Let's Talk About Health, episode 1: 5 years of COVID-19 and the risk of avian flu

[00:00:11] Sebastián Oliel: Hello, everyone. Welcome to the first episode of Hablemos de Salud, the podcast and videocast of the Pan American Health Organization. I'm Sebastián Oliel, and I'm super excited to kick off this space where we'll discuss different health topics that affect us all, with experts who know what they're talking about. Today we have a very relevant topic. It's been five years since COVID-19 shook the world, so we're going to reflect on what we've learned, and along the way, we'll ask ourselves if avian influenza A(H5N1) could be the next big threat. To address this topic, we'll speak with Dr. Jarbas Barbosa, a physician originally from Brazil, an epidemiologist, public health specialist, and director of PAHO, the oldest international public health organization in the world. Dr. Barbosa, welcome. How are you?

[00:01:01] Dr. Jarbas Barbosa: Very well, thank you, Sebastián.

[00:01:02] Sebastián Oliel: Well, thank you for joining us for this first episode, Dr. Barbosa. As we said, it's been five years since COVID-19 entered our lives. In the Americas, we saw everything from overwhelmed hospitals, vaccines arriving in dribs and drabs at first, and entire communities adapting to a new reality. What would you say has been the biggest lesson this pandemic has taught us?

[00:01:27] Dr. Jarbas Barbosa: The biggest lesson is that all the preparedness plans we had in the past proved completely insufficient to respond to the pandemic. And this is because we always plan for the future based on the past. So, what we had experienced before—the 2009 avian influenza crises, SARS, MERS, Ebola—nothing had the same characteristics as the COVID pandemic. So, I think the best lesson we have to learn is that we have to prepare countries and international organizations for the future, based on all the lessons we learned during COVID. Incorporate everything we went through. As mentioned, the lack of equitable access, the capacity of health services, the ability to implement measures based on scientific evidence. In other words, there's a whole range of lessons we're learning that must be incorporated into countries and international organizations.

[00:02:43] Sebastián Oliel: And, doctor, why was it that our region was at one point the epicenter of the pandemic, and some countries had more cases and deaths than others, perhaps compared to the region and other countries in the world? Why was our region so affected?

[00:02:59] Dr. Jarbas Barbosa: I think there's an explanation for the socioeconomic determinants of the region. Remember that before having a vaccine, the most effective measure to reduce the transmission of the virus and prevent health services from being completely overwhelmed was the famous "stay at home." But saying that to countries where 50% of their population lives in the informal economy without a social safety net? That's not effective. People had to go out to find some source of income and buy food. Telling people living in the poor neighborhoods of large Latin American cities, the favelas in Brazil, the poor neighborhoods in all the large cities in our region to avoid crowds when they live almost in a natural state of crowding; or telling them to "wash your hands several times a day" when many don't have access to water. So, these factors were key for me. We certainly also had some major leadership errors during the pandemic in some countries. For example, there was a denial of what was happening, which undoubtedly made things quite difficult.

[00:04:19] Sebastián Oliel: And how do you think we are today? Are we better prepared than before for a possible future pandemic?

[00:04:28] Dr. Jarbas Barbosa: I believe we are better prepared because many of the lessons we mentioned at the beginning are being incorporated in the countries. At PAHO, for example, during the pandemic, we were able to set up a genomic surveillance network; before the pandemic, only the United States and Canada had that capacity. Today, 30 countries in the region have the capacity to monitor influenza viruses, which we need to know when they change, or known viruses that can change, or identify a case of measles, exactly from which part of the world the virus came. And the viruses that cause health problems like dengue and chikungunya—that network was completely a pipe dream before the pandemic, but today it's a reality. We also support countries in the region to expand external evaluation processes for their detection and response capacity. We are also seeking to fill other important gaps, such as the lack of equitable access to vaccines, with initiatives to strengthen regional production capacity. So, I believe we are better prepared. We are supporting countries in implementing Pandemic Fund projects. For example, there are many countries based on this One Health approach, because it has also become even clearer than before that if we don't have surveillance that can integrate human, animal, and environmental health, we won't detect early when a virus begins to circulate among animals and how it learns to transmit to humans. So that's the path we're moving forward on. We are better prepared. Are we fully prepared yet? No, we have to continue.

