Infectious disease specialist Peter Chin-Hong, MD, presents the current state of wintertime respiratory illness, focusing on the Bay Area yet covering the reality that viruses are global travelers. He discusses anticipating and managing developments related to COVID, influenza, RSV and other viral illnesses, offering his insights on which patients should be advised to take particular precautions regarding avian flu and why there’s a disconnect between California’s H5N1 state of emergency and the “don’t panic” message from public health agencies. Included is a look at “Disease X” and the value of a collaborative response to infectious disease outbreaks anywhere in the world.
Without further ado, I would like to introduce Doctor Peter Chin Hong. I'm going to hand over the reins to him. Welcome, Doctor Chen Hong. Great, thanks so much, Maria, and thanks everybody for joining today. I thought what I'll do today is really just quickly review 5 lessons I've learned for COVID now that we're at the 5 year anniversary, and the reason why I'm doing this is not really only because we have to prepare for the next outbreak or epidemic or pandemic, but mainly because I think we haven't really Uh, pause to really take stock of what we've been through over the last 5 years or so. So just 5 quick lessons and then I'll dive straight into where we are right now with respiratory viruses, and then we'll go to the future. In this talk, I also have just a few snippets of interviews with people to just make it uh interesting and to give you other insight as well. But the focus today is really on uh the big three, COVID, RSV, and influenza. Um, and, um, you know, talking about where we're going, uh, as well. So, um, let me just uh move this forward here. So in terms of COVID lessons, just quickly for uh 5 lessons I've learned over the last 5 years, um, health equals politics equals health, and really when we think about The next uh outbreak or pandemic, uh, which will probably come in our lifetime, given what's happening with bird flu, um, alignment is key and the reason why I think the Bay Area and California to some extent did really well is because we were aligned with, uh, between, uh, public health, academia, politics, uh, everything was totally in sync. And you know, we've done before for other outbreaks, uh, HIV, uh, we did it for COVID as well, and, and, you know, became very political, uh, as we all know, it's even more political now and which makes it really tough for us in healthcare with our patients and their families. When you look at the US deaths per capita, it's still highest in the United States compared to other developed countries, uh, and even during Omicron after a change in administration, uh, the difference was even more profound, and that's probably because, um, you know, the underlying structural issues in healthcare, um. Access, uh, disparities, racism still occurs. When you look at deaths in the US and COVID, uh, it is linked to political affiliation, not mainly, not only because people got vaccines at different rates, um, but mainly because, again, alignment was very different, um, if you have a governor or um a mayor who has a different philosophy compared to healthcare providers. But again, uh, it was really great for me personally to be in the Bay Area, um, and I just remember those early dark days when everything was shut down, and, um, but we did, you know, we have really some of the best outcomes in the Bay Area in the world, actually, when you take stock and look back at it, our death rate was among the lowest in the nation, amounts of world given the amount of disease that we have, and that was really due to alignment. The second lesson was working fast, and that requires agility, strong communication, and yet again alignment. I think where the US uh fell behind was really in not seeing what the scope of the problem was. We only had tests, a few tests, and those tests came late and we're using them in the sickest of the sick, so the, the kind of no-brainers already who had COVID, but not seeing the people in the community who had asymptomatic disease or were spreading it, um. To some of these vulnerable people. There was not only delays in testing, but there's delay in rollout of, of on disparities in some medications like Paxloid that uh we saw come about later on. The third lesson was engaging with the community and I think um we did that overall pretty well in the Bay Area in particular, uh, not treating minority populations as a monolith. uh, so there were programs uh for monolingual Cantonese speakers, um, which really came in handy when there was a lot of Asian hate during the pandemic. There were efforts in the Latinx community, um. That was uh with Unidos and Salud. That was really, really um key and uh and a really important initiative and, and also in the Bayview Hunters Point area with