Peter Hoejskov: The next pandemic is not a question of if, but of when.
Alice Allan: Throughout history, pandemics have swept around the world, leaving devastation in their wake.
Alice Allan: What are we doing to prepare for the next one?
Alice Allan: Hello, I'm your host, Alice Allen, and in this special series of Health in Europe, I'll be going behind the scenes at WHO and some of the European region's major public health institutions to understand what the most likely causes of future pandemics could be and what strategies are in place to avert them.
Alice Allan: I'll talk to the experts applying the lessons of previous pandemics and focus in on the systems in place to spot threats and reduce their impact.
Alice Allan: I'll speak to the legion of public health experts quietly working away, getting on with the not very glamorous but incredibly important work of emergency preparedness Experts in surveillance, genomic sequencing, epidemiology and more the people who are containing outbreaks and laying the groundwork to mitigate the effects of pandemics, not if, but when they occur.
Alice Allan: This is Health in Europe, and in this episode we explore H5N1 bird flu my name is peter sosa hoesko.
Alice Allan: I work as a technical officer for food safety and zoonotic diseases in the who regional office for europe, based in in copenhagen zoonotic diseases have been around forever, but while their threat has always been there, the virus behind the Covid-19 pandemic, sars-cov-2, which originated in bats, and, more recently, the jump of avian flu into cattle, has put them back in the news.
Peter Hoejskov: So zoonotic diseases are diseases that can jump from animals to humans.
Peter Hoejskov: So basically, a disease that originates in an animal and transmits to a human, either directly, with direct contact between animals and humans.
Peter Hoejskov: It can be domestic animals, it can be wild animals, or it can be indirectly as well, through unsafe food, for example.
Alice Allan: Here in Europe we might think sometimes that, oh, zoonotic diseases, that's something that happens somewhere else in the world.
Alice Allan: Why are zoonotic diseases also relevant in the European region?
Peter Hoejskov: Everywhere in the world, including in the European region, there is close contacts between humans and animals.
Peter Hoejskov: We have large agricultural productions in the European region, livestock breeding sites, we have domestic animals.
Peter Hoejskov: We interact from now and then with wildlife.
Peter Hoejskov: So there is this constant interaction between humans and animals.
Peter Hoejskov: We can't completely separate ourselves from the animal world.
Peter Hoejskov: So when we have this interaction there is also a risk of transmission of diseases between animals and humans.
Alice Allan: Why are we hearing more recently about the threat of zoonotic diseases?
Peter Hoejskov: We know that the SARS-CoV-2 virus this is the virus that causes COVID-19 as a disease originated in the animal population and then, through an intermediate host, ended up in the human population and with the mutations that viruses can have, then the transmission between humans can become more serious, and that was exactly what we saw with the COVID-19 pandemic.
Peter Hoejskov: So I think that of course increases the interest and triggers the attention of we need to be better prepared for the next potential pandemic.
Peter Hoejskov: We don't know when it will happen, but we know it's very likely to happen.
Peter Hoejskov: We also know that a lot of the new infectious diseases that we see in humans originate in animals.
Alice Allan: Is there anything about our modern way of life that is increasing the risk of zoonotic transmission?
Peter Hoejskov: Yes, with more urbanisation we get closer interaction with the animal population.
Peter Hoejskov: We see climate change as a factor as well that affects how the viruses survive and how they mutate.
Peter Hoejskov: We see changes in the agricultural practices, the way we breed animals more intensive livestock breeding.
Alice Allan: Tell me about One Health.
Peter Hoejskov: One Health is an approach, it's a way of working, seeing these health threats and the health challenges that we are facing in a much more holistic and a more systematic way, realising that we cannot prevent and prepare for pandemics in the human health sector alone.
Peter Hoejskov: We need to also work across sectors, across disciplines.
Peter Hoejskov: We need to work with colleagues in other organizations or at country level with other ministries.
Peter Hoejskov: So a very close collaboration, sharing of information, joint risk assessments across the vituary services, agricultural sector, environment sector and human health.
Peter Hoejskov: And that's exactly what One Health is all about.
Peter Hoejskov: It is to see health as one across these different domains and encouraging closer interaction, closer coordination and sharing of information so we can be better prepared and act fast if we need to.
Peter Hoejskov: We have a formalized partnership with what we call the Quartipartite Organizations, so that's the Food and agriculture organization of the United Nations, it's the World Organization for Animal Health, boha, and it's the United Nations Environment Program, unep and then WHO.
