IT IS MY PLEASURE TODAY TO INTRODUCE DOCTOR CHERYL COHEN WITH PATHOGENS AT THE SOUTH AFRICAN CDC WHICH IS ALSO PROFESSOR OF EPIDEMIOLOGY AT THE UNIVERSITY. SHE HAS A LARGE BODY OF WORK OF EPIDEMIOLOGY ON PATHOGENS JUST TO NAME A FEW INFLUENZA, RSV, AND MOST RECENTLY COVID AND ADVISES WHO AND THE SOUTH AFRICAN GOVERNMENT OF VARIOUS ISSUES AROUND INFECTIOUS DISEASES. AND SHE IS VERY WELL KNOWN FOR VERY DETAILED STUDIES THAT ARE KEY TO UNDERSTAND THE PATTERNS OF IMMUNITY AND TRANSMISSIONS FRIDAY AND PATHOGENS. SO WE ARE IN FOR A TREAT TODAY BECAUSE SHE IS A GREAT SPEAKER AND ALSO TALK AN IMPORTANT ASPECT OF COVID REGARDING SOUTH AFRICA. WE WILL TAKE QUESTIONS AT THE END. SO IT IS OVER TO YOU. >>DR. COHEN: GOOD EVENING. THANKS FOR THE INTRODUCTION. >>DR. COHEN: I'M DELIGHTED AND HONORED TO PRESENT AT THIS MEETING. CECILE AND I GO BACK A VERY LONG WAY. SHE IS ONE OF THE PEOPLE WHO GOT ME STARTED ON THE FULL EFFECT AND MY PHD SUPERVISOR MANY YEARS AGO SO IT'S VERY NICE TO MEET AGAIN HERE ON THE ZOOM. THANK YOU FOR BEING HERE. TODAY I WILL TALK ABOUT OUR EXPERIENCE IN SOUTH AFRICA WITH THE COVID PANDEMIC. I WILL MAKE SOME GENERALIZATIONS TO AFRICA MORE BROADLY THAT MOST TO BE FOCUSED ON SOUTH AFRICA BECAUSE THAT'S WHERE I WORK AND THE CONTEXT OF WHAT I KNOW THE MOST ABOUT. AND ALSO JUST TO MENTION I WILL TALK TO A LITTLE BIT ABOUT INFLUENZA BECAUSE AS YOU CAN SEE MUCH OF THE WORK THAT WE DID REGARDING THE EPIDEMIOLOGY OF COVID BUILT ON THE UNDERSTANDING WE DEVELOPED FROM THAT WORK RELATED TO INFLUENZA. THESE ARE MY DISCLOSURES THE GRANT SUPPORT FROM SANOFI AVENTIS. IF YOU ARE NOT FAMILIAR WITH SOUTH AFRICA THE MAP SHOWS YOU WHERE WE ARE SITUATED AT THE SOUTHERNMOST TIP OF THE CONTINENT. INTEMPERATE CLIMATE SO THEREFORE FOR COVID AND THE FLU AND BEING SOUTH AFRICA THERE ARE A NUMBER OF ASPECTS OF THE BROADER CONTEXT THAT ARE IMPORTANT IN TERMS OF FORMULATING OR MODULATING THE EFFECTS OF THE DISEASES OF SEASONAL AND PANDEMIC AND THE IMPACT OF EACH. AND I HAVE SOME STATISTICS REGARDING SOME OF THESE. AND ONE IS THAT MANY PEOPLE IN SOUTH AFRICA ARE POOR. VERY HIGH RATES OF UNEMPLOYMENT AND ALSO THE INSECURITY OF BASIC SERVICES LIKE WATER OR ELECTRICITY WHICH CREATED THE GENERAL SOCIETAL VULNERABILITY AND REDUCED RESILIENCE TO THE PANDEMIC. THE OTHER IMPORTANT THING IS ANY INFECTIOUS DISEASE COMES INTO THE COUNTRY AS A BACKDROP OF UNDERLYING FORMER ABILITIES OF THE POPULATION AND ONE IS THE AGE DISTRIBUTION OF THE POPULATION AND THAT IS PREDICTIVE TO MOST COUNTRIES IN AFRICA AND IF YOU HAVE A YOUNG LIFE