African American populations. Again, what we learned was that you really have to use key informants, uh, people from the community talking to the community, um, and using different strategies for different populations just like you do with your patients, uh, every day. Um, and because of that, uh, we had high vaccination rates in general in, um, you know, most different areas in the community, uh, in the beginning, there were a lot of disparities and after these initiatives, uh, they were all pretty similar amongst different groups, uh, for the primary uh series at least. Fourth lesson communication is key. And trust, as you know, like with your patients, is as important as expertise. Um, I think what we Healthcare did was um worked with Talking to the community in different ways, uh, including media, um, and you can use that as a way to align science and politics and, and doing that in an empathic way. Um, I think one lesson that I got primarily in terms of uh using communication as a way to not only align but to help. Make that alignment happen is uh during Mpox and even though it primarily affected adults, uh, I still think we can learn a lot of lessons. Um, I'll talk a little bit about how Mpox is affecting kids in Africa right now, um, as a potential threat, although it's probably going to be low risk compared to other uh uh emerging infections. So this is Reggie Aki, he's an ABC anchor, and he's going to talk about the role of healthcare professionals in communication during pandemics. Well, I think it's especially important that we have people on our air and online who are part of the communities that are affected. So, uh, you know, for COVID, we are all affected. You know, there wasn't anyone that COVID didn't touch, and so that was a little bit easier, but for something like MOx, specifically in San Francisco, where we have such a large queer population. And where at the beginning, we weren't getting a lot of information about Mpox, and that's where the trouble really starts, because that's when there's misinformation, and that's when there are rumors being spread, and that's when panic can happen. So, I really saw that as an opportunity to try and prevent the panic and try and get people the help they need as fast as possible. And to be quite honest, To play a role that sometimes our positions are allowed to play where we could push major entities involved, including health departments, including our hospitals, and including our politicians to do something in the absence of action. And what we were seeing from our point of view was not a lot of alarms going off when we thought that there was an urgency. So, We play a part in that, but we also have to reach out to physicians in our community who know the players and are also a part of that community. So again, uh, communication is gonna be key, just like uh what you deal with on a day to day basis with patients, their families, but also the community as well. Um, and again, you don't have to be the world's expert in a particular area. Um, people still generally trust us a lot in, in healthcare. And finally, money talks, uh, I think one interesting, um, The effect that I saw in the pandemic was the fact that uh here in the Bay Area Silicon Valley brews the occasion and, um, you know, implemented and And use uh some of their technology like smart thermometers before our diagnostic tests were really up and running uh as a way to figure out what's going on in the community. But we do need resources and I think given the underfunding of public health historically and, and probably into the future, um, uh, it is a big threat that we'll have, um, you know, again, for the emerging threats that we have. So those are the 5 lessons I think thinking about them in context of what I'm going to talk about next would probably be really helpful. But first I'll talk about where we are right now in terms of respiratory viruses. Um, you can see that in the map of the US as of today, um, most states are actually in the east and in the middle are red, so that's high. Some states, uh, New Hampshire and Hawaii are very high. Uh, California is, uh, a late adopter in this sense, so we're still in the middle of our, um, emerging, particularly with flu, still going up. RSV is kind of uh peaked. I'll talk a little bit about that more in a little while. Uh, but meanwhile, needless to say that, um, things are still gonna be very active, uh, in the office, uh, for all of you coming up soon. So, winter is coming, of course, winter's here, but I'm talking about the respiratory virus season, uh, particularly with influenza. So even though moderate levels are in California, it's still increasing. Uh, most states, like I mentioned, have moderate or high levels of respiratory viruses, uh, RSV influenza and COVID, Hawaii and New Hampshire very high. Uh, in terms of RSV, the CDC says