Health

Health Policy and Initiatives

  • Public Health Threats and Pandemics
    How Vaccines Changed the World
    Vaccination campaigns have nearly eradicated some of the most deadly and transmissible diseases. In a rising tide of vaccine hesitancy, however, outbreaks are cropping up again.
  • United States Agency for International Development (USAID)
    The Value of Saving Women and Girls’ Lives Around the World
    Women and girls’ lives are being lost due to the abrupt and sweeping cancellation of U.S. assistance approved by Congress. Programs should be reinstated while a deliberate reform is undertaken.
  • Health
    Public Health Policy in Transition
    Play
    Thomas J. Bollyky, Bloomberg chair in global health at CFR, discusses recent changes to domestic and international health policies and the implications of a U.S. withdrawal from the World Health Organization (WHO) on global health programs and international health coordination. Manisha Juthani, commissioner of the Connecticut Department of Public Health, discusses how state health systems might be affected by changes in federal policies, trusted resources for public health data, and how state and local officials can respond to promote health and safety in their communities. A question-and-answer session follows their opening remarks. TRANSCRIPT FASKIANOS: Thank you. And welcome to the Council on Foreign Relations State and Local Officials Webinar. I’m Irina Faskianos, vice president of the National Program and Outreach here at CFR. CFR is an independent, nonpartisan membership organization, think tank and publisher focused on U.S. foreign policy. CFR is also the publisher of Foreign Affairs magazine. As always, CFR takes no institutional positions on matters of policy. Through our State and Local Officials Initiative, CFR serves as a resource on international issues affecting the priorities and agendas of state and local governments by providing background and analysis on a wide range of policy topics. We’re delighted to have you with us for today’s discussion. We have more than 580 state and local officials confirmed to join us from forty-nine states and two U.S. territories. So, again, this webinar is on the record. The video and transcript will be posted on our website after the fact, at CFR.org. We are pleased to have Tom Bollyky and Manisha Juthani with us to speak on recent changes in public health policy and implications for state and local governments in the United States. We’ve shared their full bios with you, so I will just give you a few highlights. Thomas Bollyky is the inaugural Bloomberg chair in global health at CFR and director of CFR Global Health Program. He is also a senior fellow for international economics, law, and development, and a senior consultant to the Coalition for Epidemic Preparedness Innovations. Tom Bollyky is the founding editor of Think Global Health, an online magazine that examines the ways health shapes economies, societies, and everyday lives around the world. And prior to working at CFR, he served in a variety of positions, including at the office of the U.S. Trade Representative and as a staff attorney at the AIDS Law Project. Manisha Juthani is the commissioner of the Connecticut Department of Public Health. Commissioner Juthani previously served as a professor of medicine and infectious diseases physician at Yale's School of Medicine and currently serves as an adjunct professor there. During the COVID-19 pandemic, Dr. Juthani was a leader in the COVID response at Yale, which led to her appointment as commissioner of the Connecticut Department of Public Health in 2021. So thank you both for being with us today. Tom, I’m going to first turn to you to talk about the most significant changes that we’ve seen to U.S. public health policy in the last month, and what you see is the implication of these changes for future international health coordination and data collection efforts. BOLLYKY: Great. Thank you all for joining us. Thank you to Irina and her team for coordinating this. The state and local network that her team operates is really one of the most useful, I find, resources at CFR, particularly on public health where battles are won at the state and local level. And it’s a privilege to be able to engage with you and learn from what you’re hearing on these issues as well. There's a lot going on, of course, on U.S. public health. So there's a good bit we could talk about. In my initial remarks, I'm really just going to focus on three areas. To start, I'm going to talk about vaccination. And there has been an unfortunate consequence, the cumulative effect of some of the early actions taken over this last month to perhaps undermine the support for vaccination, at a time where we have a quite a large measles outbreak ongoing, the potential emergence of dangerous avian influenza. These are risks not just for a loss of life. On measles, of course, it's also just a huge expense if it shows up in your part of the country. This is new. Vaccination for decades—U.S. immunization efforts provided immense benefits for health and had broad bipartisan support. Underlying these efforts were policies rooted in science that have been adapted and improved over time. Support for that vaccine policy framework is just as important today as it has been ever before. But it really has taken a hit, particularly after the COVID-19 crisis. To see how far we’ve traveled on measles, it was just in 2000 that measles was officially eliminated from the United States—meaning there was no measles spreading in the country. That was driven by vaccination. Typically, you need about—vaccine coverage of around 93 to 95 percent to have a sufficient level of population immunity to prevent outbreaks. There are currently, out of the forty-nine states reporting vaccination rates at the kindergarten level, thirty-one states are below the lower band of that threshold of 93 percent for coverage for the MMR vaccine. In terms of the outbreak, I’m sure most on this call are aware. Yesterday the tragic news was reported of the death of a child from measles in west Texas. An unvaccinated child is the first death from measles in the United States in ten years. Officials have reported, by last count that I’ve seen, 124 cases in Texas, mostly west Texas, since late January. Nine cases in the neighboring New Mexico county. Eighty percent of these cases involve children, who are more susceptible to this vaccine-preventable disease. Vaccination rates in the most affected county, rural Gaines County, at the center of the outbreak, are quite low. We've seen cases in seven other states—Alaska, California, Georgia, New Mexico, of course, New Jersey, New York, and Rhode Island. The total number of cases being just over 130 cases actually is more than we've seen in eight of the last fifteen years. And that's just in the first two months of this calendar year. There are probably more cases than that than we know about. We don't know how large this is going to get, but the rate of increase or the force of infection, as you might say, is strong. For reference, the last major measles outbreak we've had in the United States was in New York in 2019. That hit over a thousand cases. This could be worse. Now it is not too late. With the—with the potential for vaccination, behavioral shifts, tireless work of public health teams we could slow the spread of this outbreak. But it is concerning. At the federal level, we've not seen the type of support one would typically see for vaccination. The CDC has—itself, has been quiet on these issues—relatively quiet. We've had a number of important vaccine advisory committees postponed. The National Vaccine Advisory Committee was meant to discuss the strategic plan for national vaccination in February. That's been postponed. The Advisory Commission on Childhood Vaccination was meant to discuss the vaccine Injury Compensation Program. That's been postponed. There's been questions coming out of—at the secretary level about potential conflicts of interest among the Advisory Committee on Immunization Practice, that considers clinical information on immunization practice. Its findings influence the compensation program. Their credibility has been put in question. We had a Cabinet meeting yesterday at the White House where a reporter afforded an opportunity both to the president and the HHS secretary to speak on this, and although they did, we didn't see the call for vaccination that you would ordinarily see. We also saw in the early days of the administration an executive order restricting any federal funding to states or schools that required COVID-19 vaccination. So a broader—the cumulative effect of these actions, intended or otherwise, diminishes support for vaccination at a point where it's more critical. The second thing I would highlight is the firings of U.S. public health officials as part of the broader reduction of government workers. We’ve seen the National Institutes of Health, the nation’s premier biomedical research agency—we’ve seen an estimated number of a hundred—oh, I’m sorry—1,200 employees, most of them promising young investigators slated for larger roles, have been dismissed. Many of them have specialized knowledge that can’t easily be replaced. The CDC has seen a reduction of around 1,100 individuals. Four hundred of those are people that took the voluntary retirement in response to the request from the Office of Personnel Management. About 750 have been fired. There had been views that we might see a reduction in the Emergency Intelligence Service. Not yet, although that’s still possible. But we have seen significant decreases in personnel in the Laboratory Leadership Service Program, the Public Health Associate Program. And these are linkages between the CDC and states and locality that provide important resources in emerging outbreaks and crises. The last thing I will say is these, of course, also link to what's been happening at the international level, and the information sharing that can go on there. On the first day in office, the president, as many expected, withdrew from the World Health Organization. He did so in a manner that he renewed the withdrawal notice from 2020, suggesting it may be immediate. U.S. officials have already stopped participating in many of the networks that exist around surveillance of emerging infections and around influenza. USAID last night had 580—I’m sorry—5,800 out of 6,200 contracts terminated, in terms of its programming. There’s an expectation that the workforce there will be reduced from around 10,000 to 1,000. And, of course, they provide our eyes and ears with other countries in terms of emerging infections, as well as the good work that USAID does around HIV, malaria, and other concerns. What this boils down to is, you know, frontline public health workers here in the U.S. and abroad provide our network that we detect emerging diseases, prevent and respond to these threats, and protect everyone. That system may be unraveling. The risk of doing so is that we create blind spots, where emerging health threats incubate beyond our knowledge and provide an illusion of safety in public health that we don't—that we don't have. And that is our greatest threat potentially moving forward. So let me stop there. Lots more we can talk about. Looking forward to this exchange. FASKIANOS: Thank you, Tom. And we’re going to go to the commissioner to talk about how you are adapting your health systems in Connecticut to the federal public health policies that are obviously shifting, and the challenges that you’re facing, and where you see the opportunities, so we have a little bit of optimism. (Laughs.) So over to you. JUTHANI: Thank you very much, Irina. Thank you for the opportunity to speak with all of you today. And thank you for laying that foundation, Tom, so that I can speak to how we are dealing with things at the local level and at the state level. So what I would like to start with is that, as we entered these last few months and have seen a number of different orders and actions come through, it has been a time period of uncertainty and a time period of unrest, a bit, in terms of staff in a public health department, and state government writ large. So for us in the Department of Public Health in Connecticut, we have 154 different grants that we receive, largely from the federal government, spanning potentially up to seventeen different agencies at the federal government. And I believe that almost all of them received some sort of cease order in terms of work, initially. Half of my department is funded through federal dollars. And so where we are right now with different temporary restraining