Peter Hoejskov: So we work very closely together.
Peter Hoejskov: We have also developed joint guidance material for countries on how they can operationalize the One Health approach Basically, what are some of the tools, what are some of the techniques and how can they better implement and work across sectors at a country level, because One Health is not at the global level, only of organizations working together.
Peter Hoejskov: It comes all the way down to communities and we know the next pandemic is also going to start in a community somewhere, so we need to be better prepared at community level.
Peter Hoejskov: So One Health is at all levels and across various sectors and disciplines.
Alice Allan: Nicola Lewis is director of the Worldwide Influenza Centre at the Francis Crick Institute in London.
Alice Allan: It's a WHO collaborating centre and one of its key functions is to track strains of influenza that are circulating among animals and humans to understand how it's changing.
Nicola Lewis: So flu is fascinating and I think one of the aspects of flu that is fascinating is it's continuously evolving.
Nicola Lewis: It's changing the whole time.
Nicola Lewis: Is it's continuously evolving?
Nicola Lewis: It's changing the whole time.
Nicola Lewis: It's a virus that, when it replicates in a particular host, makes mistakes, and it makes mistakes in its genome, and that means that it's able to constantly evolve, and some of this evolution means that it's able to escape prior immunity that we might have to a particular flu virus.
Nicola Lewis: So we're merely facing a challenge constantly to try and keep up with this changing evolution.
Nicola Lewis: Flu viruses are also fascinating because they can do something else in terms of changing constantly.
Nicola Lewis: They can undergo what we call reassortment, and this happens when two different flu viruses infect a person or infect a pig at the same time and they shuffle their genetic material so that the progeny flu virus that comes out of the pig or other human is actually different.
Nicola Lewis: And this process of reassortment is also a way that flu viruses evolve.
Nicola Lewis: Now we know that flu viruses are particularly tricky to understand from this point of view, because this whole evolutionary process means that we have to stay abreast of this evolution to understand where the next threat might come from.
Alice Allan: Big scientific advances have been made in the last hundred years about understanding viruses and tracking them.
Alice Allan: How close are we to being able to keep up with flu?
Nicola Lewis: I think we're getting much, much better at trying to keep up with the evolution of these pathogens.
Nicola Lewis: I certainly think that new technologies are coming along all the time and we make the most of those, particularly in the influenza field.
Nicola Lewis: But because flu changes constantly, it constantly presents a new challenge to us.
Nicola Lewis: So we certainly can't drop our guard with flu viruses, and I think there is one certainty, and that is that there will be another flu pandemic in the future.
Alice Allan: Can you think of a particular moment when flu has done something that has shocked or surprised you?
Alice Allan: One of those moments when you've gone gosh wow, flu.
Alice Allan: That was interesting.
Nicola Lewis: I think one of the major surprises has been quite recently, actually with the H5 highly pathogenic viruses that have been circulating in bird populations, and we've been facing a massive challenge with these viruses since about 1997.
Nicola Lewis: But in about mid-2020, we suddenly saw a radical shift in the way that these viruses were evolving.
Nicola Lewis: All of a sudden, rather than being confined to particular geographic regions, they managed to switch back into wild birds, they managed to infect many more wild bird hosts and then they managed to spread globally to the extent that since 2020, they've spread not just throughout Eurasia, not just through into Europe, into Africa, but they've also hopped over the Atlantic and have now spread right the way down North America, south America, and have just turned up in Antarctica.
Nicola Lewis: We have never seen this kind of situation with a highly pathogenic H5 virus before, and I certainly think that if you'd asked me in 2019, this would not have been the picture I would have conjured up in my mind about what bird flu could do.
Alice Allan: How are scientists responding to this new behaviour?
Nicola Lewis: As researchers, we are very committed to understanding what has changed with the virus, but also what we can do to help populations of animals, and indeed the human population, be prepared to be able to counteract these infections, to be able to mitigate them and to essentially prepare for a potential pandemic from these viruses.
Nicola Lewis: So there are a number of different initiatives that we undertake to keep up with these viruses.
Nicola Lewis: The first is to sample these viruses in animal populations to characterise them, to sequence them, to antigenically characterise them, to understand what they look like in these animal populations, in bird populations, but also when they've spilled over into terrestrial mammal populations around the world.
Nicola Lewis: And the next part of this is to understand what these viruses look like relative to what we call candidate vaccine viruses.