it's probably peaked in many areas in the United States already. And I'll show you a a graph coming up soon to that effect. Um, but it's still, uh, pretty common, not as bad as last year. Um, we can talk about some of the reasons why. For influenza, uh, a lot of activity, particularly in kids, especially under 4, there've been 27 pediatric deaths so far, 11 last week alone. Uh, and if that's going to increase still in the country, uh, we'll expect, unfortunately a lot more kids getting sick and more going to the hospital. COVID is rising, particularly in the wastewater, and we don't know, um, if that means that it's gonna hit people coming up soon. It's coming a little bit later this year. It actually hasn't hit a lot of people yet. Uh, so either we have a lot of immunity and it wouldn't really do a lot of damage, or it will just be later in the season, uh, than we think. Needless to say, this is all, uh, pointing to continued, uh, activity coming up in the next few weeks. So COVID is still a big question mark and unpredictable. In terms of current vaccination uptake uh for influenza, uh, adults around 43%, uh, kids are around 43% also, so, uh. Average to low compared to most years and then COVID, um, just like last year, very similar numbers actually not a lot of uptake in the general population, including those who really needed the most, which are the oldest adults uh among us. The bottom line is all of this is pointing to, uh, coming back to pre pandemic uh periodicity and cadence, uh, plus you have the threat of COVID that we didn't have before. When you look at UCSF data, uh, just in terms of uh what the lab is testing and what they're getting come back as uh including inpatients and outpatients, you can see that flu is definitely rising in the dark blue, um, and it's probably accounting for more than 50% now of. Anybody with the sniffles in the community, uh, there's rhinovirus, uh, causing colds, and then when you look at the light blue, RSV is still kind of going up and down but not clearly down yet, um, so probably still some room to go. And then in terms of, um, other viruses, uh, a little bit of flu B, metapneumovirus, which I know is um. You know, historically important in pediatrics got a lot of attention um recently because uh China is seeing a big increase or actually just reporting a big increase, so a lot of people got concerned, but, uh, again, as you know very well, nothing new, it's been described since 2001, it's probably been around since the 1950s. Pow, a little bit of power flu. A little bit of adenoviruss, but really flu A is uh the big player right now and it will likely continue to increase. With COVID, um, a slight uptick over time, but, uh, again, nothing big yet, and, and many people don't know what's going to happen still for the rest of the season. So what about the forecast? Um, you know, I feel like the weather personnel giving you a forecast for infectious diseases. Um, I, I gave a few comments, uh, in the last few minutes, but in general, the CDC is forecasting a milder season compared to the past two seasons. When you look at COVID and flu and RSV burden together. Um, we talked about COVID being a big question mark, and RSP actually has a lower burden than predicted. So in the Maroon color is COVID, and you can see that it's coming down over time and what's predicted is this red here where maybe you'll see a bump coming up but it would not be like the last two seasons. And then when you look at RSV, uh, the peak predicted level is for 25 in the next month or so is going to be lower than the last two years. Um. Uh, and again, that's probably due to a lot of things uh factors. One factor is that the uptake of the pediatric vaccines has been really high, um, uh, in the last year when it was first available, as well as carry over immunity and part of the reason we had a lot of RSV. For the last two seasons was because of uh immunity deficits from the early years of COVID when people weren't getting together and also people didn't have carry over immunity to the next season. In terms of influenza, um, that's forecast to have still the highest peak up to January, maybe February, and you can see that in the sky blue here, uh, we'll probably continue to have a large tail that may go on until April, um, but peaking in January, February. In terms of the forecast for flu, again, um, the peak in early in January with some uncertainty, the forecasting is slightly higher burden this season compared with the last season. Part of that reason is that a lot of flu this year is driven by H3N2, and H3 is notoriously bad for, you know, uh, sending people to the hospital, including both children and adults, as opposed to H1N1. Um, and that's what happened in the UK. That's what happened in 5 countries in South America, uh, over there winter, which was during our summer. Um, but like I