While U.S. cities record numbers of COVID-19 cases and wait anxiously for approval of SARS-CoV-2 vaccines and treatments, Melbourne, Australia’s new caseload has shrunk to zero. Why? The city’s residents have done what medical leaders have told them to do since the pandemic: Wear masks and shut down for a limited time.

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“They had a terrible outbreak in Melbourne—20,000 cases—and they decided that they were going to shut down temporarily, but they were going to do something like a mandatory mask mandate, a $1000 fine if you were seen without a mask in public in Melbourne,” said Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases and a member of the White House coronavirus task force.


“And over a period of a reasonably short time, a couple of months, they went from 20.000 to the day before yesterday to zero cases in the city of Melbourne,” he told JAMA Editor-in-Chief Howard Bauchner, MD, in the latest edition of “Conversations  with Dr. Bauchner,” a JAMA Network™ podcast.

While Dr. Fauci admits that Australia is very different from the United States. For example, as an island it could close off access, but the city of Melbourne itself is comparable to U.S. urban centers.

“Melbourne is a sophisticated, big city in a big, Western-like country. Then you look at the cities around here [where a thousand or more cases a day are common], the thought of a major United States city having no infections … boy do I long for that day!”

The prospect that the case reduction was accomplished in a major global metropolis is a hopeful sign, he said. But the United States is not yet headed in that direction. The United States has averaged about 70,000 COVID-19 cases a day and, in October, about 1,000 deaths a day. About 40,000 patients are hospitalized.

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Since the beginning of the pandemic, researchers estimate about 300,000 excess deaths, which could reach to more than 400,000 by the end of the year.

“We are not in a good place,” Dr. Fauci said. Though the rate of cases and deaths fell somewhat since the early peaks, “we never got down to a low baseline,” he explained. After the initial surge that was dominated by the New York City metropolitan area, the U.S. level sank to about 20,000 cases a day.

“Then when we tried to reopen the economy,” Dr. Fauci noted. There followed a resurgence up to 70,000 daily cases, back down to 40,000 a day, and most recently seeing daily caseloads blow past 80,000.

“That’s a bad position to be in. We should have been going way down in our baseline and we are not,” he said.

The position is even more precarious as the country heads toward colder winter months and more indoor activities and the holiday season, where tradition calls for larger family gatherings and travel, he said. But there are ways to reduce the rate of infection.

As indicated by the success of Melbourne and other international locales, masking really helps, he said, though the inconsistency of masking has diminished its efficacy. Masking has become politically sensitive and many refuse to wear masks as a political statement.

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“We got to get away from that,” Dr. Fauci said.

Meanwhile, prospective remedies aren’t quite ready.

Remdesivir was recently approved as a coronavirus treatment and more treatments—including other antivirals, steroids and monoclonal antibodies—are still being researched and tested, Dr. Fauci noted, but their efficacy varies and how they should be used in the course of treatment is not yet entirely clear.

Vaccine development continues and while some manufacturers believe they will have a Food and Drug Administration emergency use authorization by December, their data has not yet been reviewed and such authorizations remain up to committee review, Dr. Fauci said.

Naturally acquired herd immunity is not a fathomable option, Dr. Fauci added. By the time an appropriate percentage of individuals have been infected, many of the vulnerable members of the population—the elderly, patients with type 2 diabetes, hypertension or obesity—may die. And no one is sure what percentage of infections could yield herd immunity.

“That’s an unacceptable pathway,” he said.

Subscribe to the “Conversations with Dr. Bauchner” podcast. Each week, he interviews leading researchers and thinkers in health care about their recent JAMA articles. Go beyond an article recap, and delve into the background, context and implications of the study or editorial.

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