Nicola Lewis: And these are viruses that the WHO network, the Global Influenza Surveillance Response Network, worldwide we take these viruses and we try to understand the similarity to potential candidate vaccine viruses we might have to use were there to be a human pandemic.
Nicola Lewis: And so, twice a year, the WHO collaborating centres that are part of this GIST-Risk Global Influenza Surveillance and Response Network come together twice a year and we have a very important job to do twice a year.
Nicola Lewis: One is to make recommendation for seasonal influenza viruses and for the vaccine strains, but the other is to look at the viruses that are circulating in animal populations and to think about what we need to prepare for, what kind of candidate vaccine viruses we might need to have in our armoury to help us, were there to be a pandemic tomorrow in our armoury to help us, were there to be a pandemic tomorrow In the European region.
Alice Allan: detections of H5N1 have been made in farmed fur animals in Finland and Spain, and also in domestic cats in Poland.
Alice Allan: Aisling Vaughan is an epidemiologist who works for WHO Europe in the High Threat Pathogens team.
Alice Allan: I started by asking her what the team had learned from working on these outbreaks.
Aisling Vaughn: I think what we learned from these events in Europe most recently was that a strong foundation of trust amongst stakeholders is really really important.
Aisling Vaughn: It enables rapid information exchange, it allows for coordinated multi-sectoral efforts and it really drives decisive actions to effectively prevent any further viral spread and then, of course, safeguard both human and animal health.
Alice Allan: How do you assess the current risk of H5N1 to humans, particularly in the light of the recent detections in cattle in the US?
Aisling Vaughn: So it's important to remember that this virus mostly affects wild birds and domestic birds.
Aisling Vaughn: It rarely affects humans and there's really no evidence yet that this virus has acquired the ability to spread well from person to person.
Aisling Vaughn: And despite the high number of clade 2344B outbreaks we've seen, and the detections in animals and as well the human exposures to this virus at the human-animal interface, relatively few infections have actually been reported to date, which is reassuring.
Aisling Vaughn: So, overall, since the beginning of 2021, 28 detections of H5N1 in humans have been reported to WHO, including the most recent case who had exposure to dairy cattle.
Aisling Vaughn: So, of all of the H5N1 cases reported in Europe and North America, they have been asymptomatic or mild.
Aisling Vaughn: So, for example, the most recent case in the US reported conjunctivitis as their only symptom.
Aisling Vaughn: All H5N1 cases so far have been sporadic infections.
Aisling Vaughn: They've occurred through direct or indirect contact with infected birds or infected mammals or environments such as live poultry markets or other premises with infected animals, and among these cases, there have been no reported human to human transmission and, in fact, there have been no reported human human transmission of H5N1 since 2007.
Aisling Vaughn: So, based on everything we know, based on all the information available, who assesses the current overall public health risk posed by H5N1 to be low, and for those with exposure to infected birds or animals or contaminated environments, the risk of infection is considered low to moderate.
Aisling Vaughn: But these viruses are continually evolving and spreading in birds and animals, so continuous real-time monitoring is needed.
Maria van Kerkhove: I think with almost certainty we will have another flu pandemic in our lifetime.
Alice Allan: Dr Maria Van Kerkhoff is the Acting Interim Director of the WHO's Department of Epidemic and Pandemic Preparedness and Prevention.
Alice Allan: She also leads on COVID-19 emergency management and she's technical lead of the WHO Health Emergencies Programme.
Alice Allan: She started her career working on avian influenza 20 years ago.
Maria van Kerkhove: I became interested in viruses, pathogens, when I was in college and when I was doing my PhD at London School of Hygiene and Tropical Medicine.
Maria van Kerkhove: And as part of my PhD work I was based in Cambodia and I was working with Institute Pasteur Cambodia on H5N1, on avian influenza, and at the time there were six or seven human cases in Cambodia.
Maria van Kerkhove: So it was relatively new and what we were doing there with colleagues across the Ministry of Health, the Ministry of Agriculture, institute Pasteur, where we're doing these outbreak investigations, and I was fascinated with outbreak investigation it was multidisciplinary, it was all One Health before it was even called One Health, you know and it was really just early detection and early action to prevent onward spread.
Maria van Kerkhove: So we were doing all these complex, comprehensive investigations in the field.
Maria van Kerkhove: Oh my gosh, I absolutely loved it.
Alice Allan: Why are we hearing so much about H5N1 recently?