orders that have been put in place is that, in fact, at this moment, right now today, we do not have any specific grants that have been given specific terminations or reductions. We also have CDC employees—for example, the EIS officer, CEFOs, which are epidemic field officers that have been positioned in Connecticut—we had threats that they would be fired but they have not, up until this point. So what this has created, though, is a lot of uncertainty in terms of where we are going to be able to move forward, where we are going to potentially have to cut back, and where our work will continue. I think the second point on uncertainty is that, as with all administrations, there's an opportunity to decide what communications should go out, what needs to be paused, what can be resumed. And there was a lot of uncertainty in the first several weeks in terms of what information we would be able to get. And for example, there was the Morbidity and Mortality Weekly Report. The one that was put on pause in the first week after Inauguration Day had three different reports on H5N1 or avian flu. Since then, those have all been published, and we do have that information available. Today another MMWR came out as expected. So that is hopeful, that we have been able to see some resumption of communication that had been paused in the first several weeks. I would also comment that we’ve had a few emergent situations where we’ve had to call the CDC for emergency input in terms of how to deal with potential threats. And we were able to get in touch with officers who were working on the ground and be able to help provide us with guidance. As Tom mentioned, a lot of public health—good, old-fashioned public health is done at the local level, at the state level. But where we do really rely on federal partners is for expertise in areas that maybe we only interact with or have exposure to on a one-off basis and not on a regular, standing basis. And that is one of the challenges that we have seen, that we anticipate, and then we worry about in terms of where that is going to take us going forward. Tom mentioned a little bit about vaccinations. I mean, this is a foundational component of our public health advances over the last century. I’ve been talking for the last several months about a Morbidity and Mortality Weekly Report, MMWR report, from 1999 talking about the ten landmark achievements in public health over that previous century. And many of the things that are in there, with vaccinations being one of the top of the list, are the types of things that we worry about every day. If you look back to the early 1900s, influenza was a leading cause of death in this country. Today, we look at diseases like heart disease, and stroke, and diabetes, and cardiovascular disease taking a higher standpoint than influenza. But that is something that can backtrack very quickly. Something that gave me pause today was when I heard that VRBPAC, which is the federal committee that meets to determine which strains of influenza will be in the next season’s flu vaccine, that meeting was canceled. I hope that it is a postponement. I hope that we have an opportunity to see that those particular candidate selections of what should be in next season's flu vaccine are determined pretty quickly because this takes time. When the flu vaccine is identified what should be in the next season, that has to be done in the spring. It takes time to manufacture these vaccines. And this could be threatening to our pharmaceutical industry. This could have impacts on people showing up for work. The impacts of health are so vast. They impact business every single day. They cannot be separated. Health and business go hand in hand because in order to be thriving members of society we need to be healthy and we be able to—we need to be able to live, and work, and participate with each other. So these are some areas of concern, but I am hopeful that we’ve seen some changes where, for example, MMWR did resume. I am a member through the Association of State and Territorial Health Officials on the ACIP, which is the immunization practice committee that evaluates all—you know, all vaccines that come forward to be able to help create that schedule of vaccines. That meeting was postponed. I am hopeful, again, that ACIP will resume and that we will have an opportunity to be able to resume those types of, really on a regular basis, meetings that help inform these things. In Connecticut, we have been fortunate that vaccine uptake is something that has always been strong in our state. Going back to 2014, since we were talking about measles, the measles, mumps, and rubella vaccine, we had a 96.65 percent uptake for kindergarteners with the MMR vaccine. We hit a low during the pandemic in 2020 of 95.28 percent, with 95 percent often being a quoted number for achieving herd immunity. But now in 2024, we are actually higher than we were pre-pandemic, at 97.7 percent. And so we have a lot to, at least, hope that, at least, we’ll be able to, hopefully, avoid a measles outbreak. But we do have under-vaccinated populations, even within that—within our state. Which is true across the country. And so this is something we worry about, and we prep for, and we try to be ready for. The other thing I want people to just be aware of is that vaccinations are a critical thing, but there are so many areas of public health that we often don’t even think about. And I often say this comment that was said to me once, which is that public health saved your life today, you just didn’t know it. So, for example, safe drinking water. If we take our foot off the gas on regulations for drinking water, whether it be toxins, whether it be chemicals, whether it be infectious agents, these are foundational things that we maintain safety in our country. That is something that is under our purview in the Connecticut Department of Public Health. Another example would be food safety. We’ve heard some concerns that there may be less oversight or regulation in terms of food safety. We know right now, for example, there’s a listeria outbreak that’s going on around the country. This is particularly concerning for women, for babies. And we’ve had two cases here in Connecticut. But this is true at our restaurants and at our distributors of food, right at the ground level. For example, our state health department has secret shoppers that go out and buy different types of meat, or dairy, or produce, and do testing to ensure that food that is out in the public that people can purchase is safe. And we get funded, often through collaborations with the federal government and with our state partners, for that type of safety. These are basic things that public health does. And so I'm hopeful because I've seen some things improve over the last several weeks. But I have areas of concern. And it is our goal to work with our federal partners, that we rely on to be able to help provide us expertise and make these broad decisions that implicate all of us and have potential impacts on all of us. And I really hope that going forward we'll be able to continue to work together with federal partners to ensure the safety in our states. Thank you. FASKIANOS: Thank you very much to you both. Let's go now to all of you for your questions and comments. And you can also use this forum to share your experience and your best practices. (Gives queuing instructions.) And nobody’s put up their hand yet. Oh, we do have the first hand. Jennifer Herring. Q: Good afternoon. I’m Jen Herring. I’m from Doylestown Township, Pennsylvania. I’m the chairman of the Board of Supervisors there. My question is, generally speaking we know that there’s—it looks like there’s some limitations on communication between the federal authorities and state and local authorities, as far as health is concerned. And I’m fearful that it’s going to increase—or, actually, decrease—less communication. Where would you recommend we get our information from, if we don’t have access to the information such as, like, a department—the CDC? JUTHANI: I can start with that, at least. I would say that I would lean into your state public health department. One of the challenges that we all face is that state public health departments and local public health departments often rely on the CDC for more expert guidance. But, you know, we're doing the best we can with the information we have, at least at the local level, for what we can communicate out. And so I think as it relates to what's happening right in front of you, and in probably your day-to-day life at a local level, your state health department is probably a good place and a good resource to be able to lean into. One of the challenges we have, to Tom’s point earlier, is we don’t know what we don’t know. When you don’t have eyes on what’s happening on a more global landscape, or potentially even at the federal level, we just may not know it. But one of the things that I would say is that a number of us, as state health officials, do get together on a weekly basis. We do share information with each other. And we may need to do that a little bit more organically. We have sent out statements as we’ve received them. I’ll give an example. Today's MMWR did comment on severe influenza in children resulting in encephalitis and more severe neurologic complications. Before I heard that in the MMWR, I had heard that from some other state health officials. And so that was something we actually also ended up sending out a notice to providers in Connecticut to let us know if they had children who were manifesting with those types of symptoms. I was glad to see that it showed up in the MMWR as well, and I was able to get a better sense of what is the CDC seeing right now in terms of how that relates to what's happening now as opposed to historically. And some of the information shared there is that right now it seems to be 13 percent of children who died from influenza this season had that presentation, historically that was 9 percent. Again, is that outside of the range of variation? We don’t really know, but that was at least helpful for me to be able to read and understand that that was something they were able to share with us. But I would very much lean into, at least from a day-to-day standpoint of your life, leaning into your local and state health departments. Now, if you’re traveling somewhere else often we might have relied on the CDC to be able to see are there certain health advisories or other things like that that may be out there. I have not seen that that is not there. So that may still be available. But I would say also looking at those specific countries and seeing what they may be reporting out on—and, you know, WHO does have a website, it has information out there. Those would be the types of things I would lean into. FASKIANOS: Tom. BOLLYKY: Great. In the arena of more positive developments, after a few weeks where much of CDC’s website, in terms of data and pages, were shut down, there has been a return of much of that information. Now, depending on the area looking there are some concerns that some demographic information has been stripped out, which, from a public health standpoint, is not always helpful. But a lot of the data that had been missing, and some of the advisories that are posted on the CDC website, have returned. So that is, depending on your area, a resource. So, for instance, when I was looking for how many states are below the threshold, at this point, you can get that information from the CDC website, whereas just a few weeks ago you could not. So you’re starting to see some of those resources come online. The only thing I'll say on the WHO side, there are concerns—leaving aside the issue of collaboration with U.S. officials and, you know, a significant number of U.S. public have health staff had been seconded to the CDC—or, to WHO, so it was a real resource there, this will be—the United States was the largest donor to WHO, representing around 16 percent of its overall budget. So they have stopped international travel by most staff unless you're locally there. So to get back to the point that we don't know what we don't know, there is going to be some diminution of the international information we have, simply by reducing the reach of the world's health agency. So that will come at a cost. And part of that cost is the collaboration and the movement of staff. FASKIANOS: I’m going to take the next question from council member Barbara Leary from Folsom, California. Q: Yeah, I’m wondering if there’s—and I don’t know what can be done about this—any movement to reinstate a lot of the research? I know, you know, that you’ve talked, you