EXPECTANCY AND OF COURSE ONE OF THE REASONS FOR THE LOWER EXPECTANCY IS THE VERY HIGH RATES OF CHRONIC COMMUNICABLE DISEASES PARTICULARLY HIV AND TUBERCULOSIS AND ALSO A POPULATION PRIVILEGE IT IS AROUND 15 PERCENT SO A HUGE BURDEN OF PEOPLE LIVING WITH HIV AND THEN JUST TO MENTION AS WELL THE EMERGING EPIDEMIC OF NONCOMMUNICABLE DISEASES WITH HIGHER RATES OF OBESITY IN THOSE FACTORS AS WELL SO JUST TALKING ABOUT LOVE FLU I STARTED OUT OF MY EPIDEMIOLOGY DEGREE ALMOST 18 YEARS AGO AND THERE WAS A FAIR AMOUNT OF WORK DONE THAT MOST WAS FOCUSED ON VIROLOGY AND SEASONALITY ON -- SEASONALITY NOT THAT MUCH IS NOT ABOUT EPIDEMIOLOGY AND I THINK THAT HAS CHANGED THERE REALLY HAS BEEN AN EXPLOSION OF KNOWLEDGE OVER THE PAST 20 YEARS AS A RESULT OF DIFFERENT GROUPS IN RESEARCH AND ONE OF THE THINGS THAT IS STRIKING IT IS A LITTLE OLD NOW THAT LOOKING AT THE DATA FROM THE FIRST SURVEILLANCE PROJECT DIFFERENT COUNTRIES AND AFRICA WERE FUNDED IN PART OF THE ACADEMIC PREPAREDNESS AND WHAT IT SHOWS IS IF YOU LOOK FOR IT IT IS COMMON AFRICA MANY OTHER COUNTRIES INCLUDING THE POPULATION WOULDN'T BE AWARE BECAUSE THERE OTHER DISEASES THAT MIMIC LIKE MALARIA AND ALSO TROPICAL COUNTRIES YOU DON'T HAVE THAT SEASONALITY THAT BRINGS INFLUENZA UP TO THE FOREFRONT BUT WITH THOSE SYSTEMATIC STUDIES WE FOUND IT WAS A COMMON CONTRIBUTOR WITH THE OUT PATIENT DISEASE SO THE OTHER IMPORTANT AREA IS A FOCUS AREA WE STARTED TO WORK ON INFLUENZA IS WITH A PROFILE OF UNDERLYING CONDITIONS AND AS I MENTIONED WE HAVE THE BEST CONDITIONS YOU DON'T SEE IN OTHER PARTS OF THE WORLD. AND TO SEE WITH THE PARTS OF SOUTH AFRICA AND YOU CAN SEE IT IS JUST ONE GRAPHIC REALLY SHOWING THE EPIDEMIOLOGY FIRST OF THE FLU IN SOUTH AFRICA. THE MOST COMMON UNDERLYING CONDITION ASSOCIATED WITH HOSPITALIZATION IS IN FACT LIVING WITH HIV SO MORE THAN 50 PERCENT OF ADULT PATIENTS IS THE RISK CONDITION AND YOU CAN SEE IT'S MORE THAN 90 PERCENT SO HIV IS THE RISK CONDITION THAT BRINGS PEOPLE TO HOSPITALS BUT INFLUENZA YOU'RE LOOKING AT THE INTERACTION BETWEEN INFLUENZA AND TUBERCULOSIS ONE -- TUBERCULOSIS EVEN IF WE ACCOUNT FOR THE ASSOCIATION WITH HIV THE EXCESS OF PEOPLE OF COLOR INFECTED WITH TUBERCULOSIS AND THE OTHER KEY POINT IS THAT WHILE THERE IS A HIGH BURDEN OF FLU THIS REALLY SHOWS THAT THE DARKER COLORS YOU CAN SEE AFRICA IN THE MIDDLE SO AFRICA PREDICTED TO THE HIGHEST MORTALITY BURDEN FOR INFLUENZA OF THAT YET BY FAR THE LOWEST COVERAGE OF VACCINES. SO THIS GRAPH SHOWS THE NUMBER OF INFLUENZA VACCINE DISTRIBUTED AND WHAT YOU SEE IS THE