mentioned, uh, seasonality is more closely aligned with pre-COVID influenza seasons, and, uh, the highest burden within California is currently in Southern California. So when you look at these graphs for the last two seasons and this season, in the green is 2022 to 2023, and you can see that uh this is the peak in uh the purple is 23 to 24, which is a lower peak than the previous year, 22. And then this year is expected that we may actually exceed the last two years, possibly driven by more H3N2 this year, and maybe not a perfect match, even though the vaccine does have H3N2 in it by some uh antigenic drift. So this is where we'll have some audience participation, and the reason why I bring this up is that. Um, you know, again, the new game in town, even though it's lower is COVID, which we didn't have before 2020. So remember 2024 was a year when we're not supposed to have a lot of anything because we're supposed to have a lot of immunity and um people resume normal activities for the most part. How many COVID deaths did we have in 2024? And to give you some perspective, with flu every year, we have about 35,000 deaths, um, on an average flu year. Uh, so that's a question for the audience. And you can all type it into the Q&A if you would like to. A, B, A, B, C, or D, and I can let Doctor Chen Hong know. One person saying D, another 50,000 B. D BC Great, um, those are all great answers, um. So everyone was fearing that we would reach 100,000. And in 2023, we actually, which was still a recovery year, again, people were already going back to normal. Um, it was 75,000, but last year it was still a respectable 50,000 or so, actually 46,901 COVID deaths. Um, again, what I anticipate is, well, actually we don't really know what will happen with COVID. We'll either continue to go down or what might happen is what we saw in flu where, uh, you know, we'll go up and down after it settles down into a pattern and the reason why is that, uh, you know, some What people are experiencing with lower deaths is just carry over immunity, but particularly with the oldest adults, um, the more than 90% of the hospitalizations are in those in California who might have gotten a lot of shots early in the pandemic, but they didn't continue to get boosters. Uh, so, you know, time will tell what will happen with COVID, but definitely, you know, a big threat. It's like having a new flu. On top of regular flu every year, so it shouldn't really be underemphasized. Doctor Chen Hong, your last slide, someone's asking um about deaths. Uh, any chance you know the breakout of what the pediatric death is from COVID COVID? I wanna say that's a great question. Mostly mean uh adults. I wanna say it's like around 1000 kids or like in the high hundreds, um, and that again, that is really shocking when you think about influenza, so, um, not, uh, something to be discounted, uh, either. Thank you. You're welcome. Um, so again, You know, even if it's in the 50,000 range, uh, it's going to be very similar to or more than flu and pneumonia. Probably more than kidney disease and about similar to diabetes deaths of everyone in the country. So again, you know, it's something we need to continue to emphasize. So I talked to Carlos Del Rio, who was the previous president of the Infectious Disease Society of America, about what we still need to do in COVID as a uh health sciences and scientific community uh for the future. Well, you know, COVID is, is, as you know, for us here to stay, and but the virus continues to change. It is there is increasing levels of immunity in the population, but it's still causing significant disease and mortality and morbidity, especially in older individuals. I think the most important thing is we need better vaccines. The vaccines we currently have, as you know, are not sterilizing vaccines. They, they, they prevent. From getting severe disease, but also the, the, it produces significant waning immunity so we clearly need better vaccines and there's some, some recent scientific data suggesting that part of the reason for that is that it may not be creating the kind of memory B cells that we need. So, uh, better vaccines is, is a clearly an important topic there. The other one is therapeutics. I mean, the therapeutics we have, uh, you know, you and I do HIV. I think about, you know, I that I think about, uh, you know, uh. Uh, pack over it a little bit like I think about AZT or DDI and HIV. I mean they're antiretrovirals, but they're not the best drugs available. We we need discovery to better drugs for, for COVID, but the same thing can be said about about influenza. I mean, all respiratory viruses are in the same category and quite frankly, one of my biggest concerns right now is You know, H5N1 and it is beginning to spread among people and and and what are we doing? I clearly think we're not prepared and with the misinformation and