[00:06:22] Sebastián Oliel: Doctor, we also know that due to the pandemic, the lockdowns, and the limited access to regular health services, many health indicators have declined. How are we doing today in that regard?

[00:06:36] Dr. Jarbas Barbosa: If the pandemic has had a negative impact on all priority public health programs, in countries with good information systems, for example, we can verify that there was what we call excess mortality, that is, more deaths than would be expected from cancer, from cardiovascular diseases, because people were afraid to go to a hospital, because services were closed, many in order to focus on the response to the pandemic. In other words, we had an increase in the waiting line for procedures. We had a setback in vaccinations. We estimate that around 23% of children stopped getting vaccinated. Maternal mortality, which is an excellent indicator of access to health services and the quality of care, grew almost 100% in the region. Fortunately, this is already improving. In the Americas, I believe it is important to recognize and value the efforts made by all countries. It's the region of the world where vaccination rates recovered the fastest to where we were in 2019, although we're not satisfied. We want to go much further. We want to continue increasing vaccination coverage evenly throughout the region.

We also want to reduce maternal mortality to the level it was in 2019, although we also want to continue making progress there. On the other hand, during those moments of the pandemic, it became very clear that we need to more quickly incorporate some solutions to make health systems more resilient. For example, more appropriate triage, such as the use of telehealth or telemedicine. During some periods, having access to a teleconsultation was the only way for a person with a mental health condition to see a psychologist or psychiatrist; or for a person with hypertension to be able to share what they were experiencing with a doctor. I believe this requires us to further accelerate the implementation of telehealth/telemedicine, because in addition to preparing for a future pandemic, it can improve access today. Enabling people in remote areas to see a neurologist or cardiologist without having to travel two or three days, and it also improves the quality of primary health care itself. [00:09:13] Sebastián Oliel: Of course. Well, it's great to hear that we've recovered what was lost and that there are options to move forward more quickly. And I wanted to ask you about today, Doctor. How are we doing today regarding COVID-19? We can say that it's already an endemic disease that's here to stay. Do we have to continue worrying or not? And whether we should get vaccinated or not? What's happening today?

[00:09:34] Dr. Jarbas Barbosa: The virus is still here. Surely, since we don't have a vaccine capable of completely eliminating transmission, it's likely going to continue for at least a couple of years. Just like the influenza virus that accompanies humanity to this day. So, in that scenario, two things are necessary: ​​first, very active surveillance to identify whether the virus, which has the capacity to evolve, could evolve into a new variant that could again produce severe cases as in the past; second, continue protecting the community. It's very important that adults who are vulnerable to developing a severe case of COVID, such as older adults and people with chronic illnesses, receive their vaccinations every year so they can renew their protection. COVID continues to cause deaths in the region. When we look at the numbers, it's a few hundred deaths every week. That's why it's important to ensure that these most vulnerable people can be protected by the vaccine and health services. We must always be vigilant to quickly identify and appropriately manage a case.

[00:11:04] Sebastián Oliel: It's clear that COVID-19 has taught us many lessons to reflect on and improve. But speaking of being prepared, there's another topic that's gaining attention: avian flu. There's been a lot of talk lately about the A(H5N1) avian flu virus, its jump to mammals, and the possibility that it could become the next pandemic. In this second part of Let's Talk About Health, we spoke with PAHO Director Dr. Jarbas Barbosa about how real this concern is. Dr. Barbosa, let's start with the basics: what's happening with avian flu right now? Why does this issue have us so alert and vigilant?