know, about the MMWR being re-released, but I guess I’m concerned about a lot of scientists and other people who have been let go or who are not being able to pursue their interests in research, tracking problems, et cetera. And does anybody have any idea about how that might be addressed or changed? I think we’re in uncharted territory at this point, so just looking for some other thoughts on that. BOLLYKY: So just a little bit, and then—I'll start. I think there has been some effort for them—in terms of the cuts—at the federal level to U.S. public health employees because it was done largely around probationary employees—so less in a targeted manner and more where there might be the legal flexibility to pursue those reductions in force—you've lost a lot of people with particular expertise. So this was famously, has been reported, you saw that at USDA that the office that they had assembled around tracking the avian influenza outbreak had been gutted. You saw that at parts of the FDA, where, you know, we had brought in—or, the FDA had brought in, rather, people with particular areas of expertise that they've had to now try to hire back. EIS is an area that had been on the chopping block and, at least as of yet, given the outcry about the important role that that program plays, that has not happened. So I do think, in terms of communication, particularly from the state and local level, the importance of programs to the good work that you all do can have an effect when people have a greater appreciation of the value. I do want to point out one thing, though, that I am concerned, particularly as this has largely fallen on probationary government employees, that we are really eviscerating our next generation of public health experts and scientists. And that will have an effect not only, of course, on these people’s careers, but also on people who are considering entering the field. And it comes at a time where state and local—the state and local public health workforce has already been under stress due to the pandemic and is at low numbers. So really, the combination of this disincentive, losing potentially a generation of people, with some of the fatigue that is going on at the state and local level is really quite damaging. So again, you’ve—if you value these programs and particular areas of exchange with the federal government that are important to you, then don’t be quiet about it. JUTHANI: If I can just add one other piece to that, which is in my former role in academia the cut to indirect rates in terms of NIH funding, which funds many different types of support of research in academia, it has also had a chilling effect in the academic world where some academic institutions are not taking on graduate students in a variety of different areas. And in terms of the pipeline you talked about, of people doing research and not being able to pursue that research, some of that is because academia is feeling the pullback, whether it be from NIH dollars, a little bit different than some of the other public health funding that we’ve been talking about, more about scientific research. But really, this is an ecosystem and a continuum where people train in academia and then enter the private sector, enter the public sector, and really continue great scientific work. And it has been the stance of the United States for many, many decades that we wanted to invest in science, and scientific development, and that scientific pipeline. And so I do have concerns and worry that not only are we taking a hit to the public health workforce and generation of public health workers, but also to the scientific workforce writ large. BOLLYKY: Irina, I'm just going to add one quick thing, if I may, on that point. I have a particular concern about infectious disease research. One change, that there's proposed legislation in Congress but also apparently some support of the incoming team at the NIH, is to split NIAID, the portion of NIH that focuses on infectious diseases, into three subgroups—infectious disease, immunology, and autoimmune diseases. The thought is that this might build on some comments made during the campaign to defund or decrease funding to infectious disease research. And it really couldn't come at a worse time, given the range of things we're following. But it is not a lucrative area of medicine, to begin with, and to limit the research opportunities for people in this field is going to be a real disincentive to people pursuing it. FASKIANOS: Thank you. JUTHANI: As a—I’m sorry if I could just say one other thing. FASKIANOS: No, go ahead. JUTHANI: As an infectious disease doctor, I can attest to the fact that it is not one of the most lucrative areas of medicine. But I can also say that when we talk about public health we often think about communicable diseases, and infectious diseases being a large part of that, and the noncommunicable diseases. And we—because we've been able to have great scientific advances on the communicable diseases—in our vaccine programs, and antibiotics, and treatments, and antivirals—we've been able to focus on the noncommunicable diseases, meaning heart disease and cancer, and the things that take many, many decades to get worse in order to then cause worse morbidity and mortality. But if we don't have control of the communicable diseases that generally have morbidity and mortality more immediately, we will be losing decades of progress that we've made in public health. FASKIANOS: Thank you. I’m going to go next to Bill Taupier, who’s the director of administration and safety, in Massachusetts. Q: Oh. Thank you for having me. My question has to do with a little bit about USAID, and where it has been essentially eliminated, for all intents and purposes. My question is about, you know, outbreaks overseas, and how we can—you know, we learn a lot from those to fight diseases at home. But what is your opinion going to happen now with outbreaks of things like Ebola or Hantavirus, or other places—other diseases that could go unchecked? BOLLYKY: We’re going to be at greater risk. I think there might be a perception among some in the U.S. public that because of the struggles we saw around the COVID response, not just in the U.S. but other countries as well, that we really don’t know or are unable to contain—prevent, detect, or respond to outbreaks of dangerous diseases. And it’s not so. If you just take viral hemorrhagic fevers, things like Ebola or Marburg, you think about the Ebola outbreak in West Africa in 2013 to 2015, a little bit in ’16, that took 20,000 lives, or more. It costs billions of dollars in terms of the response. With each subsequent outbreak of Ebola virus, as well as other hemorrhagic fevers, we have gotten much better, even in low-resource countries, in containing this. The reason why you do not hear about these outbreaks in the same way that we heard about that particular West Africa Ebola outbreak is because of the build-up of these systems. USAID funding is responsible for the identification of the first COVID case outside of China. It is responsible for the development of the vaccine that we now have against mpox, and the world uses. I mean, the list just goes on and on and on of how these have kept us safe. And I do have concerns in these environments that—with the cutting of these programs, that we may not see that persist. If you had asked me even at the start of yesterday I would have told you that I think that some of the treatment programs around HIV or malaria, around in terms of the use of insecticide-treated bed nets, that those programs will probably survive in some form, even at the State Department. But we did learn overnight, with the cutting of these programs that I mentioned, or these grants, that many of the programs that had received waivers, the grants supporting those programs have been cut anyway. So I don't—I really can't say what's going to happen, but your question raises a real concern that gets at the heart of safety for all Americans and people worldwide. FASKIANOS: A question from Laura Bellis, Tulsa City Council member. Q: Hello. Yeah, I'm a Tulsa City Council member here in Oklahoma. And I also work in maternal-child health. And obviously, just geographically proximity-wise, too close to Texas for comfort. And our vaccine rates are also, as anyone can imagine, low, relative to where they should be. And so I'm curious if you all have any advisement, when we look at—whether it partnership, as Manisha has mentioned, with, you know, our state or local health departments, just what we can proactively do, acknowledging that we are likely to see a measles outbreak here? That we are in a certain type of policy and health environment that is not always very pro-public health. And just curious if there's anything you all would recommend trying to proactively do in the time we have prior to an outbreak. JUTHANI: Yeah. What I would recommend is, first, getting some knowledge with your local health department and state health department on areas that may be under-vaccinated right now. They should have eyes on that. They should know where those pockets exist. And, you know, like you said, proactively doing some of those interventions. And we do get funding to do this type of work, where we go within communities, identify what some of the barriers to vaccination may be, try to do that type of ground-building and communication with communities in terms of helping to overcome whatever vaccine hesitancy may exist, and then have vaccination campaigns to be able to, in fact, allow increases in vaccination rates. That’s some proactive work that could be done right now. Of course, you know, many health departments are stretched thin as is. Of course, we are dependent on our funding to be able to do that kind of work. But right now, I would say that that type of work is possible, and I would encourage you to connect with your local and state health departments. You know, every state is a little bit different. Connecticut is a home-rule state. We have fifty-nine local health departments and/or districts. I know that there are states like Massachusetts that have many more. There are others that have county-level government, and so there is a lot more economies of scale. But that's where I would really lean in and start there, to try to prepare yourself for what you've identified as a potential risk. FASKIANOS: Tom, do you have anything? BOLLYKY: Yeah. The only thing I would say here is part of what’s been hard about this first month is that, you know, vaccination rates have gone down. I think there is an important national conversation to be had. The part of the secretary of HHS confirmation hearings that resonate with me is being transparent that vaccines have a balance—all medical products have a balance of benefits and risks, and talking in those terms. I think it’s important that we engage in populations in a respectful way. I thought the advice that was just provided is very useful in that regard. I think there is work to be done. I think the fact that we did see a death, tragically, yesterday, hopefully provides an example of what the cost of under-vaccination might be. And there may be more receptivity to these vaccination campaigns than we might otherwise find. So I think looking for a way to have respectful, transparent conversations at this moment, given the national attention to this issue, is important. So I thank you for worrying about it. And, you know, the support you might be able to—or, the partnership you might have with your state and local officials. FASKIANOS: Great. I’m going to go next to Destini Cooper. If you could identify yourself, please. Q: Can you hear me? FASKIANOS: Yes. Q: Hi. This is Destini Cooper. I’m a policy analyst at the Legislative Council here in Nevada. And we're actually in our legislative session right now. I have a public health background. And I kind of want to know what you think the kind of pushback on public health will be when we're already in the world of vaccine hesitancy and things of that nature? And I just feel like in a world where we're trying to restore health—trust in the health care system or in the public health world, do you think that this will have some type of backlash? Because, as we know, as funding goes down or funding is taken away, then we lose services and we lose—you know, vaccine accessibility goes away, and people get sicker because we have more uninsured. And then the blame is, oh, well, vaccines don't work. Now we have more sick people. And now things that we made great strides in are now going backwards. So do you think that public health will kind of get the blame again when, how do I say it, basically options are taken