challenge we've had across the board, and it's not just a political party, it's not an administration, it's not any one discipline: everyone lacked creative imagination to imagine that where we're at today could actually happen.

On the spread of COVID-19: I liken it more to a forest fire. Wherever there is wood to burn—susceptible humans—it’s going to find it.

On contact tracing: This is the one time in contact tracing we don't have anything to offer anyone other than to stay in your place for 2 weeks and don't go to work. I mean, with HIV we were able to offer people AZT [zidovudine]. We have some real challenges of what we do to stop this transmission short of distancing. I think distancing, distancing, and distancing is really the only focus we have, and it has proven to be successful.

On COVID-19 vaccine: A vaccine is only a vaccine. It's nothing until it's a vaccination. And I think that's where we're going to have to understand how we’re going to deliver this. I worry about supply chains. There are people who will want billions of dose vials right now. Can the glass companies make them? How are we going to deliver it? Right now Operation Warp Speed is talking about the military delivering it. I can tell you from many of my colleagues in public health, that is not seen as a good idea.

On lessons from pandemic 2009 influenza A(H1N1): The US Department of Health and Human Services (HHS), with good intention, kept promising influenza vaccine to the public. And when it didn't arrive on time because of challenges growing the virus, when people got very upset and concerned, literally it threatened the credibility of HHS. I worry here that we don't over promise when a COVID-19 vaccine might come because I think that we will set ourselves up for failure.

Robert Redfield, MD

Director of the US Centers for Disease Control and Prevention

On masking: I think the data are clearly there that masking works—whether it’s a face covering, whether it’s a simple surgical mask, or whether it’s masks that are used in the clinical setting. If the American public all embraced masking now, and we really did it rigorously, maybe more like the Germans who when they say everyone isolate, I think they got a lot of cooperation. When we isolated, we probably had less than half the American public do it. If we could get everybody to wear a mask right now, I really do think over the next 4, 6, 8 weeks, we could bring this epidemic under control.

Flavia Machado, MD, PhD

Chief of the Intensive Care Sector of the Anesthesiology, Pain, and Intensive Care Department at the Federal University of São Paulo, Brazil

On conflicting priorities: We need to be prepared for the new reality, which is already happening. For instance, in our hospital if you have COVID-19 you will get an ICU bed. But if you have a non-COVID patient, it will be much more difficult to get an ICU bed. So in hospitals where you have the 2 tracks—COVID and non-COVID—now things are getting worse for the non-COVID. The elective surgeries are happening again, so we are starting to move again to the non-COVID. And we will need to be prepared for this, not for 2 or 3 or 4 months, but until a vaccine is available broadly. So I would say, in the next 1 or 2 years, we will need to learn how to have COVID and non-COVID tracks. And we need to have new rules about testing patients for transmission for elective surgery, so the challenges of having the 2 tracks are going to be present for a long time.

Kalpalatha Guntupalli, MD

Chief of the Pulmonary, Critical Care, and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine

On the corticosteroid dexamethasone: Since the trial with dexamethasone came out of England, that has caught on quite rapidly. We’re familiar with the drug. We have used it, and we don’t see that many side effects. And also, the side effects—we know what to expect. It's not like some other drugs maybe that we are trying, like antivirals—we're not so familiar with it. I think we're familiar with this. So I think the one that has made a difference in the last few weeks, I would say is the dexamethasone for patients. If they're requiring any supplemental oxygen or the oxygen saturation is less than 94% on room air, they're considering giving dexamethasone 6 mg that they recommended in the trial.

On what’s unique about the COVID-19 pandemic: This is the first time when we are seeing that the same disease is filling the whole hospital. I remember with H1N1, we had 36 patients for 16 beds. But here we have the entire hospital, like New York and even in our place, 100 patients are in the hospital that have one disease.

Second thing is when is the last time we have seen that some of your friends are affected? I mean not because they had an MI [myocardial infarction] or gallbladder or something. They are affected by contracting it, either from the community or from work.

And the third thing is, when was there a crisis, a medical crisis, that you wanted to volunteer for, but you couldn't because you are needed in your [own hospital]? I remember when we had difficulties. I had friends calling me, saying, “Can we come and do something for you?” And they did come and help. But here, you know, I can't send our people to New York because we don't know when we're going to surge or if they contract the disease and come back, how are we going to manage? So I think some of those are unique.

And when did we see the sports arenas become hospitals, or Central Park? I think this is a once-in-a-century occurrence. And in some ways, I think being a central part of this, I think we should keep our eyes open [and look around us]. It's not just treating patients; there's a lot going on, on so many fronts. Look at the interns. They are managing this surge with amazing professionalism. I am so proud.

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Editor’s Note: For a complete list of livestream interviews by JAMA Network Editor in Chief Howard Bauchner, MD, that focus on the coronavirus disease 2019 (COVID-19) pandemic, visit Conversations With Dr Bauchner.

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