[00:11:46] Dr. Jarbas Barbosa: Yes, when we think about a pandemic, a public health emergency of international concern, there are always two strong candidates: coronaviruses, such as COVID-19, MERS, and SARS; Or the influenza viruses that already produced four or five pandemics in the last century and produced one already in this century, in 2009. Because influenza viruses have the ability to circulate, not only among humans, but also among birds, such as avian influenza. And they can have combinations, that is, acquire, as it were, bits of DNA and with that learn to transmit to people and learn to transmit from one person to another. When that happens, it's a completely new virus for humans, so it transmits very quickly and can produce serious cases. Daily influenza has been under observation since 2005-2006, when all the preparations for a future avian influenza pandemic began. The most recent cause for concern is that two years ago, we first observed cases of this avian influenza virus circulating in the region in the Patagonia region. It's been many years, but being the first time among mammals is what drew attention to the possibility that it might be a different variant. And now that we have a situation where there are many cases, not only in chickens in the United States, for example, but also in dairy cows, on many farms, and we have had many cases of workers who had contact with the animal. To date, no outbreak transmitted from one human to another has been identified, but we must maintain very close monitoring of what's happening and adopt all the containment measures that are recommended when there is, for example, an outbreak among poultry. Measures must be taken to contain it immediately so it doesn't spread. It's a challenge because, with all the developments in economic activity related to animal protein production, there's a lot of exchange of biological materials to start new farms or to improve production. In other words, there's a very significant exchange of biological materials from chickens and cattle. So we have to be very careful because that can facilitate the incorporation of elements of a human influenza virus into the bird virus, which can then become a new virus that could be the source of a new pandemic. [00:14:52] Sebastián Oliel: Well, the virus continues to mutate, it can mutate, and it can be transmitted from human to human, this avian flu virus. It's not happening yet, but it is being monitored. And I wanted to know a little more about that if you could tell us: What is PAHO doing, what are countries and the international community doing to monitor and control the current outbreaks?

[00:15:14] Dr. Jarbas Barbosa: Yes, the first step is to have transparent, objective, and direct information. So PAHO coordinates a regional surveillance network where we receive information from countries and, at the same time, we also search for information. It's like a search engine on social media, on the internet, that seeks to identify information about outbreaks, about a new, unknown disease, about a fever. A verification process begins with each country, and that allows for a platform to share all the information. We do this every day with the countries that receive this information, and at the same time, we do so based on meetings with experts, recommendations for surveillance, and for case management. These are rare cases, but cases continue to occur among workers who have contact with these sick animals. We also discuss what measures should be taken to contain and prevent this from turning into new outbreaks that could impact health, but also the economy, as is happening now with the rising price of eggs, which are a cheap source of protein for a large part of the population. So PAHO does this, coordinates the surveillance network, and provides countries with technical cooperation with information, recommendations, and preparation.

[00:16:48] Sebastián Oliel: Perfect. And one topic that interests us also has to do with the vaccine? And perhaps it's not well understood whether there's a vaccine for animals and whether there's a vaccine for people. How are we doing in that regard, with a vaccine for avian influenza?

[00:17:03] Dr. Jarbas Barbosa: For influenza, we have vaccines that are produced every year. They're vaccines that generally protect against the three strains of the virus or four strains of viruses that circulated most the previous winter. That protects people. It's a vaccine similar to the COVID vaccine.

[00:17:25] Sebastián Oliel: That would be a vaccine for influenza or the flu we're used to.

[00:17:29] Dr. Jarbas Barbosa: For human influenza, the one we're used to. And it's an important vaccine because it's similar to the COVID vaccination, which doesn't have the ability to completely prevent transmission, but it does reduce the chance of severe disease and deaths. So it's important to maintain vaccination. Second, in the event of a new virus that becomes a pandemic, this vaccine production base will produce the vaccines for the pandemic. Fortunately, we already have three influenza vaccine producers in the region today, and we're working directly with the region's producers to strengthen them. They could already develop and offer a vaccine for the human population in the event of a new pandemic influenza virus.

[00:18:16] Sebastián Oliel: So, would you say we're better prepared now to produce a new vaccine, if necessary, a new pandemic influenza vaccine in the region and around the world?

[00:18:25] Dr. Jarbas Barbosa: Yes, we are, because in 2009, during the last influenza pandemic, we didn't have any production in the region. So, PAHO, through the Vaccine Revolving Fund, had to import all of the region's vaccines, and some countries only received them about six months after the rich countries. Now, we have an agreement with producers that in the event of a pandemic, a portion of that production will go to support the response in all countries.