away? Like, when we have to pull back on services and stuff, do you think the increase in health outcomes and, well, the lack of health outcomes—I guess, the decrease in health outcomes, do you think that public health will get the brunt of that again? Because COVID was our fault, right? Nobody believed in public health until COVID came, and then it was, oh, public health is here, and it’s terrible. So do you think that it’ll kind of be our fault again when we lose funding and we have to roll back these programs and the world gets sicker again, for lack of a better term? FASKIANOS: Who wants to start? (Laughs.) JUTHANI: I guess I can start. You know, I—Destini, I appreciate that comment. I don’t know that I would have thought of it that way, but I guess anything is possible. I would not have predicted the way the COVID pandemic happened and the divide that we ended up in after seeing a remarkable development of a vaccine that has saved millions of lives. So, you know, I think, to your point, is there a narrative or dynamic that has been set up that that could happen? I guess it could. You know, I guess I would have liked to think that with a reduction—and more health care problems, with a reduction in public health and preventative measures, that people would see that difference. But, you know, I guess we don’t know. My perspective in general is to try to work within my circle of influence, figure out where I can actually try to make a difference, and make a difference there, in that circle of influence. Because otherwise these questions become existential and feel like we’re never going to be able to make progress. But if I can look at—for the state of Connecticut, can I try to show people that I genuinely care, that I have read the science, and that, in my medical opinion, this is their best path forward, and try to bring people along and meet them where they’re at, then I’ve done my job for the day. And I think that that’s all we can each try to do. I hope we don’t end up in a place like you’ve outlined. Is it possible? I guess it could be. BOLLYKY: Two things, just to say quickly. We do a lot of work—have done a lot of research here on the drivers of differences between countries, how they did during the pandemic, controlling for relevant biological factors, and at the state level. And what a lot of that research has shown—and I’m happy through Irina to circulate the Lancet studies we’ve done on these things—is that, you know, trust—social trust, how communities interact with one another, played an outsized role in the differences between outcomes. There is actually a fair amount of research on how to engage with people who may not be trusting of public health or more inclined to blame public health for the problems. It is leveraging local—the people that are more trusted in those communities, physicians and nurses, the people that you engage with every day, the institutions you engage with every day, maintaining those relationships even in between crises, I think, is honestly one of the major lessons of the COVID pandemic for me, at least. And I think one that is going to be important in this moment. The second point I would make is I read an op-ed by a former Democratic political operative in the New York Times that talked about one strategy around this moment, from that political perspective, is waiting for the consequences of some of these actions to manifest, and therefore pointing out the folly of them. And I will say, from a public health standpoint, I don’t want that. I don’t want to wait that long. (Laughs.) I think we really need to be clear about what the consequences might be and try to engage with communities in an open and transparent way up front. And, you know, I think it’s really incumbent on all of us to do as much of that as possible. FASKIANOS: Thank you. There’s a raised hand, a number begins with 856, no name. So you’ll have to really help us identify yourself, your name and affiliation, please. Q: Yes. This is Laurie Lehmann. I’m City Council, Cape Coral, Florida. And I just want a clarification. You know, obviously, no one has mentioned Florida. Would my best bet be to talk to the county-level or the state-level public health departments to find out where we are lacking and what we can do about things? JUTHANI: Your local health department is always the group that is the most close and proximate to the conditions of what's going on, on the ground in your situation. So I think that that would most certainly be what I advise anybody, honestly, in any state, because they really know what's going on, on the ground most close to you. They can reach out to experts, whether it be at the state level or at the CDC level, to get additional information should it be necessary. So I think your instincts are correct to lean on the people who are closest to the ground where you are. FASKIANOS: Great. There are no more raised hands, but just a question about sources of good data. At the state level are there other organizations who are compiling the data that you could commend to people? JUTHANI: I would say that I think that this is a fluid and evolving situation. I think, to Tom’s point, we know that a number of CDC websites came down, and then now are back up. There are other things that are coming down and are—look to be permanently down in other agencies, as he mentioned the most recent changes that we’ve heard from USAID. So I think we’re going to need to keep on evolving and reassessing as time goes on. You know, I think there is the opportunity that maybe there will be other organizations, whether it be foundations, whether it be independent organizations, whether it be philanthropy, whether it be academia, whether it be partnerships of the like, who may try to fill voids that may develop, but I think we really don’t know what those voids are just yet. And trying to figure that out is, I think, where we are right now. FASKIANOS: Great. And, Tom, how would you say that other countries are beginning to fill the void of the leadership role of the United States in the global public health space? You know, with the exit from WHO, I mean, what is on the horizon here? BOLLYKY: Great question. I think, unfortunately, the events of the last month have had several knock-on effects. One is that governments who might be more politically aligned with the White House at the moment, some of them have—Argentina withdrew also from the World Health Organization, to emulate the action taken by the U.S. Reportedly, Hungary and Russia are considering doing the same. So this may spur, among some governments, emulation. In terms of the broader conversation about the Ukraine conflict, and indicating a potential need for more of a European role on defense on the European continent. This week, the U.K.—which outside of the U.S. is the largest government donor to global health—announced that it would decrease its foreign aid budget from 0.5 percent of GDP to 0.3 by 2027, so that it could invest more in the military, in response. Germany just, of course, had an election. There's enormous economic pressures going on in Germany right now. Germany has historically been a supporter of multilateralism, in the World Health Organization in particular. The World Health Organization has an office in Germany that does surveillance, data surveillance. I think there is some risk that you will see a pullback there as well. In terms of in-country, I think there have been some moves by aid-recipient countries to assume more of the burden. You've seen that in South Africa and Ghana, some conversations for that. But right now, the average government in sub-Saharan Africa spends $92 per person on health, which is less than a fifth of what it is in the less—the next lowest region. And their ability to assume some of these programs is going to be limited, outside of a handful of countries that are better resourced. Where we do see some governments responding has been China, particularly in countries where the U.S. has—or—and China has been grappling for influence, Southeast Asia and some Latin American countries. You've seen China offer to pay for some of the programs. I think in those strategic countries you will see that. I think overall China is not likely to assume the burden for U.S. programs in less strategic regions, or focusing on cross-border health threats. They tend to focus more on infrastructure projects. So we will see less of the focus on global health security and infectious disease or mother-child programs and more focus on healthcare infrastructure and products. FASKIANOS: Great. Roberta Smith from Routt County Public Health asked about programs like the polio eradication programs and Peace Corps, assuming they are also in danger. And then there's another question from MaryAnn O'Connor, who's the Massachusetts director in the city of Medford. Who's on the ground working on the outbreak in the Congo? So maybe you can just put those together. BOLLYKY: Yeah. So just quickly, on polio eradication, the U.S. provided money to the World Health Organization in two forms. One, like all governments, it pays assessed contributions, effectively membership dues. And then the other way is voluntary contributions. We, the U.S., historically provided significantly more in voluntary contributions. Much of that money went to two areas—the emergency program of the World Health Organization and polio eradication. So the withdrawal from the U.S. from WHO is going to have a consequence. Another major funder of polio eradication has been the U.K. government. So I don't know what will happen there in this area. It has been a priority for the Gates Foundation, so you may see them step up somewhat. But you may see some consequences. I have not seen anything in terms of the Peace Corps program. And maybe that will continue, but it’s difficult to know if they just haven’t gotten to it yet or if that’s more of a decision. I just haven’t seen any discussion. FASKIANOS: Great. Manisha, I wanted to give you a minute just to wrap up, and then I wanted to go back to you, Tom, just to say a few words about Think Global Health, because I think this community, this group could really benefit from it. So, Manisha, over to you before we close. And then we’ll go to Tom. JUTHANI: I think I would just make a plug to everybody that a lot of public health is local. And we do rely on federal partnerships and, obviously, international partnerships. But all of you are on the ground in your local communities. Advocate for public health locally. Press on and support the public health people that are doing that hard work and getting a lot of, potentially, counter messages to the work that they’re trying to do. And support them. Support the young people who are trying to do this work in that space in your local communities. And don’t be silent if you value public health, because I think that is going to be helpful not only in your state legislatures but at the federal government as well, to be able to show how public health has helped in terms of our society. FASKIANOS: Tom. BOLLYKY: Great. Thank you for the kind opportunity just to put in a plug for Think Global Health. It’s our online magazine that looks at how—tries to take—much focus on health is how things affect our—other things affect our health. This website looks at how health shapes economies, societies, and everyday lives. It looks from the other way. It’s a form of investment. I think we saw that in the pandemic. I think some of the political upheavals here are also related to what happened in the COVID pandemic. It is a multi-contributor site, so we do have a fair amount of domestic coverage of what’s happening in the U.S. So I would encourage you all to read it, but also, for those that are looking to write on these areas, we have that opportunity as well, and we welcome that. FASKIANOS: Wonderful. Well, thank you both for this hour. We really appreciate your taking the time and for the work you are obviously doing. And to all of you on the call for the work that you’re doing in your communities. It does take a village. We will be sending out the video and transcript. And we can put together some of the resources that were mentioned during this call. And, as always, we encourage you to visit CFR.org, ForeignAffairs.com, and, of course, ThinkGlobalHealth.org, that Tom just mentioned, for the latest analysis on international trends and how they are affecting the United States. And we welcome your suggestions for future webinars. You can email us at [email protected]. So, again, thank you to Commissioner Juthani and Tom Bollyky for this conversation. And we look forward to continuing it down the line. So thank you all.