the lack of trust in vaccines, I worry that we're not prepared as a society should there be an outbreak of H5N1 in the in the insuring months. Great, thanks so much, Carlos. That was awesome. So people talk about a quaddemic, and of course, I don't think there's any comparison in terms of going to the hospital with the big 3 of COVID RSV and influenza, but we have been seeing probably the highest levels of norovirus, um. In the country for about 10 years, um, and that's again due to many factors that we can talk about including. People getting back together again, less carry over immunity, um, but, you know, we also have not a new strain particularly, but a particularly bad strain this year that's uh very, very transmissible, so that's why people actually have less immunity because we hadn't seen the strain for a few years, and then number 2, it's very infectious, um, so, uh, that's what probably is going on. So norovirus, uh, no reminders needed for this group, but, uh, just a level that sudden onset of vomiting and diarrhea with fever, stomach pain and body aches. So that's where the flu part comes in the stomach flu. Um, it is something where you're minding your own business and all of a sudden you get hit by this dump truck of vomiting and diarrhea. And unlike food poisoning, which is toxin mediated. This kind of lasts for 2 or 3 days, so that's the other way you can distinguish norovirus from just um toxic, toxin associated food poisoning. Uh, a lot of people get infected every year, 20 million a year, uh, cruise ships, daycare, uh, dorms, kindergarten. There've been 91 outbreaks in the first week of December alone, um, and which was about double from the previous year, and we mentioned the reasons, including the strain. Uh GII. 17. Uh, it's very, very easy to get, uh, to give you some perspective with salmonella, you need about thousands of organisms. With norovirus, you can be infected with as few as 10, and it's also very hardy, so that's why. Hand sanitizers aren't great for norovirus, you need something to wash it completely off and abrade it, and that's why washing hands with soap and water for 20 seconds is really the solution. Um, so what to do, you get it by eating it, of course, uh, not from our story methods. Um, you wash hands with soap and water, wash fruits and vegetables, limit contact with infected people, and food. Caregivers in the home, say you have a parent who has no virus to protect the kids, they shouldn't really be preparing food until 2 days after their symptoms are completely resolved. I always talk to patients about knowing the signs of dehydration as a reason to bring themselves or their kids into the urgent care of the hospital or the office. So in terms of um what's next. Uh, it's all about avian flu right now. The temperature is definitely rising, um. Just a few words about avian flu, H5N1. It's been around for about 30 years, but it's really picked up in the last few years. Actually, while we were busy with COVID, even avian flu was raging in birds, uh, probably driven by a mutation that started around 2020. And uh now it's hitting all these flocks and wild birds, uh, flying all over the place, uh, and that's the reason why it's affecting zoo animals and, um, you know, people outside of the traditional risk factors of of dairy cows and chickens. Uh, so far, the mortality rate is about 50% around the world in the 30 years. There've been about 1000 people infected. And about 500 deaths. And the reason why we have deaths is because our body's immune system isn't used to The antigens on H5N1, uh, the last four pandemics for influenza have all been driven by its origins in birds. So again, we've seen this before, and that's why a lot of people are just very cautious about what's going on. There have been 67 human cases so far in the US, mainly from poultry workers and dairy workers, uh, 38 human cases in California. Mainly in the central valley, around Turlock, etc. uh, mainly conjunctivitis or pikeye. Touching, uh, cow's udders and then touching eyes or being splashed by milk, where there's a super high viral load, cause the virus is really infecting primarily the udders of cows. Um, there've been at least 2 people sick without known animal exposure, one child in Alameda County, um, another child in San Francisco, um. One adult in Missouri, uh, and then potentially um another adult in Delaware and of course there's, although not confirmed because the CDC did not have enough samples, there's a child in Marin who drank raw milk. Uh, the raw milk was positive, but the human sample was positive in the local DPH labs, but not confirmed by CDC, not because. They did and the test was negative. The the specimen was thought to be degraded by the time it got there. Um, Which, you know, is concerning because, again, it really speaks to what's going on in wild birds and that thinking about