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Anthony Fauci faces the ‘perpetual challenge’ of emerging infections


 

EXPERT ANALYSIS FROM ACP INTERNAL MEDICINE

 

SAN DIEGO– Reflecting on his 33-year career as director of the National Institute of Allergy and Infectious Diseases, Anthony S. Fauci, MD, can say one thing for certain: Emerging and re-emerging infectious diseases in the continental United States are here to stay.

In an article that he and his colleagues published in the Lancet in 2008, they used the term “perpetual challenge” to describe emerging infections, a descriptor that resonates with him to this day.

Dr. Anthony S. Fauci
“When you think about emerging and re-emerging infectious diseases, they have always been with us, they are clearly with us now, and we will certainly be seeing them in the future in an absolute predictable way,” Dr. Fauci told a capacity crowd during a keynote lecture on the opening day of the annual meeting of the American College of Physicians.

Global examples of emerging and re-emerging infectious diseases he discussed include dengue, West Nile virus, chikungunya, and carbapenem-resistant Enterobacteriaceae, “which is becoming a progressively more serious problem in hospitalized patients,” said Dr. Fauci, who is also chief of the NIAID Laboratory of Immunoregulation.

“We had a serious challenge with that at our own clinical center in Bethesda just a few years ago,” he noted. Numerous cases of antimicrobial resistance in methicillin-resistant Staphylococcus aureus, Clostridium difficile, and Neisseria gonorrhoeae have been reported.

Dr. Fauci described the Ebola outbreak as “a globally important disease that had ripple effects in the United States that were unpredicted,” referring to the case of the infected man who traveled from Monrovia to Dallas on Sept. 19, 2014, and developed Ebola symptoms 5 days later. Between 2014 and 2016, there were 28,616 cases and 11,310 deaths combined in the countries of Guinea, Sierra Leone, and Liberia.

“There is virtually no health care system in those three countries,” he said. “There’s a distrust in authority, and anything we tried to do as a global health [effort] made things worse. What we’re trying to do now is built sustainable health care issues in countries that don’t have it.”

Of particular concern to public health officials worldwide is getting a lid on Zika virus, a mosquito-borne illness that can be passed from a pregnant woman to her fetus and cause an increased risk of microcephaly, particularly during the first trimester.

“Not only is there microcephaly, there’s a whole host of abnormalities that involve hearing loss, visual abnormalities, and a variety of other issues,” Dr. Fauci said. “There are about 50 countries in the Americas and the Caribbean that have Zika virus transmission.”

According to data from the Centers for Disease Control and Prevention, from Jan. 1, 2015, to March 29, 2017, there were 5,182 reported cases of Zika virus disease in the 50 states and the District of Columbia. The majority of those (4,886) were travel associated, 222 were locally acquired mosquito-borne, 45 were sexually transmitted, 27 congenital, 1 was laboratory acquired, and 1 was unknown.

At the same time, there have been 38,303 cases in the U.S. territories. Of those, 38,156 were locally acquired, and 147 were travel associated. “That’s why there’s such an intense effort to develop a Zika vaccine,” he said.

According to the CDC, as of March 15, 2017, there are 265 cases of locally transmitted cases in Florida: 216 by mosquito and the rest by sexual transmission. “Talk about surprises,” Dr. Fauci said. “Zika is the first mosquito-borne infection that can result in a congenital abnormality, the first mosquito-borne infection that can be sexually transmitted, and now we’re learning more about this problem, which is the reason why it’s very important for us to develop a vaccine.”

A phase I trial of a DNA vaccine developed by the NIH Vaccine Research Center has reached its enrollment goal of 80 patients age 18-35 years. Initial results are expected sometime in the first quarter of 2017. A phase II trial in the United States and Puerto Rico is expected to launch soon.

Dr. Fauci closed his presentation by sharing lessons learned from previous pandemics.

The first lesson is that global surveillance is required. “Namely, know what’s going on in real time,” he said. “That has to be linked to transparency and communication. So that if something happens in China, we don’t find out about it months later, but we know about it in real time.”

Infrastructure and capacity building are also important. “The lack of capacity in West Africa can ultimately have an indirect impact on us here in the United States,” he said.

“Finally, we need to coordinate and collaborate; we need adaptable platforms for vaccines,” Dr. Fauci cautioned. “Importantly, we need a stable funding mechanism such as a public health emergency fund so that we do not have to go scrambling before the Congress when we need emergency funds.”
 
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