Experts in this Topic

Thomas E. Donilon
Thomas E. Donilon

Distinguished Fellow

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    Play
    Jennifer Nuzzo, senior fellow senior fellow for global health at CFR, discusses the spread of the avian influenza in poultry and dairy cows in the United States and risks that zoonotic diseases pose to human populations. Rick Bright, former chief executive officer of the Pandemic Prevention Institute at the Rockefeller Foundation, discusses measures being taken to mitigate the spread of avian influenza and U.S. preparedness for future pandemics. A question-and-answer session follow their opening remarks. TRANSCRIPT FASKIANOS: Thank you. Welcome to the Council on Foreign Relations State and Local Officials Webinar Series. I’m Irina Faskianos, vice president of the National Program and Outreach here at CFR. CFR is an independent and nonpartisan membership organization, think tank, and publisher focused on U.S. foreign policy. CFR is also the publisher of Foreign Affairs magazine. As always, CFR takes no institutional positions on matters of policy.  Through our State and Local Officials Initiative, CFR serves as a resource on international issues affecting the priorities and agendas of state and local governments by providing analysis on a wide range of policy topics. We appreciate you taking the time to be with us for this on-the-record discussion. We’re delighted to have over 300 participants from forty-seven U.S. states and territories. I want to remind everyone that the webinar is on the record, video and transcript will be posted on our website after the fact at CFR.org, and we will circulate it as well.  We are pleased to have Dr. Jennifer Nuzzo and Dr. Rick Bright with us today to lead the discussion on “Avian Flu Outbreak and Preventing the Next Pandemic.” I will share a few highlights from their distinguished bios. Dr. Jennifer Nuzzo is a senior fellow for global health at the Council on Foreign Relations, where her work focuses on global health security, public health preparedness and response, and health systems resilience. She is a professor of epidemiology and the inaugural director of the Pandemic Center at Brown University’s School of Public Health. And she also directs the Outbreak Observatory, which conducts operational research to improve outbreak preparedness and response.  Dr. Rick Bright is the CEO and founder of Bright Global Health and works as a consultant for pandemic preparedness. He previously served as head of the Pandemic Prevention Institute at the Rockefeller Foundation. He was also the director of the Biomedical Advanced Research and Development Authority, known as BARDA, and the deputy assistant secretary for preparedness and response in the U.S. Department of Health and Human Services. And he was a member of the Biden-Harris Transition Advisory Board on COVID-19.  So thank you both for being with us today. I think we’ll begin with you, Dr. Nuzzo. If you can talk about the current status of the avian flu outbreak, the symptoms, risks it poses to animal and human populations, especially those working in food processing plants. NUZZO: Thank you so much, Irina. I really appreciate the introduction and the opportunity to participate in this session. I wish we didn’t have to talk about H5N1. H5N1 is an influenza A virus, we are—particularly called a highly pathogenic avian influenza A virus. It predominantly infects birds, but humans that have—humans have been infected, particularly those who have had contact with infected animals. And while we’re having this webinar now and we’re talking about this now, and it’s been in the news a lot now, I think it’s really important to understand that this is not a new virus. It’s actually one that we’ve been tracking for quite some time.  In fact, this virus was first recognized in the late ’90s, when it was detected in geese. Then in 1997, it caused a fairly large outbreak among humans. About eighteen cases were identified in Hong Kong, and of these six died. This was enough to prompt, you know, massive concern, you know, big chicken culling operations and attention on live markets, which thankfully sort of, you know, contained that human outbreak. But it didn’t eliminate the virus. In fact, the virus continued to circulate in birds, and ultimately spread to domesticated ducks. And this is thought to have then kind of contributed to the reemergence of the virus in humans in 2003, late 2003-early 2004, when we started to see outbreaks in a number of neighboring countries in Asia. About eight initially and then we saw the virus spread to a number of other countries as well.  Since this virus was first identified till now there have been about 900—just under 900 known human cases. But nearly half of these have died. And this statistic, while incredibly imprecise, is enough to be alarming, because typically when we, you know, find cases and we calculate the percentage of those who died, 50 percent is really—you know, really, really ranks up there in terms of severity. It certainly is on track to put, you know, H5N1 to be a much deadlier virus in terms of that percentage than, you know, the virus that caused the COVID-19 pandemic, certainly more so than seasonal influenza. So there’s a reason why we’ve been worrying about this virus for a number of decades.  As I said, the majority of these cases are known to have had exposures with sick animals. But there is some evidence that there may have been human—very limited human-to-human transmission. You know, people who have gotten it that didn’t quite know what they were exposed to. There was actually a study that looked back at that 1997 outbreak in Hong Kong and found evidence that healthcare workers who cared for some of those sick patients may have been infected, possibly without symptoms—which is concerning. But nonetheless, we haven’t seen any evidence of sustained transmission between humans.  And that’s fortunate because were we to see evidence of that, were we to see that, you know, multiple generations of people—meaning like, one person can give it to the next who could give it to the next—were we to see evidence of that, that would truly signify, I think, the beginning of a new pandemic, or perhaps the start of one, were we not able to contain it swiftly. Remember, this is—this is a new virus. You know, nearly—hardly anyone has actually gotten this virus. And so that that immune—that naive immune state, meaning we haven’t had, you know, background immunity to it, would make us likely all susceptible to this virus. So again, were are we to see evidence of sustained human-to-human transmission, that would very much signify the start of a pandemic.  Now, that hasn’t happened yet. And that is quite fortunate. But nonetheless, the worry about H5N1 persists. You know, I would say this virus has continued to circulate on the planet and hasn’t gone away, but I think some of the attention around the virus really, you know, began to wane a bit. In part because the majority of the human cases that we have seen to date really occurred between 2003 to 2015. And then there was a relative lull in the occurrence of human cases. And why that is isn’t quite clear. But that, combined with the occurrence of other health emergencies—including a pandemic caused by a completely different influenza virus, one that occurred in 2009—that was due to the H1N1 virus, not H5N1—you know, I think it really helped to, unfortunately, distract us from the threat that H5N1 poses. I would say that all kind of came to a screeching halt, that relative quiet and that relative distraction that people, you know, who kind of track these things were experiencing, really about a couple of years ago when we started to see much more viral activity from this virus. Started to see a massive kind of geographic expansion, the virus turning up in parts of the world that we typically hadn’t seen it, and also a massive species expansion. Meaning it was starting to not just affect chickens, and ducks, and other wild birds, but many other species—including mammals. And, you know, for me, that’s when I started getting worried because, you know, mammals are a lot more like humans than chickens are. And so that, you know, increases concerns that perhaps this virus is getting increasingly better at infecting things that are more like humans than chickens are.  That backdrop had been happening. And then really I think concern ratcheted up even higher when in March we heard about an outbreak on dairy farms—dairy cattle farms in Texas. That was surprising. One, because we hadn’t previously seen H5N1 in cows before. But also, influenza A infections have not regularly been reported in cows. And so that, you know, was just unexpected from a scientific perspective. But from a public health perspective it was concerning because, again, yet another mammal that this virus was capable of infecting. But in this case, it’s a mammal that humans have very close contact with. And so that raises concerns that humans would be, you know, exposed to—you know, humans would be exposed to this virus because they are exposed to these mammals quite closely.  Those concerns were realized when then we saw, you know, a case of H5N1 in a dairy worker. And then subsequently we have now found a second case in a dairy worker. This is quite concerning. Fortunately, these two infections were relatively mild. The dairy workers didn’t require hospitalization. They experienced eye inflammation, conjunctivitis. They didn’t have a positive respiratory specimen, which, you know, I think is an important finding. But it does raise the possibility that this virus is starting to do things that we don’t want it to do. There have also been just anecdotal reports from vets who are working on the farms that other workers may have experienced symptoms too. So I think reason to believe that these two cases may not represent the totality of dairy workers who have been infected, and certainly don’t necessarily mean they will be the only two dairy workers infected. Since then, of course, there have been more news developments. You know, finding of viral genetic material in pasteurized milk. Not entirely surprising that we would find it, but certainly concerning given the number of positive samples found, which suggests that this virus may be on more farms than our surveillance is telling us. Also recently, last week, there was a report that they found the virus in muscle tissue from a specimen taken at a slaughterhouse. So, again, concerning that this—concerning evidence that this virus may have a much larger geographic footprint than just the amount of testing that’s happening on farms would suggest.  And that’s really, I think, where I just want to maybe call our attention to. You know, the biggest worry that I have right now is really in protecting farmworkers. We have ample evidence right now to know that this virus, while it is not yet a pandemic threat—it may not cause a pandemic, we don’t know for sure, we have reasons to be worried, we don’t know for sure. But what we do know is that farmworkers who are exposed to this virus in the course of their occupation can get infected. And we know historically that this virus has not produced—you know, has not typically been a mild virus. And so that really, I think, creates an urgent public health situation where we should be acting to protect these farmworkers.  Unfortunately, the level of testing that we’re doing right now is really not sufficient to allow us to protect farmworkers. You know, the testing that USDA is requiring is quite limited. They recently put into place a new policy that people are calling sort of the test to move policy. If lactating dairy cows are going to be moved across state lines, it is required that cows from that herd be tested. But the farmers can basically pick the number of cows that get tested. There’s a maximum number that’s established. So, as you can imagine, that’s not quite comprehensive enough to find all of the infected—all of the cattle that may be infected. Other than that, testing is largely voluntary. It’s limited to cows with symptoms. It does not include beef cattle. And so you can imagine that there are lots of holes in our abilities to figure out which farms have the virus and which don’t. Which makes it hard to protect the workers on those farms. The testing that’s happening is not happening on the farms themselves. It has to be sent to a lab. So the test results aren’t timely enough to protect workers. So there’s just a lot of ways where exposures can happen that we wouldn’t know about, which, again, makes it hard to make sure that the workers can get, you know, access to antivirals that could protect them if they’re—you know, protect them from severe illness if they are infected. It also makes it hard to stay ahead of this virus and to understand what might be next for it.  So that’s the area that I think I’m most worried about right now, is, again, making sure these farmworkers have the protection they need. In my view, enhanced testing is really critical to that. I also think we need, you know, to make sure there’s greater use of protective equipment, particularly eye protection. I think we should also be talking about using vaccines and expanding access to therapeutics. But I know Rick will have a lot to say about that, so I will let him address that.  But I just want to sort of end with this overall notion that this virus has had a lot of ups and downs in the twenty-plus years that we have been tracking it. I will say I am much more worried now than I have been in those past twenty years. And I don’t think we should be waiting for it to be obvious that this represents a broader public health threat for us to act. We should be trying to get ahead of this virus so that it doesn’t become the catastrophe that we fear that it could be. We have tools, but we need to make much more proactive use of those tools. And I know Rick will have a lot to say about that. But I’m grateful he’s here to enlighten us on that front.  