risks outside of just the touching the dairy cows or um poultry and broadening that to um you know, wild birds and dead birds and sick birds is is really what's going on right now. There's been the first death in Louisiana in the United States, uh, as many people know. That was an older male who's older 65 with other comorbidities, who had backyard chickens, and likely what happened is that wild birds interact with these chickens. Um, chickens get very sick and get sick fast, uh, and the owner the chickens just interact with the chickens, got really sick and died, unfortunately. And that happened in Louisiana. California, as you know, has declared a state of emergency of bird flu and cattle. We are the epicenter of bird flu right now in the country, uh, in humans, um, and we have so many cows infected and the majority of human cases, most of them, uh, as you know, have been very mild, and that's because bird flu hasn't really figured out a way of unlocking. The combination key to get inside our bodies yet. Uh, but there were some, uh, there's been studies, uh, from Uh, San Diego, for example, La Jolla, the most recent, uh, good study. Showing that that time to developing that mutation is not as far away as people think and also of course, uh that person dying in Louisiana suggests that uh that particular variant figured out a way to enter that person's body and make that person very sick and historically we know that that can happen uh as well. So what the state of emergency is meant to do is to really um give more resources to public health, have more flexibility. Do hiring um with less bureaucracy, uh, and have a little bit more hands on deck. Uh, it also is funding, uh, more surveillance, passive surveillance. So right now there's a move in California has already started doing it, um, but let's in the rest of the country where with every flu A that gets diagnosed, uh, they're gonna subtype it if it's not H3 or H1. To look for H5, um, and that's how that, uh, child in San Francisco was detected. It was through passive surveillance from the Department of Public Health. Um, we've been seeing deaths in zoo animals, and that's because of the wild woods flying over, uh, in California, Oregon, uh, Arizona, there's a Pacific Flyway with a certain flight pattern of wild birds, and that potentially might be explaining why Washington State, Oregon. Cats in LA, zoo animals in Phoenix, uh, are getting infected, and the main two animals that get infected and do very poorly are birds, of course, as well as cats. Uh, so for cats, um, When they get infected, it's very fast, high proportion die, it looks like rabies, uh, so this is really also impacting domesticated cats as well. Where the barn cats and some of the dairy cows got really sick after they drank the milk. Um, there were cats in LA and in Oregon, uh, house cats that died, um, probably from exposure to at least raw turkey meat in the case of LA as well as raw milk, um, in, in some cases. Um, so what's happening is that we have to educate patients about their own cats at home, their own backyard chickens, um, particularly if they look really sick and they want to take them to the vet, they have to really wear PPE around that. But in terms of you and I and the community right now, uh, it's still no reason to panic now. Um, there's no proven human to human transmission yet. The risk is still very low for the general population. Which is weird, right, because we have a state of emergency and I think I always get questions from the community as to why is this this this connect between a state of emergency, but yet we're saying don't worry, don't panic, uh, and that's because a lot of activities happening right now amongst animals and we're trying to anticipate when it will happen and cross over to humans and trying to be prepared, uh, frankly, although there are lots of threats to that right now. So how do you keep yourself safe from H5N1 and how to keep your patients, their children and their pets safe, uh, get your flu shot. The reason why is that if somebody gets co-infected with both uh bird flu and human flu, even though The bird flu is still having a hard time entering our bodies, they can exchange genes and that reassortment, um, can make it such that that bird flu will pick up some of those genes from regular flu. In fact, that's what, that's what happens in pigs, and that's why swine flu happened in 2009, and there's already been at least one pig infected in the United States in that way. Um, California DPH has also funded a lot of, uh, dairy workers to get flu shots independent of the regular mechanisms, and that's really to address that, uh, potential. Of course, don't handle sick cows or animals even more than ever now. Don't drink raw milk or cheese even more now because the risk is still going up. Don't feed pets raw milk or meat, especially cats, and