Vaccine passports, masks & herd immunity. Bhekisisa asked Dr Anthony Fauci

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  • In the United States (US), Covid-19 has become a pandemic of the unvaccinated: 99.5% of Covid-related deaths in the US are among people who have not had a jab.
  • Making it easy to get vaccinated, so taking vaccinations into communities, has proven to be one of the most effective strategies to counter vaccine hesitancy in the US.
  • Herd immunity against Covid-19 is achievable, Anthony Fauci says, but only if we vaccinate enough people and distribute shots equitably among countries.

Whether you’re for or against him, you must have heard of Anthony Fauci.

In the United States (US), where he’s President Joe Biden’s chief medical advisor and the head of the National Institutes of Allergy and Infectious Diseases (NIAID), his face, along with slogans such as “in Fauci we trust”, is emblazoned on coffee mugs, cup cakes, face masks, bottle openers and bumper stickers; there are even Fauci socks and saint candles.

But, as much as Fauci is lauded, so he is also despised. He’s been crucified by former US president Donald Trump’s supporters, who accused him of stalling Trump’s efforts to reopen the economy. His detractors have also claimed he’s secretly working for pharmaceutical companies and China, and exaggerating the threat of the coronavirus for personal gain.

During America’s devastating Covid-19 pandemic, in which more than 600 000 people have died, Fauci has played a crucial role in shaping the country’s Covid policies and fighting Trump’s endorsements of unproven treatments and stigmatising, unscientific statements.

The infectious diseases expert’s strong insistence on evidence-based health policies has caused such divides between Republican and Democrat supporters in the US, that both #TeamFauci and #FireFauci hashtags have trended on social media.

In fact, Fauci has received so many personal threats from rightwingers, that the US justice department has assigned bodyguards to him.

But in the health and science worlds, Fauci, 80, was known decades before Covid politics - and controversy is nothing new to him.

The medical advisor of every administration since Ronald Reagan, Fauci has led the NIAID through six administrations and several viral epidemics since 1984, most notably the HIV epidemic, filled with its own HIV dissident squabbles, which Fauci has fiercely opposed.

The journal Science reports that he has testified before a congressional hearing 245 times, often about the country’s HIV budget, that he found lacking. “You either get praised or you get killed. You just got to know when to duck,” he told the journal.

I learned of Fauci as a young journalist when I reported on HIV in the late 1990s and early 2000s during South Africa’s devastating HIV denialist period. At international Aids conferences reporters would fight over interviews with him and scientists and researchers would line up in endlessly long lines to speak to him. Sessions at which Fauci spoke would have people spilling out the doors.

On Sunday, I got a chance to interview Fauci for Bhekisisa and Newzroom Afrika’s brand new television programme, HealthHub. I asked him 18 questions about the future of Covid. Below is an edited, print version of that interview.

1. The United States (US) now says fully vaccinated people should wear masks indoors - previously you said they didn’t have to. Why and will we be wearing masks forever?

That is certainly not something that I think is in the future for us. The basis of our recommendation is that the Delta variant [that is now dominant in both the US and SA] has a high degree of transmissibility. It is well handled by the vaccines we are currently using, so the ultimate solution to all of this is to get as many people vaccinated as we possibly can.

The Centres for Disease Control (CDC) noticed that vaccinated people who have breakthrough infections caused by the Delta variant (a breakthrough infection is when a vaccinated person gets infected because vaccines are never 100% effective) have the capability of transmitting the virus to someone else.

The CDC acted with an abundance of caution and says that if [vaccinated people] go in an indoor public setting in an area in the US that has a high or substantial degree of transmission, they should be wearing masks. This is not only to protect themselves, so that they don't get infected, but also because they can inadvertently pass on the virus [if they are infected].

They can, for example, pass it onto someone in their home, a child or an elderly person, or someone who has an underlying immune deficiency that might make them more susceptible to a severe outcome.

We don't anticipate that that means there's going to be mask wearing forever, we believe that once we get this under control with vaccination, we won't be needing to do this at all.

2. Do we have an idea of when a new variant, which will become dominant, will emerge and what to expect of it - for instance, if it will have a better ability to escape immunity than the Delta variant?

There are no indications that that's the case, but all of what you said is entirely possible. One of the reasons why we continue to push to get as many people vaccinated as quickly as we possibly can, not only in our own country, but throughout the world is that viruses do not mutate unless they are allowed to replicate and spread. If you prevent the virus from spreading, it will not mutate, and you will not get another variant.