FASKIANOS: Wonderful. Thank you so much, Jennifer.  And, Rick, over to you. BRIGHT: Well, great. Thank you for hosting this, Irina. And actually, I could never do a better job than Jennifer laying out that background. You know, I started my post—my graduate student work in 1997 with the spillover of H5N1 in Hong Kong from those birds into humans. And so for twenty-seven years, I’ll age myself, twenty-seven years I’ve been like Detective Colombo with an open—file open case tracking this virus. And we’ve seen it come. We’ve seen it kind of abate. And we’ve seen it come. We’ve seen a kind of abate. And I think at some points we fool ourselves into thinking if it’s abated this many times over history, then maybe we shouldn’t worry so much about it.  And so I tell people that, you know, we are more prepared for an influenza pandemic than for any other pathogen pandemic, probably, that we know of. And that is why I’m concerned, is because of that preparedness. The twenty-something years of investment in understanding the virus, understanding the vaccines, and how they work, their challenges, and antiviral drugs and diagnostics—therein gives me the concern, knowing those vulnerabilities. And that some might be easily misled into thinking we’re ready, that we have this under control. You know, and so because of what we know about this virus, we know it is a shapeshifter. We know it can rapidly change. We know it can jump to different hosts and different species rapidly, and change, and evolve. Part of that is the nature of influenza viruses. They are these negative-stranded RNA viruses, so when they replicate themselves it’s kind of sloppy and they introduce these mutations. And those mutations can help it be more lethal, or adapt, or spread to humans and other hosts.  Sometimes because the genetic makeup of the virus is fragmented, there’s all these segments inside that virus, you can have two viruses infect a person, or an animal, or a seasonal virus and the H5N1 virus. And they’ll recombine and reassort. And you’ll have this virus that comes out with some of the best or worst of all worlds. And so we know the tricks of this virus. And because of that, we’ve been somewhat placated that we kind of think is manageable in the bird population. When we see a jump from the wild birds—ducks, geese—that’s sort of this reservoir. We’re never going to annihilate it from wild ducks. But when we see it jump to birds in the past, domestic poultry, we basically wipe out the flock and decontaminate the area. And that seems to abate it somewhat.  Never in history have we seen this virus spread in such a sustained way to so many different mammalian species. And that is a concern I want to echo that Jennifer’s put forth. Also want to say that this is such a rapidly evolving situation that anything we see today or know today can change tomorrow. It can change very, very quickly because of the nature of the virus. And also, I think, because of the complacency that we might also see now, because we think we have it ready. So some of the things we’ve invested in, we’ve invested probably $10 billion at the federal level. I was the head of the influenza division at BARDA before I became the director of BARDA. And through the many—or, ten years I was there, $10 billion in designing vaccines, changing vaccines, trying to transition from a 1940s technology of egg-based vaccines, to cell-based, to recombinant-based vaccines that could probably be designed and manufactured faster than egg-based vaccines. We’ve invested in antiviral drugs and we’ve invested in diagnostics.  So I’m going to tell you that that’s good news, because we have a lot of experience and a lot of expertise. The bad news is 90 percent of our global capacity of making influenza vaccines are still in 1940s technology of eggs. For the United States supply alone, it would take 900,000 eggs going into a facility every single day for six months without fail just to make a supply of H5N1 vaccine for the United States. In parallel, we would have to make a new—a chemical component of that vaccine called an adjuvant. And the adjuvant would have to be added to that vaccine. And we only have two manufacturers of that adjuvant for the world.  Globally, we only have about the capability, capacity to make four billion doses of egg-based pandemic flu vaccine in a year’s time. And Bill Gates and the Gates Foundation, about 2017 I think it was—2016-2017—did a model a transmission model showing that if we were to have a virus such as the H5N1 influenza virus that transmitted efficiently between people and cause a severe illness and death, in a six month period of time we could see ten million deaths in the United—around the world—around the world. And so that tells you that we have to move swiftly. That tells you 90 percent of our capacity is based on a 1940s technology.  We did invest in a cell-based vaccine approach. We have one manufacturer in the United States, Seqirus, that can make a limited supply of cell-based influenza vaccines. And we have three other manufacturers globally, so four total around the world that can make a cell-based vaccine. So that would come in handy, primarily, if an H5N1, which is a bird flu virus, were to infect the chicken flocks that are required to lay those eggs that are needed for that vaccine. Imagine how vulnerable that supply chain is. Those are fertilized eggs, by the way. So those are embryonated. Those aren’t just eggs we can go to the grocery store and buy. And they’re very select.  So we have this candidate vaccine virus, that CDC mentions, the CVV, which is a starting material for an H5N1 that was made from a virus in 2020. And we could put that in our limited egg capacity. And what we learned from the 2009 H1N1 pandemic, that many of you were probably involved in, that we overestimated the productivity of that vaccine capacity. At the federal level, we were promising the country that we would have 120 million doses of vaccine six to nine months out, by October of 2009. And because the virus did not grow well, that candidate vaccine virus, CVV, didn’t grow well in eggs. At the end of October, we only had seventeen million doses for the United States, mostly for the world. And that came after two major waves of the virus in 2009. So it tells you we need a lot—to do a lot on the vaccine front.  On the antiviral front, we really have two classes of antiviral drugs. We had three in 2003 and 2004. The adamantane drugs, the M2 blockers, many of you might be familiar with. I actually published a paper in The Lancet showing that 100 percent of the viruses circulating, seasonal influenza, were resistant to that drug. We were using that drug for many years thinking it was working and saving our older population when it wasn’t, because no one did the testing. We weren’t doing the right surveillance and monitoring for drug resistance. So we’ve sort of learned our lesson. And we track the neuraminidase inhibitors—so Tamiflu, and Relenza, also Tamivir and Zanamivir.  And in 2008, we learned that every seasonal virus circulating was completely resistant to Tamiflu. We were lucky with the 2009 H1N1 pandemic strain, because it reintroduced a sensitive neuraminidase in that virus that circulated for the pandemic. Therefore, also Tamivir or Tamiflu was effective. But it was only three months into that pandemic we started seeing resistant viruses to also Tamivir or Tamiflu. So it shows you how vulnerable we are to that particular antiviral drug. So we invested in another one called Baloxavir or Zofluza. It works in a different mechanism and a different part of the influenza virus. In our stockpile, we have about 600,000 doses of that. And we have about 75 or 80 million doses of Tamiflu. But that Tamiflu drug was purchased in 2005, and 2006, and 2007, some of it. So it’s past its expiry date.  And I imagine that once we were in a full-blown response and we started shipping our limited supplies of Tamiflu from the stockpile to the states, we’ll see what we saw in 2022 in the influenza season, when we had spot shortages, and they started shipping out the oldest material from our stockpile. Many of the states didn’t accept it. It was hard to describe to people why they were getting a drug that said it expired in 2007 or in 2010. So we have a number of things to do in the antiviral drugs. In the testing space and diagnostics, we don’t have a test that will tell a clinician that a patient has H5N1. We have rapid antigen tests and some other lab tests that would tell you it’s influenza A or influenza B. But we don’t have one that says, this is H5N1. We need to have a test that we can really rapidly detect when a person is infected with this virus, because the antivirals that we have really only work if you use them in the first thirty-six to forty-eight hours of symptoms when you’re infected with this virus. And we also know from H5N1 viruses, traditionally it took about twelve to fifteen times the dose of Tamiflu to inhibit H5N1 viruses, compared to a seasonal H1N1 virus. So the limited supply we have would be cut by maybe fifteenfold.  So when you hear messages that we’re ready, we have this, I want you to really think about how ready are we. And therefore, it leads to the question, what can we be doing now to be better prepared? And that would be accelerated development of tests that can be in the hands of people and clinicians at point of care that could distinguish rapidly an H5 infection. It would be to accelerate the procurement of stockpiles at the federal level, and maybe the state level even. That’s a diversified stockpile that might be as part Tamiflu, might be part Zofluza, or Baloxavir. So we have at least options, if we saw resistance developing to the other. And, of course, we need to think about vaccination and how we can invest in technologies that would scale more rapidly so we can have more doses quickly that are independent of eggs. I talked about the recombinant-based vaccine that we built with protein sciences. That technology has been acquired by Sanofi Pasteur, and basically offshored and moved to—out of the U.S. So in the U.S. we don’t have that capability any longer.  We do have a stockpile, a surge capacity of eggs. We can surge to from 600,000 to 900,000 eggs a day pretty rapidly. But I’ve already described the vulnerabilities. So I think it goes back to, number one, what you’re thinking is, how do I tell people now—or, how do I reduce the chances of getting infected with this virus, while we figure out some of this other stuff that may not be directly in your hands? And, as Jennifer noted, I mean, the greatest risk are to those who are in close contact to the virus. That means those who are in close contact to infected animals. That might be an infected dairy cow. Might be infected cats, or birds, or raccoons, or skunks, or alpacas now. So if you see a sick animal, just stay away from it. Call animal control and let them handle the sick animal or dead animal. Avoiding contact with that is going to help reduce your risk.  Of course, we know that the milk coming from infected cows has very high titers of H5N1 virus in it, if it’s not pasteurized. So raw milk has super high virus titers, some of the highest titers of virus I’ve seen in any substrate. When we have this quantitative PCR analysis and you get a three, that means there’s a lot of virus in that milk. So discouraging raw milk consumption and raw meat, or undercooked meat, from potentially infected animals is primarily important. Keeping a distance from infected animals, staying off and the dairy farms, et cetera. If you have people in your states and areas that work on dairy farms, the CDC has put out some really important guidance on how to protect themselves working on those farms.  I know it looks uncomfortable. I can’t imagine working on a dairy farm and having to really gown up. The instructions that came out today look almost as if they’re protecting themselves from an Ebola outbreak, other than the hood. But they’re—the head-to-toe clothing and protection, head covers, the right type of respirators, eye covers, gloves—this is really important if they are working in environments that have infected animals, because you don’t want them to be the test cased that this virus infects and then have further opportunity for adaptation in the human population. But those are primarily simple things to do, sometimes complex to implement.  But right now, the general population, if they can stay away from infected animals and products, they’re pretty safe. But I do think it’s a ticking clock. I do think we’re about to hit midnight. I’ve never seen this virus take hold in mammals, so far—so broadly distributed in such a sustained way. And we are not doing the testing. We have not done serology studies. And maybe you can do that at the state level to start getting a baseline of human immunology, who is exposed, what level exposure there is among the general population, high risk individuals. Imagine if a lot of the infected dairy cows are going to slaughter, which they are, and if there is infected meat product going to your fast-food restaurants where a lot of this dairy cow meat goes. It goes into pink slime and it goes into fast food burgers, a lot of it.  