Maria van Kerkhove: So there's a lot of attention right now to avian influenza and there's a massive epizootic across the world.
Maria van Kerkhove: It has expanded greatly in the last couple of years.
Maria van Kerkhove: This is particular on H5N1, but not only H5N1.
Maria van Kerkhove: We see in wild birds, we see in domestic poultry, we see in spillover into mammals, including humans.
Maria van Kerkhove: But this is being detected in new countries Right now.
Maria van Kerkhove: There's been quite a lot of attention on H5N1 in dairy cows, in dairy cattle in the US, and you know it is unfortunate that the world starts to pay attention when you see this in high-income countries.
Maria van Kerkhove: But we will use this attention to draw awareness to one the global influenza and surveillance response system that's been in place for 70 years.
Maria van Kerkhove: Who did not wake up to flu.
Maria van Kerkhove: We've been working on this for quite a long time because we know there's seasonal influenza, there's a potential for pandemic influenza and there's all these novel subtypes of avian influenza.
Maria van Kerkhove: And we work with the PIP framework of looking at how do we have better capacities in countries for these types of detection, but also how do we share viruses with our global lab network, our national influenza centres, our WHO collaborating centres to identify certain viruses that should be thought of for vaccines.
Alice Allan: The PIP framework is WHO's Pandemic Influenza Preparedness Framework.
Maria van Kerkhove: So we have these candidate vaccine viruses, including many H5N1 vaccines, which prompt us already to have H5N1 vaccines, which prompt us already to have H5N1 vaccines in development.
Maria van Kerkhove: Now I do want to contextualize this that since 2017, we've only had 28 human cases of avian influenza and we have not seen human-to-human transmission.
Maria van Kerkhove: We're constantly looking because our worry is that these viruses can be more adapted for transmission.
Maria van Kerkhove: We have not seen that yet, but we are concerned.
Maria van Kerkhove: The more opportunity this virus has to circulate, the more opportunities we see for infection in different species, and these viruses can combine the genetic components of it, can combine and potentially cause a new virus of influenza that could be highly transmissible.
Maria van Kerkhove: That's what happened in 2009.
Maria van Kerkhove: So we're constantly thinking about this.
Maria van Kerkhove: Not just thinking, but taking action to be better prepared.
Maria van Kerkhove: What we want to do is prevent, prevent, prevent.
Maria van Kerkhove: There are some treatments for influenza.
Maria van Kerkhove: We have vaccination, so there's a seasonal vaccine campaign every year.
Maria van Kerkhove: We urge people to get not only COVID vaccines but also influenza vaccines, and there are H5N1 vaccines in development, should we need them.
Alice Allan: This recent species jump into cattle.
Alice Allan: What's WHO or what are your partner agencies doing to understand that development and any potential risks to humans?
Maria van Kerkhove: Yeah, quite a bit actually.
Maria van Kerkhove: So what we're trying to do is enhance the surveillance.
Maria van Kerkhove: We have a global surveillance system in humans as part of our GISRIS system, which is looking at sentinel sites, so patients that are going into hospitals.
Maria van Kerkhove: Some are non-hospital sites.
Maria van Kerkhove: We're working with FAO and WOHA on surveillance in animals, so in wild birds, in poultry, in livestock, and now that we're seeing infections in certain species we want to make sure that those species are tested more systematically.
Maria van Kerkhove: So not just dairy cattle in the US, but we would ask more globally for surveillance to include these animals, but not only in the animals themselves but looking in the products of those animals, like milk and milk products.
Maria van Kerkhove: So there's a lot of work that has to happen there to understand the extent of circulation.
Maria van Kerkhove: We advise that sequencing be conducted and shared because there's a lot that we can gain in our understanding of transmission and circulation with the sequence information.
Maria van Kerkhove: So I don't have the full picture, but that's just because the work is ongoing as we are talking about this right now.
Maria van Kerkhove: We also are very actively engaging with our WHO collaborating centers, national influenza centers, to make sure that samples that need to be in the right labs to do the right types of laboratory research type studies are ongoing and that information is shared and we're constantly doing risk assessments.
Alice Allan: What kind of key factors could contribute to a species jump to humans for H5N1?
Maria van Kerkhove: So one is opportunity right.
Maria van Kerkhove: So, as these species intermix with each other, you know, we have wild birds that are flying, and so there's opportunities for the virus to spread between poultry and other species, wild birds and other species and that's what we think has happened here, based on the sequencing information.