LITTLE SLIP ON TOP OF THE ORANGE. SO YOU CAN SEE ESSENTIALLY YOU CAN BARELY SEE THOSE AND THERE ARE REASONS FOR WHY THE DISTRIBUTION IS 11 AFRICA PERHAPS THE MOST IMPORTANT COMPETING A PREVALENCE BUT ALSO PERHAPS MORE THAN BOTH OF THOSE IS THERE IS A REAL DIFFICULTY OF ANNUAL RISK-BASED VACCINATION STRATEGIES IN AFRICANS SETTING. AND BECAUSE OF THIS AND THE DIFFICULTY THAT WHEN YOU DEVELOP THE RESEARCH INTEREST UNDERSTANDING THE TRANSMISSION OF INFLUENZA AND IT IS THE THOUGHT THAT PERHAPS WE IN AFRICA IT COULD BE A USEFUL STRATEGY TO VACCINATE THE CHILDREN WHO ARE THE TRANSMITTERS AND NOW WE VACCINATE CHILDREN REDUCING TRANSMISSION THROUGH THE BORDER COMMUNITY TO REDUCE THE BURDEN FOR ALL INDIVIDUALS INCLUDING THE MILLIONS OF PEOPLE IN SOUTH AFRICA. SO WITH THAT IN MIND THE STUDY WAS CALLED THE FIRST STUDY THAT WAS CONDUCTED BEFORE COVID. BUT BECAUSE OF THE PANDEMIC PUBLICATION WAS DELAYED UNTIL 2021. THE INTENSIVE AND AMBITIOUS CODES OF 225 HOUSEHOLDS AND THEY DID NASAL LARYNGEAL FOR TEN MONTHS OF THE YEAR THAN A DIFFERENT COHORT SO A VERY INTENSIVE STUDY AND THE INTENT WAS TO CAPTURE THAT BURDEN THAT LIES BELOW THE SURFACE FOCUSING ON SYMPTOMATIC DISEASE. TO UNDERSTAND NOT ONLY A DISEASE BUT THOSE ASYMPTOMATIC INFECTIONS DRIVING TRANSMISSION EVEN THOUGH THEY DON'T MAKE PEOPLE SICK. IN VERY HIGH INCIDENCE AND ASYMPTOMATIC ONLY 56 PERCENT WERE SYMPTOMATIC AND THEN THOSE THAT WERE MUCH LESS LIKELY WITH THOSE WITH FOOD BUT THEY DID TRUST THOSE WITH INFLUENZA. AND THEN THERE'S A VERY HIGH INCIDENCE OF YOUNG CHILDREN AT LEAST 67 SO THERE IS REALLY HIGH FOR REPEAT INFECTIONS AND THEN WE CONCLUDED VACCINATION IS ALL EFFECTIVE AND IN AFRICA AND THOSE THAT WE NEEDED MODELING BUT THEN COVID CAME. SO WE HAVE NOT PURSUED THAT LINE OF INVESTIGATION FURTHER. AND THEN THE MAIN FOCUS WHICH IS COVID AND SERRATED THE BEGINNING OF MY CAREER IN 2009 PANDEMIC IN AFRICA WAS THAT VACCINES DID COME TO AFRICA BUT THEY CAME TO LATE THIS GRAPH SHOWS THE GRAY LINE OF THE PANDEMIC AND THE BLACK LINES ARE THE VACCINE DOSES DISTRIBUTED SO MANY CAME TO AFRICA BUT THEY CAME TO LATE SO THE IMPACT WAS NOT GREAT BUT HOW THIS NEEDS TO BE IMPROVED IN FUTURE PANDEMICS WITH THE EXPERIENCE IT WAS DIFFERENT. SO MAYBE ON TO COVID ONE OF THE ROLES IS TO GENERATE EVIDENCE TO GUIDE POLICY AND THE MAIN QUESTION WE WERE CONCERNED ABOUT WAS THE EPIDEMIOLOGY SPECIFICALLY TO OTHER PARTS OF THE WORLD AND HOW DO WE MEASURE THAT? AND THE KEY AREAS WAS BURDEN OF DISEASE AND THE SEVERITY AND WAS KEY IN TERMS THAT WE NEEDED TO GENERATE OUR LOCAL