And, of course, the FDA says if you cook that meat to 140 and 160 degrees it removes the virus. However, if you handle that meat in the process of it being cooked, you’re at high risk. So it’s really important to think about the entire chain of transmission, potential exposure, and protecting all people on the farm all the way through the market to the slaughterhouse and processing plants. So, I’ll stop there. Again, to remind you, this is an evolving situation. What we know today will change tomorrow. More crops—more animals are exposed. So pay attention. FASKIANOS: Thank you very much for that. And now we’re going to go to all of your questions and comments. Please use this forum to share best practices as well as what you’re doing in your own communities. (Gives queuing instructions.) And so with that, I’m going to go first to Renee Yarbough-Williams, who is the chief of staff and the office of Maryland Delaware (sic; Delegate) Cheryl Pasteur. Basically: Can the virus live in pasteurized milk? And how do—how will we know which farms are infected? Is there any tracking system that’s happening now? Or is it really as it gets reported out? BRIGHT: I think either of us can do that—Jen, do you want to do that first, and then I’ll take the next? Or either way? But, yes, why don’t we do that? NUZZO: So they have found genetic material of the virus in pasteurized milk. They have so far, from the tests done to see if you can grow the virus from milk, have not been able to. I’m reassured by that. I haven’t worried about drinking milk. My kids drink it a lot of times. I am not currently worried about that. I am worried for people who, as Rick said, are exposed to raw milk prior to pasteurization, because of the level of the exposure and because the process of pasteurization has not been able to render that virus incapable of infecting us. So that’s my concern. Regarding tracking, as I said, we’re not doing a lot of testing. So I wouldn’t assume that because you see it in some—know that it’s in some places, it doesn’t mean that it’s not in other places. BRIGHT: Yeah. And I’ll add to because—and this is where we can learn more from the states, and local levels, and others directly dealing with this. And I will agree that the limited experiments that have been done to show that heat can inactivate H5N1 in milk in a simulated pasteurization process does seem to be effective, if the amount of virus going into that process is low to moderate. And so my concern is the way we consolidate milk from various farms and take it to a pasteurization facility, it involves picking up milk—maybe one truck or a few trucks—picking up milk from various farms. If the ratio of milk from infected farms going into one tanker truck is low—so if you’re picking up milk from ten farms and two of those farms have infected cattle and eight are unaffected you’ve diluted that virus out quite a bit. And I think that pasteurization can handle it.  But as we continue to see this outbreak spread broaden and spread out across the country and farms, the ratio of infected milk will go up in that tanker, in that—in that batch going through pasteurization. So we don’t yet have data on the effectiveness of pasteurization as that viral titer gets higher going through that process. So that’s why it’s important to pay attention. And if there is anything noted that changes, and the pasteurization is not completely effective, that’s what we need to be completely aware of and be able to respond quickly. FASKIANOS: Thank you. I’m going to take the next question from Sean Murphy. Has a written question, but let me just see—oh, also a raised hand. If you can say who you are, that would be great. And unmute yourself, please.  Q: Hi, there. Can you hear me?  FASKIANOS: We can. Q: My name is Sean Murphy. I’m the mayor pro tem for a small town in Colorado.  My question is, what would you advocate on the local level for getting prepared for a pandemic like this? Thank you.  BRIGHT: I think that was— NUZZO: So—go ahead. BRIGHT: On the—on the basic level we know how this virus spreads. So I think it’s going to be—it sounds simple, but I know it’s going to be a very difficult conversation coming through COVID, what we know is hand hygiene can rid the virus—if you come in contact with it, you touch it, washing your hands actually can prevent you from getting infected and transferring that to your eyes, your nose, or your mouth. We also know that respirators—N95 respirators—are quite effective at managing the spread of influenza. So it could already be at the basic level in the community just awareness of hygiene, once again. No one needs to start wearing a mask right now, or being extra overly conscious for H5N1. But now’s a good time to reinforce just general hand hygiene and the concept that if this were to spread, we might have to wear respirators to protect ourselves again. NUZZO: And I would maybe just add, I think in the short term the thing that I’m most worried about is protecting these farmworkers. I’m quite concerned that there are a number of reasons why infections in this population may not be—might not be found as much as we would like to be able to find them. One, just to understand what’s going on with this virus but, two, really to protect these farmworkers. And so I think really outreach to providers who, particularly in farming communities, that these farmworkers may rely on, just what the symptoms are. You know, these—so far, the two known cases, publicly known cases, have had eye infections. And that might not be what clinicians think to try to test. It’s unfortunately a little cumbersome to test that right now, but nonetheless it would be important to think H5N1 if there were a farmworker with an eye infection.  So just in the short term, just doing outreach for the purposes of protecting farm workers. In the longer term, agree with the list that Rick gave. I will just also queue that this virus—we don’t yet know what a pandemic strain of H5N1 would look like, and if it will be the same as what we’ve seen so far. Again, the data that we have on H5N1 is quite limited. But the data that we have are enough to be concerning. We do typically know that influenza may be different than the SARS-CoV-2 virus that causes COVID-19. And one key difference could be that influenza viruses often are hard on kids. And there was a lot of debate about schools and whether kids should be in schools. I will tell you, I was on the side of keep the schools open.  It’s harder to argue in the context of a virus that is disproportionately affecting kids, a virus, influenza, we know is often seeded to the community from kids. And so that, I think, creates another scenario. So if I were a local leader, one of the things I would be doing is if there were a pandemic, what actions would we as a community be willing to take to stop the spread of this? What are the red lines for us as a community? What would make us shift our feelings on those red lines? Think about if we did need to start vaccinating again, how would we do it? Could we build on the infrastructure that we just used for COVID? Does that infrastructure still exist?  So I would be kind of going through those scenarios, again, hoping we never, ever need to act on them. But that if we did, that we would, you know, be able to hit the ground running, instead of trying to figure it out de novo. FASKIANOS: Thank you very much. The next question from Steven O’Connor, who’s an attorney: Is there an mRNA H5N1 vaccine in the pipeline? BRIGHT: That’s a great question. And a good answer is there are multiple H5N1 mRNA vaccine candidates in development. And Moderna has started a clinical trial. And also, BioNTech and Pfizer are also in clinical studies with H5N1 mRNA-based vaccines. Also, caveat to say that we’ve had—they’ve had many years of work in developing an mRNA-based vaccine for influenza. And there have been some technical challenges to address in that process. So we’re still learning. So even though they have a candidate in the clinic for H5N1, we still may need to optimize that in some ways. But the good news is that they are moving forward. They’re doing this at risk. And we should have some clinical data read out in a matter of months, I would say. FASKIANOS: Great. I’m going to go next, an oral question from Patrick Jordan, if you can accept the unmute prompt and tell us who you are. There we go. I see you’re unmuted. Nothing. OK, waiting. I’m going to go next to—there are a couple of questions in the chat about unpasteurized products. So one question about pasteurized eggs are not readily available. And then there’s another question from Deirdre Goins about, does this warrant a state pulling unpasteurized dairy products from shelves? Because this—you know, the outbreak. And how can states begin testing farms? What policies would you recommend, you know, putting into place at the subnational level? NUZZO: So in terms of unpasteurized products, first of all, there’s long been reasons to avoid unpasteurized products. Eggs, obviously, can be cooked. So that’s—you know, but eating raw eggs has long not been recommended. So I personally, you know, fall in the position that this has long been public health guidance and it should continue to be. I worry about the sort of rise in sort of, you know, fashion, I guess, of raw milk as a product that some people perceive to be beneficial. I quite worry about raw milk, not just the consumption but also, as Rick said, touching it and other exposure. So, yes, unpasteurized products represent a risk.  I will say, though, in terms of testing, I think one of the things—there is a notable difference in terms of our approach to handling H5N1 chicken farms versus cattle farms. Sorry, if you call them cattle farms. And the difference is that this virus has typically killed the chickens. And so the response to H5N1 in chicken farms has been much more aggressive, in part, because of the risk to the industry. So while I worry a lot that this virus is circulating on cattle farms and we are unaware because, you know, the cows are not being killed and because we know that asymptomatic cows can be infected. We don’t fully understand their abilities to transmit it, but we have to assume that that’s possible, in chicken farms it’s different.  Another key difference also is that there are financial incentives for identification and reporting of infections in poultry farms that don’t exist yet for cattle farms. And so I worry—my worry is focused right now on the cattle farms, because I think that the incentives are really, really important. We obviously have to balance multiple priorities here. The objective isn’t to put our farmers out of business. The objective is to be able to produce these products safely in a way that won’t harm the general public, but also won’t harm the workers who are involved in their production. And I think the incentives are key to that.  This is why I’m so interested in making sure we have available tools that can protect workers on these farms, such as personal protective equipment, but ultimately vaccines because it is—well, as Rick said, it’s hard to wear these personal protective equipment in the context of these farms. And, you know, we want to make sure if we have a tool that can protect humans, we should be using it on these high-risk individuals.  FASKIANOS: Rick? BRIGHT: No, I mean, that’s exactly right. I mean, and the does bring up a question, maybe some things to think about at state-level policies. There could be discussions and considerations to making the vaccines that we have in the stockpile available to vaccinate high-risk individuals, those working on farms—dairy farms, or in the slaughterhouses, or milk processing. And so even though the vaccines that we have in the stockpile may not be exact match of what could circulate if this were to become an efficient human-to-human transmitting virus, we’ve done a number of clinical trials through the years with our stockpile and what we call prime-boost studies or mix and match studies. And there’s a number of published data that show if we were to give the first dose of vaccine now, with what we have in the stockpile, it would prime the immunity of those of the highest risk.  And we know that takes two doses of an H5N1 vaccine to make a sufficient level of immunity in a person, because this is a virus we’ve never seen before in people. But the data show that we published in our prime-boost studies, that if we do the first dose with what we have now on the stockpile when that virus takes off, and we have the match to vaccine, we can give that second dose and it will actually make that immune response really robust to match what was circulating even before that virus took off, and then the circulating strain that became a pandemic. So there’s a lot of data to support discussions and considerations for perhaps immunizing at least a first priming dose in individuals at a high risk. FASKIANOS: Great. And just to say that that question from Deirdre Goins, works in the office of Representative Andrew Gray in Alaska.  