So the best way to prevent the evolution of yet another variant, that could be more problematic than the one we’re dealing with, is to get as many people vaccinated as quickly as you possibly can.

3. We know vaccines help us to not fall seriously ill with Covid, but, as you’ve mentioned, there’s still a chance that you could get infected. How do we frame vaccine messages that convey the realistic ability of vaccines, so that anti vaxxers don't use breakthrough infections as ammunition for their arguments that vaccines don’t work?

You have to give them the data and if they listen to the data, it will become apparent to them. There's one very compelling bit of data for why you should get vaccinated. In the United States 99.5% of all the deaths due to Covid are among unvaccinated people. Only 0.5% of such deaths are among vaccinated people.

The most important reason to get vaccinated is not so that you don't have to wear a mask. It is to save your life, to prevent you from getting infected and ultimately potentially getting seriously ill and dying. That's the argument that one needs to use when people say why should I get vaccinated - it's the 600 000 deaths in the United States that we've had that should convince people why they should get vaccinated.

4. As you've rightly mentioned, in countries such as yours large proportions of the population have been vaccinated, but you also have states where some people don't want to get vaccinated. If you have to look back over the past year, what lessons can South Africa learn from the US: what are the best ways to convince people to get vaccinated?

In the United States we've reached somewhat of a stone wall. We have about 100-million people who are eligible to be vaccinated who do not want to get vaccinated.

There are multiple reasons, but sometimes the reason is just the accessibility and the ease of getting vaccinated. Some people are inherently against vaccines, but some people are on the fence, and if you make it extremely easy for them to get vaccinated, you find that many people who would otherwise not get vaccinated immediately, will actually get vaccinated if you outreach to them and make it easy.

What we've done in the United States is to make vaccines available in over 40 000 pharmacies throughout the country. We have mobile units going out into not easily accessible geographic areas.

We have trusted messengers in society, reaching out to people. So lessons learned from the United States for South Africa is to outreach to the communities and to make it very easy and accessible for them to get vaccinated.

5. A controversial way to get people vaccinated is to make it compulsory for certain groups, such as health workers, to get vaccinated. Some of the federal departments in your country are looking into this. Is this viable and is it something that we should be looking into closer as the pandemic progresses?

The answer to that question is yes, but I think that we've got to be careful. If you have an overall mandate from the central government, that would not go over well in the United States - if there was a mandate for everyone in the country to get vaccinated.

But you can do something very effective that's a bit short of that and that is to say if you want to work in this particular department, you've got to get vaccinated. This was recently done in the United States veteran affairs agency and that has been successful thus far.

The mayor of New York City has said you either get vaccinated or you go to get tested at least once a week - so people who feel they don't want to go through the trouble of getting tested, may say, all right, I'll get vaccinated. It’s those kinds of inducements that I think are going to be successful in getting more people vaccinated over the next months to a year.

6. Some countries have announced that you need a green pass, in other words, proof of vaccination or a negative test, before you can, for instance, dine indoors or go to venues with large crowds. Is that what the future looks like?

In some countries that is going to work. There is a lot of resistance against vaccine passports as a national issue in the United States, but we're having a functional version of that anyway.

I will imagine that, once Covid vaccines get full approval from the Food and Drug Administration, that from a legal standpoint, many organisations will feel quite comfortable with saying, unless you can prove to me that you're vaccinated, you can't come to this university or college, or you can't work in this particular establishment.

That would be the functional equivalent of a vaccine passport, but it won't come centrally from the federal government.

7. How would we apply vaccine passports internationally without perpetuating vaccine inequity, so that countries that don't administer vaccines that are recognised by everyone, or that have vaccinated very few people, are not discriminated against?

That's a very good point: until you get equity, it's going to be very difficult on an international level. There are [vaccine passport] requirements internationally - for instance, there are some African countries that I have visited where you can't get into the country unless you have a yellow fever certificate.

But the yellow fever vaccine is available to everybody throughout the world, so you're not discriminating against some people. I think you have to have equity before you do that [implement Covid vaccine passports] at an international level.

8. How ethical is it for countries such as the US to vaccinate adolescents, who are not that vulnerable to falling seriously ill with Covid-19, when African countries don’t have enough jabs to vaccinate their most vulnerable populations?

Obviously, that is a consideration that is very much discussed at the level of ethics and that's the reason why we in the United States are pushing as hard as we possibly can to get as many doses to [poorer countries], including South Africa.