we PPE for handling sick birds in backyard flocks. Um, so moving on now to another emerging threat, which is Mbox, um. So, I'll take you back to the 50s where Mbox first was isolated in the Congo, and, and this was in a lab in, in Copenhagen. And it mainly affected kids who were going into the forest, handling, uh, you know, infected, uh, animals, small mammals, etc. and they were getting sick and uh the mortality rate was around 10%, uh, sometimes up to 20% in kids. And then in 2022, uh, we saw a big outbreak primarily amongst gay and bisexual men, spread by sexual networks, uh, and that's clade too. Um, that was about 100,000 cases in More than 100 countries, um, still circulating in the United States. So if you have any adolescent patients, it's really important for them who are sexually active, uh, who are identified as gay, bisexual, to really get, uh, that, um. Mpox shot, um, they're still available. Um, but then what happened, so that mortality rate is pretty low, less than 1%. So again, I told you about this 10 to 20% mortality, less than 1% mortality, primarily in HIV infected patients with uh uncontrolled CD4 count uh viral load, sorry, and then. In the last year or two, there's this new mutation called clade 1B, which has features of both clade 1A, the original, and what we saw in 2022, and that's also affecting children, but also um spread by sexual networks as well as household contacts. So now there have been cases in. Multiple countries outside of the dozen or so uh African countries, including countries that hadn't seen it before, like Rwanda. Um, 70% of the cases in Africa and 70% of deaths for 1B, the new one, is among children, uh, so that's why it's getting a lot of attention. That's why the WHO, uh, has designated it a public health emergency of international concern, um, as a way to divert resources and vaccines, uh, to the countries that are most affected. So, you know, we did have a case in San Mateo, um, and, but from a traveler and the CEC doesn't anticipate there will be a big threat, uh in the United States, um, at this moment, uh, we still have the one from 2022 circulating like I mentioned. Um, other emerging threats are really related to climate change, um, and we can spend a whole talk on climate change, but one exemplar of that, uh, is dengue fever. So this past year for the first time, There've been so many cases of dengue in Los Angeles that haven't traveled. We do have mosquitoes that can transmit dengue and as um weather increases or changes in um in patterns, uh, we will see more dengue. Um, this, uh, spread by the Aedes aegypti mosquito, which also transmits Zika and chikungunya. Uh, symptoms are severe headache, pain behind eyes, joint and muscle pains, rash, and there are 4 types of dengue. It's a situation, as you might remember, where if you get one type. And you get infected with another type, that's when you can get hemorrhagic dengue fever because of that, uh, sort of like super an general like immune system gone crazy after it gets primed by the first infection, which is generally uncomfortable but doesn't cause people to get very, very sick. Uh, and I mentioned some of the causes, which is climate change and it's really rising globally. There have been other mosquito-borne diseases that have also been affected by climate change. We know about West Nile, uh, we're kind of out of the season now. Luckily, Doctor Fauci got West Nile, wrote an op ed in The New York Times, which is uh very powerful, I thought, um. Uh, we've seen the emergence of a new, uh, mosquito infection. In the world called Orouche virus, that's mainly in South America, but also in travelers to the United States, um, more than 20 cases um of this Apouch virus, um, spread by, uh, mites and mosquitoes. Um, The thing with our approaches it's like Zika where it can cause uh preterm births and also um cause microencephalopathy, microencephalopathy or small heads basically. Um, but not probably at the same risk as Zika. So there are all these emerging, uh, mosquito-borne diseases which really related to climate change, which you'll probably see over the next few years, um, in here in the Bay Area, uh, and in California. And then to put all this together, uh, the WHO really wants us to think about something called Disease X, which is really a placeholder. Um, they even brought it up before COVID, which is in 2018, and represents the knowledge that a serious international epidemic could be caused by a pathogen currently unknown to cause human disease. Um, everyone thinks the next outbreak or epidemic or pandemic would be a respiratory virus. That's currently circling animals like bird flu, um, so really calling out for strengthening primary care, research and development, spending more and spending smarter, and, uh, thinking on prevention, where we only spend about 3% of our national budget and prevention