So Patrick Jordan, who was unable to unmute or we were having technical difficulties, wrote something I want to just read out loud: Getting back to the mayor pro tem from Colorado, here in Ionia County in Michigan, we’re at ground zero for avian flu. Our health department is working closely with the state. We’ve tested twelve to fifteen dairy farm workers with zero positive. But the critical thing here, with the migrant farmworkers, is building relationships with the organizations that serve migrant families, that migrant families trust and are used to working with. So I just wanted to read that because I think that is a good contribution to the discussion. BRIGHT: Irina, can I say— FASKIANOS: Yeah, please go ahead. BRIGHT: I’d say that we should make a poster with that statement on it, because that is crucial. I mean, and we’re learning that much of the workforce across the U.S. at highest risk are likely to be migrant workers. And there are so many issues with getting health care and tracking or monitoring for infection or sickness, or treatment and recovery in this population. And the relationships that are built now around trust and trying to help and make things available are critically important, because in the context of an outbreak and something really devastating it’s that much harder to build trust and work on those communication lines. NUZZO: And just to add that that’s likely to be a durable benefit. Meaning that it’s not just an avian flu benefit to doing that. I mean, this was critical for the H1N1 pandemic in 2009, which didn’t involve avian—an avian influenza virus, but nonetheless this was a vulnerable group. And there was some stigma because the virus was thought to, you know, have started in Mexico. So there was—there was really to do that. There was a mumps outbreak on mushroom farms. So, anyway, this is something that I think public health would benefit from, just regardless, because I think the overarching lesson from all of these events is that, you know, outbreaks, epidemics, pandemics, they expose our vulnerabilities. And that remains a highly vulnerable population and worthy of having strong relationships and, as Rick said, a high degree of trust. BRIGHT: And, Irina, as you get the next question, I’m going to add one more, because that was such a good comment. It was loaded. I loved it. You should have the next panel—he can be on the next panel. But he also mentioned the fact that they’re testing some exposed individuals, monitoring. One of the biggest gaps that we have right now in this outbreak, in the animals as it adapts to humans potentially, we don’t have access to those data. So we have no data in serology, or the virus, and the things that are happening in people or the animals. And we understand that there are jurisdictional challenges. There are database challenges. So many issues, even in the United States, between the federal level and the state level, the state and local, local and the farm, and et cetera.  And it’s so important at the non-federal level—wherever you fall in the local, state, wherever it might be—sharing data in real-time, as real-time as possible, is the only way we’re going to understand what’s happening and be able to sharpen our tools that we have and be able to get in front of this virus. If the data aren’t shared for whatever reason, made publicly available for whatever reason, then we will be caught flatfooted. We won’t know that this is taking off and spreading and killing a lot of people until so many people are infected and dying that we can’t stop it any longer. The key is held right now in the sampling that Patrick just described. FASKIANOS: Thank you. Next question from Jonathan Olvera in Lacy Lakeview, Texas: What season do you believe will be the highest risk for transmission? Or what season should we be aiming for our preparation? NUZZO: I don’t know that we know this answer. I mean, there’s a couple of ways of looking at it. Typically, respiratory flu viruses, we see a higher activity in the months that we go inside where there’s not a lot of humidity. So that’s the kind of late fall, early winter, early spring. Why we’re seeing these infections now, don’t know. Maybe tied to bird migration. But we’re still learning about this virus. And I would say that’s one of the concerns that I have—and I’m just going to—I’ve been looking at the questions in the box and there’s a lot of questions about where. And I would say we can’t answer where because the type of testing that we’re doing is—we’re only finding cases where we are shining a light. And we are not shining a light in enough places to know for sure.  We should be shining a light so we can answer these questions. So we don’t fully know why it is now. I worry, though, that we are looking at the numbers and looking at where the cases are and drawing the conclusions on not only incredibly limited data, but possibly highly biased data. So one of the concerns I have is if you look at the USDA map of which farms—which states have infected farms, that map has remained unchanged for weeks, despite the fact that they keep finding more and more farms in the states that have already identified outbreaks. So this virus is moving around. We’re finding it in wastewater. It may be from wild birds. We don’t know. But the number of states reporting outbreaks hasn’t changed.  So that that makes me highly suspicious that what we’re seeing is an artifact of our surveillance and not an indication of the viral activity. So I worry that some people think that this is on the nadir because we just haven’t found more and more states, and that this is just on the way out. I would love that to be true. But I cannot tell you that, based on the data that I’m seeing. So that’s my overarching, like, take home for everyone today, is don’t assume evidence of absence is evidence—you know, that the absence of evidence is evidence of absence. We really don’t know where this is. We need to be much more proactive in our testing to get ahead of it.  One way—you know, people have asked me, well, if we’ve only had two human cases in dairy workers, and those cases have been mild, does that mean this virus may be much more mild than we think? If we did serology studies that told us that, like, 90 percent of the population had already had this virus, that would change my opinion about it. But we haven’t done that and we don’t know. I would like to see us do much more testing to better answer these questions. I think the fact that in the 1997 outbreak when they tested healthcare workers, they did serologic studies, they looked for evidence of prior infection, they found that these workers likely were infected and that many of them didn’t have symptoms. That was that virus, not this one. But that’s interesting and important to know. But we haven’t done the kinds of studies that would allow us to better answer some of these questions. And that’s to our peril. BRIGHT: Yeah. I’ll just add too H1N1 started in April, went through May, June, the summer is when we had the waves. 1918 H1N1 pandemic also burned through the summers. So it started in the spring and burned through the summer. So it’s unusual that we don’t see—when we see these pandemic flu virus outbreaks really take off in the spring and go through the summer. This is unusual, non-seasonal influenza virus. I worry that we might—if it abates in this summer, that we might think it’s under control or under management. And it will cloak itself within the seasonal winter respiratory viruses because we don’t have test monitoring for H5. We’ll just think is influenza A and we’ll miss it. And it will adapt during that time, and then when the spring hits next year, it’s really six weeks—six months after that when we could see this resurgence. So we could be blessed with a window of time to prepare, but I would not relax if I did see—if I saw the reporting drop in cases lower or the next month. I would intensify preparation for the spring. FASKIANOS: So there’s a question from Mayor James Fahey of Corrales Village in New Mexico: Do you know if anything is being done on swine surveillance, as it is my understanding that they both have the Alpha 26 23 receptors? BRIGHT: There is some surveillance in swine. I mean, again, when we think about the ratio of testing for human influenza viruses versus swine surveillance or, you know, cattle surveillance, or other animals, it’s very limited. But, I mean, the infections that we see in pigs historically aren’t that harmful to the pig. So the pigs can be coinfected with a seasonal influenza virus, human strain, and a H5N1 avian strain. It really is in the combination of those two viruses in that mixing vessel that we see things that can emerge. And we see actually an unusual triple reassort, we call it, strain that emerges most years lately around the state fair time. And so we constantly see this unusual reassort – (inaudible) – come out of pigs around state fairs. And it’s affected several states for many years.  And so I would say, because of that we have some decent surveillance in the swine population. It could be bolstered, probably should be, in context of what we’re seeing now. The thing we don’t have a lot of is reporting and sharing of those data. So even if farmers, and veterinarians, and others are testing in swine, there is not a lot of information about viruses that have been found in swine. They’re not sharing the sequences, necessarily, or posting them in the database, like, GISAID database where most influenza sequences are collected and analyzed. And so if there is additional testing being done in various animal populations, I can’t emphasize enough the importance of submitting and sharing that data into a database that will allow us to monitor for mutations, evolution, or recombination events in any of those animal populations to be better prepared for a human outbreak. FASKIANOS: Wonderful. And there was a question asked about is the stream readily detectable by wastewater surveillance. Jennifer just answered it in the answer thing. I’m just going to read it for the— NUZZO: I’m trying to get to these questions. I see a lot, so I’m just typing them if I can. FASKIANOS: Yeah, no, that’s great. CDC is doing a wastewater testing for influenza A. H5N1 is not—is one, but not the only. And it will soon do testing for H5 specifically. And she put in the chat the link to the CDC.gov. So you should take a look there.  We don’t have much time left. We’ve got, like, three minutes. So I wanted to just ask—this is probably a good question—how would an H5N1 outbreak compare to COVID-19, given low uptake of the most recent COVID-19 vaccine? What can be done about vaccine hesitancy in the public? And that comes from Steven O’Connor, who asked a question earlier. So if you could answer that and leave us with any final thoughts, that would be great. And I’m sorry we couldn’t get to all the questions here. NUZZO: So one key way is that, you know, I would say a blessing of COVID-19 is that it largely spared kids. It didn’t fully spare kids, but compared to influenza viruses it did. We don’t know what an H5N1 pandemic will look like. But the fact that young children, as well as older adults, could be affected—possibly young, healthy adults. You know, we just—there’s a larger age range, I think, to worry about. So that is—that is one key way. I am worried about our willingness to do what it takes to respond to a flu pandemic now, following a COVID-19 pandemic, given sort of where we are politically and where we are just from a pandemic fatigue standpoint.  I will say that it is important to note that we do regularly use influenza vaccines. But a pandemic H5N1 vaccine would not be like a regular seasonal flu vaccine, likely because, as Rick mentioned, it would use an adjuvant, which is an additive that’s meant to provoke a higher immune response. That’s not something we use that frequently in our vaccines. And I think it’s something that warrants specific conversations with the public about what adjuvants are and why we would use them and what it would mean that they might have more of a reaction than they would otherwise get, and why that potentially is beneficial. So I think there’s a lot of work that we have to do on the front end to talk to people about these vaccines, to hear their concerns about it. Anyway, I’m just—I’ll stop there so Rick can say—get some words. BRIGHT: Well, I think that’s important. I think the conversation should start now. And they just start in the high-risk communities. I think they should start—the lessons for from COVID-19 vaccination is there’s a lot of distrust. There was a lack of information and details from the federal level to the state and to the locals. And we should now use the time we have to have those conversations, build those trusted messengers and relationships—on the farms, in the communities, in the barbershops. I mean, I’ve worked with a lot of groups that taught us a lot of lessons. Now’s the time to have those conversations. And you can have them with seasonal influenza. And you can talk about the differences in how bad different influenza viruses can be and the importance of vaccination.  Jennifer has mentioned something that’s really critical in avian influenza viruses or pandemic influenza. It hits the very young and the very old hardest sometimes, and sometimes they’ll hit those with the most robust immune response. Sometimes your body’s immune response does more harm to you than the virus itself. So it’s really important to think about educating everyone for vaccination to make sure that they are protected when that time comes. And I’ll leave you the thought of we are better prepared for influenza than any other pathogen, and therein lies the rub. We can’t be complacent. We can’t think this is going to pass. We must do everything now in this window of opportunity to educate, communicate, and prepare. FASKIANOS: Wonderful. That was a great note to end on. So thank you both, Dr. Jennifer Nuzzo and Dr. Rick Bright for sharing your expertise with us today. And thanks to all of you for joining us for your questions and comments. We will send a link to the webinar recording and a transcript. Until then you can follow Jennifer Nuzzo on X at @JenniferNuzzo, and Rick Bright at @RickABright. And, as always, we encourage you to go to ForeignAffairs.com, and ThinkGlobalHealth.org for the latest developments and analysis on international trends and how they’re affecting the United States—and, of course, CFR.org. And please do send us your suggestions for future webinars by emailing [email protected]. So thank you all again for being with us. And thank you to you, Jennifer and Rick, for your time. We really appreciate your expertise. BRIGHT: Thank you. Been a pleasure. (END)  
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