[00:18:55] Sebastián Oliel: Good. We're glad to know about these advances. I think they make us all feel more at ease. And doctor, if you had to give some advice to the people who are listening to us or watching us to prevent, let's say, these sporadic cases of avian influenza that has passed from animals to humans, which have been very few, but what are the recommendations being given now to avoid that?

[00:19:20] Dr. Jarbas Barbosa: The risk is low, and the risk is particularly felt by farm workers, that is, people who have direct contact with animals. And if there's an outbreak among animals, that could eventually lead to a human case as well. It's absolutely safe to eat chicken or eggs, if you cook them, bake them, sauté them, or eat them raw, because there's no possibility of transmitting the virus. Pay attention to the recommendations of health authorities. Don't listen to or believe rumors or conspiracy theories. It's a natural occurrence that animal viruses can, unfortunately, learn or gain the ability to transmit to humans, and to prevent that from happening, we truly must always maintain very close surveillance so that it can be quickly identified when that might happen and take containment measures at the earliest opportunity.

[00:20:30] Sebastián Oliel: Doctor, one more question, which people are also asking a lot on social media, especially: Do you think the world could go back to experiencing something like what we experienced at the beginning of the pandemic with the lockdowns?

[00:20:42] Dr. Jarbas Barbosa: It's difficult to predict that because COVID-19 was truly a surprise to everyone, as it was a pandemic that combined two important characteristics: one, it had the capacity to transmit very, very strongly, very quickly, and at the same time, it had the capacity to produce severe cases, also very severe. That's why the first wave in developed countries, like in Italy, in northern Italy, which is the richest part of Italy, and here in New York, we had completely overwhelmed health services because they didn't have the capacity to offer beds, intensive care beds, or oxygen for the large number of severe cases. So, that was a very unique characteristic. Can it happen again? Yes, it can. That's why the lessons we're learning about how to increase hospital capacity, for example, quickly, such as implementing telehealth to reduce the need for consultations and being able to use resources to respond. I mean, all of those things that are now part of the plans seek to respond exactly to a need like that.

[00:22:01] Sebastián Oliel: Very well, Dr. Barbosa. And before we say goodbye, we'd like to know a little more about you. This is a question we'll ask all our future interviewees. What motivated you to dedicate yourself to public health?

[00:22:15] Dr. Jarbas Barbosa: Look, when I started in medicine, I didn't think about public health; I thought about being a psychiatrist. But then, during those changes in my youth, I went to become a surgeon and spent about two years accompanying surgeons, and I believed that was what I wanted to do. Then I switched again to infectious diseases and pediatrics. And when I had the opportunity to take a course in public health, I really loved the possibility of acting collectively. In other words, the benefit that a doctor, a surgeon, a clinician can provide for one person could be achieved with public health for millions of people. At that time, still in medical school, I learned about the changes taking place in the treatment of diarrhea. It was a very important cause of death in Africa, but also in the Americas, in poor areas of Latin America. At that time, an oral treatment was being used based on operational research conducted in some poor countries, which completely changed the way it was treated. It was a relatively simple measure, but it changed everything. I think that was what I loved most. Saying, look, if this happened with that and reducing diarrheal diseases and infant mortality, other measures can also be adopted when this reality is known and can be influenced. So, I think that was what I loved most about public health. [00:24:01] Sebastián Oliel: Dr. Barbosa, Director of PAHO, thank you so much for joining us on Let's Talk About Health, the first episode of the Pan American Health Organization's podcast and videocast, and for sharing your experience and giving us this mix of reflection and hope about COVID and avian flu. And with that, we come to the end of this first episode of Let's Talk About Health, the PAHO podcast and videocast. For those of you who are listening or following us on YouTube, please leave your comments and questions, because this is just beginning. Subscribe, ring the bell, and we'll see you in the next episode to continue talking about health. Thank you very much, and take care of yourselves. Thank you, Dr. Barbosa.

[00:24:40] Dr. Jarbas Barbosa: Thank you.