and data sharing. So, I had an opportunity to just talk to one of my colleagues, uh, and good friends, Bonnie Maldonado, who's um As many of you might know from Stanford, uh, as to her, uh, thoughts about where what we still need, um, in terms of uh healthcare and um science. Uh, we've learned, the good news is we've learned a lot from COVID, we've learned a lot from flu. We have lots of technology. I don't think we are gonna have a a problem understanding how to harness technology, but what we need to do is learn how to implement technology and we also need how to, um, we also need to learn how to do surveillance the right way globally and quickly. So as an epidemiologist, um, I can tell you that All of us card-carrying epidemiologists really believe in the power of surveillance and everyone thinks it's boring, but it is really, um, you, you need to get out there and do the spy work, the groundwork, just get the data out as fast as you can, get it back and organize it at a global scale. We are capable of doing that today, especially with AI and then building technologies is not hard to do. Um, the hard part is implementing and disseminating technology. So that there is global equity. What we saw with the pandemic was that we moved relatively fast, but we got hung up in where, how well we were able to disseminate technology and information. So I think those are the major areas and then the The other big area would be really how do we communicate effectively and we're talking about not just at the local state or national level but at the global level, how do we communicate so that people understand that that um what we're doing is really laying the groundwork for understanding. Uh, what might come along the way? How do we address the immediate issues, the medium-term issues, and the long-term issues. So we have the scientific expertise. We just have to learn how to apply it and apply it equitably across the globe. Thanks so much, Bonnie. That was great. So what he was talking about was really um Communication and global equity, but I would even say we're having a hard time with local equity, uh, as you all know, and already I think vaccinations, although we look at averages, are really have fallen behind in in subgroup populations. So the takeaways for this last few minutes have been um COVID-19 lessons, thinking about alignment, speed, community, communication, uh, and resources, um, and trying to apply these lessons to the next outbreak or pandemic, but also reflecting on some of the successes and taking stock of what we've been through. I didn't talk about some of the other consequences, we can certainly do that in terms of long COVID, mental health, um, loneliness, uh, some of these other, uh, repercussions of the pandemic that we're still dealing with, but still haven't fully addressed. In terms of where we are now, we talked about COVID still being a question mark. Influenza is still on its way up, uh, possibly going to exceed the last two seasons. If you look at South America, if you look at the UK, if you look at the CDC projections, that curve might actually look bigger than the last 2 seasons. Uh, we're having a late start in California, uh, as we often do with influenza. And we also have the threat of bird flu, uh, with a lot of cool mingling of flu viruses. We talked about the fact that RSV has probably peaked, um, but still does mean you're not going to see a lot of cases. Um, and part of that not so bad season compared to the last two is that this carry over immunity and also the success of some of the vaccinations, particularly in pregnant people and in um kids, um, that's been more widespread in use. And the 4th, um, infection we talked about and virus was norovirus, of course, um, not as important in terms of mortality and hospitalizations history, but certainly causing a lot of disruptions in school and work um in families right now. In terms of what's next, we spend a lot of time talking about H5N1 bird flu, uh, and, um, how that's moving really at slow pace, but it's steady, and the question for me is not when it will cross over more into the human populations, but when, but if not if but when. uh, we talked about MOx and the new variant that's the reason why it's designated as a public health emergency of international concern by. Uh, the WO, we talked about dengue in LA as a marker of climate change and Disease X. Um, we talked about the need for better vaccines and therapeutics and COVID, um, but technology is probably the easy part. It's implementing the technology so that all our families and all our populations are reap these benefits, um, communication, alignment, all these very human skills are much more challenging. than the science and the brass stacks of developing something in the lab, uh, which is challenging itself. So I'll stop here and I'm happy to take any questions.