We have half a billion doses that we've already pledged, 200-million of which will go out this year and 300-million which will go out at the beginning of next year. [The US has also pledged] $4-billion doses going to COVAX.

But you're absolutely right, it's extremely important... wealthy countries really do have a moral obligation to do whatever they can to provide equity for the distribution of interventions that are life saving for those countries that don't have the resources to do it themselves.

9. Would it be fair of poorer countries to say, well until we have vaccinations for our vulnerable part of the population, wealthier countries should not go and vaccinate adolescents, would that be a fair thing to say?

I think you should try to do both as opposed to one or the other. I don't think we have to do one or the other and create a dynamic of opposition, I think we could try to do both

10. There is a running debate about whether we will need booster shots or not against Covid. How far are we with a decision for that?

If you're talking about a booster for an otherwise normal person, where the durability of the protection is in question (so how long does the effective vaccine continue to protect you and after a certain number of months, do you get a diminution in protection that would suggest that you have a boost), we don’t have enough data right now.

What is a bit different from that is what do you do about people who are immunosuppressed, people with organ transplants, people on cancer chemotherapy, people with autoimmune diseases, who are immunocompromised? [People who] never got an adequate response to begin with to the vaccine.

Getting them a dose is much more of a medical emergency issue than getting it for someone who is normal, who has a good response and you're just worried about how long that response is going to last.

11. Initially, our goal with vaccines was to reach herd immunity, but for the immediate future, it looks like containment might be a more realistic goal. Are we ever going to see herd immunity - is that achievable?

Herd immunity is a concept that certainly is achievable, which means you get enough people vaccinated and or having been infected and are left with lasting protective immunity.

I know one way you could reach it really easily, is get 100% of the people vaccinated and then you really do have good herd immunity.

You're likely not going to get 100% of the people vaccinated, but if you get a very overwhelming majority plus the people who've already been infected and are protected, to some extent, you will reach it.

What we don't know now is what's called the threshold of herd immunity - we don't know what that number is. When you don't know, the best thing to do is to get as many people vaccinated as quickly as you possibly can.

12. Will the fact that we have breakthrough infections, and that vaccinated people who get infected are able to transmit the virus, make it harder for us to reach herd immunity?

It makes it more difficult if you can transmit even if you have been vaccinated, but if the proportion of people that do that is low, which it is [if we vaccinate enough people], you're not going to interfere with herd immunity. Ultimately, you will get there.

If everybody who was vaccinated ends up getting infected and transmitting, then obviously you would never crush the outbreak, but we're talking about a relatively small fraction of people who are doing that.

13. You’ve mentioned that we can't just have one country vaccinated, we need to have everyone in the world vaccinated. But that is much harder in some parts of the world where we don't have vaccines. How are we going to bridge this?

We're going to reach it by a global effort on the part of the wealthy countries in the world through the WHO and COVAX and independently.

The US is doing a lot through COVAX, but we're also doing direct involvement with different countries by getting vaccine doses [to them].

The ultimate capability would be to build capacity so that you don't have to rely on giving people vaccines, you can have them make their own vaccines. That's the ultimate goal.

For the immediate future, because it's such an emergent situation, we would have to rely on actually donating doses to those countries that don't have the capability.

14. Is there sufficient capacity, for instance in Africa, to manufacture vaccines, because this is quite a long-term goal?

No, right now there's not sufficient capacity for sure, but we can build that capacity. That's what I think should be a goal starting right now to do that.

15. Will life ever return to normal again - in the way that we knew it before Covid-19?

I believe it will, but it's in our hands to make sure it does and we've got to act. We've got to get people vaccinated, we've got to produce a lot more vaccines. And we’ve got to make sure they get equitably distributed. If we do that, we will return to normal, but I hope the normal will be a better normal than we started out with.

16. What will be the better part?

Being prepared for the next epidemic.

17. How far are we away from our next pandemic and will it be a coronavirus as well?

I don't know that. If I knew that we would be much better prepared. That's one of the things, those are the unknowns, that you really don't know.

18. So lastly, how can we be better prepared, what is it that we can do?

We can build better capacity globally, have better surveillance systems and communications. We can have better collegial interactions with companies and countries in order to be more collaborative and cooperative, as well as to build up the fundamental science.

The reason why we were so lucky in getting highly effective vaccines, was because of the extraordinary investments that were made and fundamental basic and clinical research - that allowed us to move so rapidly to get effective vaccines.

We need to continue the strong support of biomedical research.

*This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter

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