Maria van Kerkhove: We're also very carefully looking at the viruses and looking at the mutations within the viruses and any changes that would favor mammalian adaptations what they call it would favor a transmission in mammals.
Maria van Kerkhove: Now we're seeing some changes, but these are mainly, primarily poultry viruses and they have not adapted well to transmit between people and in mammals, and that's a really important thing that we're tracking.
Maria van Kerkhove: We have a lot of really fantastic I mean this with the utmost respect super nerdy scientists, who I adore, around the world who are looking at this with us.
Maria van Kerkhove: So it's not just WHO sitting here saying what do we think?
Maria van Kerkhove: What we do is we bring together the best minds in the world as part of our global influenza surveillance and response system.
Maria van Kerkhove: We do this for COVID as well and for SARS-CoV-2, of what do these changes in the viruses mean from a public health point of view?
Maria van Kerkhove: So that is something that's also ongoing.
Alice Allan: There've been a lot of headlines recently predicting that the next pandemic is going to be caused by an influenza virus that's jumped from animals to humans.
Alice Allan: How do you assess that risk?
Maria van Kerkhove: For me, flu is a certainty because it's so much in circulation.
Maria van Kerkhove: It's infected many different species.
Maria van Kerkhove: We have avian influenza and the opportunities for reassortance, the opportunities for a pandemic influenza virus are high.
Maria van Kerkhove: That's why we have a whole system in place to be prepared for this.
Maria van Kerkhove: The challenge is will we see another coronavirus pandemic, given that we had SARS-CoV-2 cause, a pandemic for sure.
Maria van Kerkhove: This is an opportunity.
Maria van Kerkhove: Question is will we see an arbovirus pandemic?
Maria van Kerkhove: Now, I'm not saying this to scare people who are listening to this, but for us it's something that we have to be prepared for.
Maria van Kerkhove: So we have to think out of the box, really prepare for what are the known threats, but also think out of the box, for you know, really prepare for what are the known threats, but also think out of the box, you know, for something different, perhaps waterborne or whatnot.
Maria van Kerkhove: So for me, pandemics, unfortunately, are part of what we will deal with in our lifetimes.
Maria van Kerkhove: I don't believe this will be the last pandemic we will deal with in our lifetimes.
Alice Allan: We know we weren't prepared for the COVID-19 pandemic.
Alice Allan: Are we prepared for the next one?
Maria van Kerkhove: Yes and no.
Maria van Kerkhove: Yes because we do have strong systems that are in place.
Maria van Kerkhove: We have learned a lot in the last four years from COVID.
Maria van Kerkhove: We have strengthened PCR capacity, sequencing capacity.
Maria van Kerkhove: We have stronger community engagement.
Maria van Kerkhove: We have many systems that are in place to ensure better clinical care and infection prevention and control and good coordination in our emergency operation centers and supply chain.
Maria van Kerkhove: No, on the other hand no because I think the world's trust in science you know there's been a lot of, there's been a lot of distrust, um, over the last couple of years, and that's something we have to work on.
Maria van Kerkhove: You can develop the best interventions in the world, but if they're not implemented by communities, they're useless.
Maria van Kerkhove: We still have challenges with equity and access to these materials and I think you know, in many respects we are better off and in others we are not.
Maria van Kerkhove: I'm optimistic.
Maria van Kerkhove: That's what gets me out of bed every day, otherwise I wouldn't be able to do this job.
Maria van Kerkhove: I'm hopeful with the pandemic agreement that is being discussed and negotiated right now by all of our member states to get this done.
Maria van Kerkhove: They want to get this done because we have to do.
Maria van Kerkhove: We can't just have a handshake and say, oh, we'll do better next time.
Maria van Kerkhove: There have to be commitments in place to ensure that we do better the next time.
Maria van Kerkhove: Again, covid-19 did not have to be as bad as it was, as it is, and we owe it to our children, our grandchildren, to make sure that we we keep up these systems and have that commitment in place to make sure that we do better the next time.
Alice Allan: In future episodes I'll talk to experts who are tracking disease outbreaks, trying to understand them better and preparing for future pandemics Not if, but when they happen.
Alice Allan: Health in Europe is produced by the World Health Organization.
Alice Allan: Music for this episode is by Ben Howells, Richard Duttonall and Gareth Thomas.
Alice Allan: Sound engineering is by David Barrett.
Alice Allan: My name's Alice Allen.
Alice Allan: Thanks for listening, Thank you.