DATA. AS AN OVERVIEW OF THE AFRICAN PANDEMIC EXPERIENCE THAT SINCE THEN CASES HAVE BEEN VERY LOW BUT YOU CAN SEE 2022 THE END OF 2022 BUT ON THE BOTTOM YOU CAN SEE WHAT ARE THE GREAT SUCCESSES WAS FOR SURVEILLANCE IN SOUTH AFRICA WHICH WAS VERY EFFECTIVE TO RAPIDLY GENERATE SEQUENCES AND PUBLISH THEM AND YOU CAN SEE THE DIFFERENT VARIANTS IF YOU LOOK AT THE TRAJECTORY IT IS STRIKING THAT TWO OF THEM LIKELY AROSE WITHIN THE REGION AND SUB-SAHARAN AFRICA AND OF COURSE WHAT THAT MEANT WE CANNOT NECESSARILY RELY ON OTHER COUNTRIES TO TELL US SO RESPECT FOR SEVERE DISEASE AND SUMMARIZING DATA FROM A VERY IMPRESSIVE PROGRAM THOSE IN SOUTH AFRICA READILY COMMITTED A PROGRAM THAT WAS ABLE TO CAPTURE INSIDE WITH THE PUBLIC AND PRIVATE SECTOR WITH THE EPIDEMIOLOGIC DATA ON ALL OF THESE CASES AND THEN TO ANALYZE THE DATA AND THERE WERE MANY PUBLICATIONS BUT ONE OF THE EARLY ONES IS LOOKING AT RISK FACTORS FOR SEVERE COVID-19 AND YOU CAN SEE YOU CAN SEE THAT IN SOUTH AFRICA THE TYPICAL RESPECTIVE IS SIMILAR WHICH IS VERY STEEP AND STRONG IN AGE INCREASING MORTALITY AND THEN THE CHANGE OF DIABETES AND THEN HERE YOU CAN SEE IN PARTICULAR WITH HIV AND REALLY WHAT YOU CAN SEE IS ALSO TUBERCULOSIS HAVE AN INCREASE BUT NOT ENORMOUS ORDERS IT'S ABOUT THE SAME SIZE AS NONCOMMUNICABLE AND IF YOU LOOK ON THE RIGHT, AT THE THEN DIAGRAM BETWEEN 20 AND ALL THE AGES THAT PROPORTION OF ALL CASES THAT WE SEE WHAT PROPORTION OF THOSE CASES ACTUALLY HAVE DIFFERENT UNDERLYING COMORBIDITIES? AND IN THE RED AND IN THE GREEN YOU HAVE HIV SO THEY ARE IMPORTUNED CONTRIBUTING COMMODITIES SO AT ALL AGES THE NONCOMMUNICABLE DISEASES THAT IS QUITE DIFFERENT FROM THE PICTURE THAT YOU SEE SO COVID IS AN OPPORTUNITY INFECTION BUT YOU DO SEE MORE SEVERE DISEASE ASSOCIATED WITH UNDERLYING HIV. BUT NOT AS INTENSE FOR INFLUENZA. ANOTHER QUESTION THAT WE HAD RELATED TO HIV IN PARTICULAR IS IF THEY POTENTIALLY SHARED COVID FOR LONGER BUT THAT WAS A DID SHARE SARS/COV2 LONGER THAN THIS COULD TRANSLATE INTO TRANSMISSION SO THIS SHOWS TUESDAY'S ONE WAS ON THE LEFT IS A VERY CLASSIC STUDY OF HOSPITALITY INDIVIDUALS WITH SARS/COV2 AND ENROLLED THOSE WITH HIV AND FOLLOW THEM UP WITH FREQUENT SWABS TO SEE HOW LONG AND WHAT WE FOUND IT STRIKING THOSE LIVING WITH HIV WERE WELL CONTROLLED WITH TREATMENT ACTUALLY NO DIFFERENT BUT THOSE LIVING WITH HIV WERE NOT SUPPRESSED SO WE HAD OUR HIGH VIRAL ALERT SO THERE WAS INCREASE BUT IT WAS CAN FIND IT VERY DIFFICULT TO STUDY AND THEN WE DID A MORE AMBITIOUS STUDY THE SECOND PART OF PEOPLE LIVING SHARED WITH