With the U.S. recently passing the milestone of 100,000 deaths from COVID-19, MedPage Today Editor-in-Chief Martin Makary, MD, of Johns Hopkins University, discusses reasons behind a potential spike in cases in our nation's Sun Belt states, what China has taught us about the value of masks, and what vaccines and treatments in the pipeline are most exciting to him.

Click here to watch part one of this discussion on what we've learned and how it can help us prepare.

The following is a transcript of their remarks:

Greg Laub: You've mentioned that second wave. If there is a second wave, with such a small fraction of the population being infected at this point, do you think a second wave would infect basically the same amount of people in the fall, in the winter?

Marty Makary: It turns out the other four major coronaviruses that have been around for years are seasonal. This may, in fact, be the fifth seasonal coronavirus. Now, we've had very promising news with the therapeutics and vaccines, but it is likely -- and most experts would say that it is likely -- that this is going to come back in the fall.

We've already seen selective pockets where there are outbreaks during warm weather. Remember, while this coronavirus appears to be seasonal, we don't know to what extent. Early on, the Sun Belt states did not get hit nearly as hard as was projected. Now, almost in a mini second wave within the first wave, we are starting to see cases not just increase, but hospitalizations increase, which I think is the best metric of how epidemic an infection is in that particular community.

It does lag behind -- about 8 to 14 days behind the infections -- but hospitalizations are still going up right now in Alabama. In Montgomery, Alabama, in particular, where the mayor there said last weekend that the ICUs are full, that there are no more available ICUs as of last weekend. Mississippi is seeing an increase in hospitalizations. Parts of Wisconsin, Minnesota, the District of Columbia, and Georgia.

Why are we seeing increases with warm weather right now? That is concerning. Because as we reopen the country, cases and hospitalizations will go up. We've known that. But we were hoping to have a lower baseline rate of infection as we reopen the country. We did not see a rapid decline. Most of the models used, what we call, a symmetric epidemic curve, which is a steep increase and a rapid decline. We didn't have that. That was not our experience.

The models were based on the experience in Wuhan, China, but they had very harsh and draconian shutdown conditions. Maybe that's why they had the rapid decline. Our experience has been more like the European experience, where we've seen a slower decline, and in some parts of the country -- where there may be, say, a disregard for the risk of the infection -- a long plateau and a very slow decline.

Even potentially, in some areas now, we're seeing a second mini-wave within the first wave, so I am concerned about that. I am worried about the fall. I think we can look at the other seasonal coronaviruses and say, "This is a threat."

At the same time, look at Brazil. Brazil is very concerning right now, over 1,000 deaths a day and increasing for a country a little larger than half our size. The most concerning feature is that it's warm in Brazil. It's in the 60s and 70s. Part of Brazil is at the equator. For them to have such a bad epidemic in Brazil with warm climate is a concern for what we could have when the cold season comes back and magnifies the problem.

Laub: With 100,000 deaths, the COVID-19 cloud is very dark. But if there is a silver lining, or multiple silver linings, what would they be?

Makary: I think there are a couple good silver linings that have come out of this horrible tragedy. One, for example, is that we will probably save thousands of people from influenza year to year because of the best practices that the public has now finally accepted, adopted, and believes in. That's important.

We've been oddly complacent about influenza deaths year to year: 81,000 deaths 33.5 years ago, just from seasonal influenza, so that is, I think, one positive. Maybe we thought we were too cool for masks in the past and we're now recognizing the value.

For me, this has been an evolution and a change in my own thinking. I'm kind of amused at the discussion around masks because I have been wearing a mask most of my adult life as a surgeon, but it turns out there's tremendous value in places where people can't maintain social distance.

I talked to a surgeon in China who has been sort of reassigned to Wuhan during the ICUs being overwhelmed there. I asked him, after the fact, once the epidemic had really calmed down, I said, "Wuhan is a city of 11 million people. You had a terrible outbreak there. How were you able to essentially manage the broader population of China, over 1.1 billion, without the same thing that happened in Wuhan happening around the rest of the country?" The virus is certainly not 100% extinguished. How were they able to manage the coronavirus in China, in a country of 1.1 billion, after the outbreaks in Wuhan and Harbin? You know what he said? He said, "It's because of masks. Everybody wears a mask." I thought, "You know, that is powerful."

The data has come out and the CDC guidance has come out, even last week, that the risk of droplet airborne transmission from person-to-person contact, breathing, from speaking, even, from that airborne droplet transmission, is far greater than from the transmission of the virus through surfaces. We're increasingly learning the value of wearing masks in a situation like that and I think it's powerful.

Laub: Now, everyone discusses the economic cost of a shutdown and how many people are suffering, but there's varying data on the cost medically of a shutdown. What are the true medical costs of a shutdown?

Makary: The public health data traditionally lags behind some of the more immediate claims. It turns out in this situation maybe the data on the public health consequences of the shutdown might actually be worse than some of the initial predictions.

It turns out that some New York hospitals have already reported a 30% to 50% drop in new cancer patients. Not existing cancer patients, but new cancer patients. Most hospitals are describing a reduction in cancer screenings to the point of a near-elimination of screenings.

In one study by Epic, the electronic health records company, through their Epic health research network, they identified an overall reduction in cancer screenings between 86% and 94%. That's cervical cancer, colon cancer, and breast cancer screenings, so there are going to be downstream effects of that.

Laub: Finally, the thing everyone has been talking about and looking forward to is vaccines, treatments. What are some of the most exciting treatments going on now? What do you see in the future?

Makary: If you would have told me three months ago we'd be this far along where we actually have multiple vaccines that have demonstrated that they can produce a neutralizing antibody by May, I would have told you, "I really don't think so. That sounds overly ambitious." But it turns out we're here. That's exactly what we have.

Many pharma companies have sort of deserted the vaccine business because of the liability and the low margins. There's been a big effort now to consolidate resources, and so you've got a lot of great news coming out right now.

There is a virus that J&J just announced with an adenovirus carrier. It's the viral carriers of the portion of the genetic code that can generate an immune response. They appear to generate a more robust immune response than simply using a protein coat, which some companies like Novavax are doing, an Australian company.

AstraZeneca and the Oxford mRNA vaccine has already demonstrated effectiveness in rhesus monkeys, which is basically the closest physiological lab compared to a human being. It's as close as we get in terms of a human's physiology.

That's impressive, generating neutralizing antibody in rhesus monkeys to the point where the monkeys have actually been exposed to the virus and don't get sick. Whereas the monkeys exposed to the virus and were not vaccinated with that mRNA virus or vaccine did not get sick. I mean, that's pretty impressive, once again, showing that we're beyond the feasibility of this. Now, it's really going to be a matter of figuring out the right dosage.

We've got multiple companies. Merck has been a little quiet with what they're doing. Sanofi is using the traditional approach. Pfizer has a lot of experience making vaccines, so we're seeing a lot of companies put their heads together.

The vaccine helps, even if it's 5% or 10% of people. Even if it's those who are high-risk. Even if it's selectively given to cashiers, TSA agents, healthcare workers, and those who are known vectors of transmission. All of that helps.

All of it's good news, along with remdesivir, and some of the new stuff now like some of the medications like Actemra, which are designed to work with remdesivir to reduce the cytokine storm. It's basically an immune modulator, so it's a new approach to this infection.

A lot of exciting things and I think it's impressive. When we let the scientific community do its work, it's pretty impressive what it can produce.

Laub: I want to thank you, Dr. Makary. It's been a pleasure having you here at your home, MedPage Today. Thanks for joining us.

Makary: Good to be with you.

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Can We Flatten the Second Wave Without Universal Masking? - MedPage Today