LONGER NOW THAT STUDY IT WAS A TYPICAL STUDY. AND ESSENTIALLY WHAT YOU DO IS LOOK FOR THOSE WITH SYMPTOMATIC DISEASE AND THEN WHEN YOU FIND THEM ARE THEY THE FIRST CASE THEN WHAT YOU DO IS EVERYBODY IN THE HOUSE AND WITH THAT DATA TO WORK OUT THE PROPORTION AND THEN BECOME INFECTED. ARE WE CALL THE HOUSEHOLD ACCUMULATIVE INFECTION RISK. THAT IS A LOT OF EFFORT SO WHAT WE FOUND IN THE STUDY IS THAT WE HAVE THE SAME PICTURE WITH THE TENDENCY BUT NOT ABLE TO DEMONSTRATE. SO OF COURSE THERE ARE OTHER REASONS WHY AND THESE ARE LIMITATIONS TO THE STUDY DESIGN. SO WE NOTICE A LOT ARE ASYMPTOMATIC THEY MAY NOT ACTUALLY BE THE FIRST CASE OF THE HOUSEHOLD. LOOKING AT A QUESTION LIKE THIS YOU TO GET THE WRONG ANSWER BECAUSE WAS RESPONSIBLE AND THEN THAT OTHER LIMITATION IS THAT THE DESIGN SO ONE OF THE STUDIES THAT CAN ADDRESS IS LIKE THE FIRST STUDY FOR INFLUENZA. FOR THIS REASON AND ALONG WITH THE FACT IT IS BECOMING APPARENT THOSE TYPES OF QUESTIONS YOU WANTED TO ANSWER WITH THE FLU WOULD BE VERY IMPORTANT WITH COVID AS WELL. 'S WHAT WE DID QUITE EARLY ON IN THE PANDEMIC WE DECIDED THE INTENSIVE TRANSMISSION STUDY SO WHAT WE DID WAS THE FIRST STUDY THERE WERE TWO SETS AND THEN WE ENROLL JUST OVER 200 INDIVIDUALS AND THEN FOLLOWED THEM UP VERY INTENSIVELY WITH JULY OF 2020 JUST THE MIDDLE OF THE FIRST WAVE 14 MONTHS THROUGH AUGUST 2021 AND GIVING NASAL SWABS TO EVERYONE AND ALSO TESTED FOR SYMPTOMS AND ASKED ABOUT HEALTH SEEKING AND THIS JUST SHOWS FROM THE TYPE OF STUDY IT IS A MOSAIC AND EACH ROW IS A PERSON IF WE DO GET A SWAB IF IT WAS NEGATIVE AND WHAT YOU CAN SEE IS THAT INFLUENZA INFECTIONS SO THIS IS A VERY LONG AND YOU CAN SEE VERY BEAUTIFUL VISUALIZE OF THE PATHOGEN WITHIN A POPULATION IRRESPECTIVE OF SYMPTOMS SO IT GETS BELOW THE SURFACE TO UNDERSTAND THE DYNAMICS IN THE COMMUNITY SHOWING THOSE DISTINCT WAVES THAT WE HAD IN OUR STUDIES SO JUST TO SUMMARIZE PUBLISHED IN 2022 AND TO HAVE SOME RECENT DATA BUT MANY SWABS WERE TESTED COME OVER 100,090 PERCENT OF POTENTIAL VISITS WITH THE REALLY HIGH TECH RATES NOW IT'S NOT SO STRIKING THAT AT THAT TIME THEY WERE VERY HIGH. BY THE END OF AUGUST 62 PERCENT AND 90 PERCENT OF HOUSEHOLDS EVEN THOUGH VISITING TWICE A WEEK AND THEY WERE ONLY 50 PERCENT AND IN THE SECONDARY RATE WAS 25 PERCENT WITH MORE TRANSMISSION THAN FROM DELTA AND ALSO DOING SOME WORK ANALYZING THE DATA IN THE ANALYTIC FRAME AND THOSE ARE THE DIFFERENT VARIANTS AND THAT IS RELATIVELY SIMILAR FOR THE DIFFERENT VARIANTS. AND THEN DISENTANGLE THE DIFFERENT STAGES. AND THEN WHAT CAME OUT IN THE STUDY TO TOUCH ON HIV BEFORE VERY SIMILAR TO THE OTHER STUDY PEOPLE LIVING WITH HIV BUT NOT REALLY A SIGNIFICANT EVENTS TO MAKE THAT DETERMINANT THAT ARE SYMPTOMS TO BE ASSOCIATED WITH THE LOWER CITY VALUE AND THEN NOW WE KNOW THIS THAT THEY HAD A LOW VIRAL LOAD. BUT THEN WITH THE NEW VARIANCE , NEW QUESTIONS AND AS YOU KNOW THAT IT IS SOUTH AFRICA SO WE REALLY COULD NOT TURN TO ANYONE TO ASK FOR ANSWERS. AND ONE OF THE STRIKING THINGS ARE THE BIG QUESTIONS WHEN OMICRON MERGE. AND 60 PERCENT ARE IMMUNE WITH THE RAPID RATES OF INCREASE. AND THEN BY A THE MODELING AND ANALYSIS. SO WHAT JULIA HAS DONE IS SET UP A SURVEILLANCE PROGRAM TO LOOK FOR IMMUNE ESCAPE. AND THAT WAS A MODEL THAT LOOKED AT THE RATES OF INFECTION AND IT LOOKS AT THE PREVIOUS FICTION RATES AND IT LOOKS FOR THOSE DEVIATIONS THAT SUGGEST EVEN AT THAT TIME IT WASN'T SUCH A CLEAR IDEA AND WHAT IS REALLY REMARKABLE IS THAT WE IDENTIFIED THE FIRST CASES OF ALL MICRON. EVEN ON THE FIRST DAY WE WERE CHECKING THE RESULTS BECAUSE IT DIDN'T MAKE SENSE. BUT WE HAD A MEETING AND SHE SAID WE HAVE SEEN THIS WEIRD SIGNAL. AND OF COURSE THAT DEVIATION IS REAL. AND THEN THE OTHER CRITICAL QUESTION TO BE CONCERNED ABOUT WAS THE SEVERITY WHETHER OR NOT WE SAW THE CASES STREAMING AND WILL THIS TRANSLATE AND WILL IT OVERWHELM THE HOSPITALS? AND THEN WE PIVOTED WITH THE SURVEILLANCE PROGRAMS. AND THEN SHE UTILIZE THE PROGRAM WITH THE HOSPITALIZATION PROGRAM OF EVERY HOSPITALIZED CASE AND LOOKING AT THE DATA FOR THE PCR AND MANY PEOPLE ARE FAMILIAR THAT OMICRON HAD A FAILURE THAT IF YOU TARGET SO USING THE PROXY WE COULD COMPARE THE CASES TO DESCRIBE THE EFFECT THAT ALTHOUGH THE CASE RATES WERE REALLY HIGH THERE WAS THAT SEVERITY. AND THEN THAT MORE CLASSIC DATA AND THE DISCONNECT WITH THE HOSPITALIZATIONS BUT THAT REALLY DIDN'T MOVE. AND THEN TO DATE NOT TO SEE THOSE HIGH RATES OF HOSPITALIZATION BECAUSE OF THOSE HIGH LEVELS OF IMMUNITY. SO THOSE WAS KEY DATA TO GUIDE PUBLIC HEALTH ACTION AND TO GET THEM EARLY SO WE CAN MAKE SOME DECISIONS. BUT IT DISPLAYS THAT WE SEE THIS APPARENT CONTINUATION BUT WHAT IS AT UNDERLYING DYNAMIC THAT GIVES RISE? HOW MUCH IS ABOUT WE INFECTIONS ARE TRUE ATTENUATION AND HOW MANY PEOPLE REALLY ARE AFFECTED ONE -- INFECTED WITH ALL MICRON? AND TO GET THOSE QUESTIONS FROM BELOW THE SURFACE SOME AGAIN THIS IS WORK DONE. IT IS JUST A TIMELINE AND FOR 14 MONTHS WE SWABBED EVERYBODY TWICE A WEEK. IT IS SHADED HERE. THE BOTTOM GRAPH IS URBAN AND THIS IS TIME AND ALL THE DIFFERENT WAVES. YOU CAN SEE WE SWABBED EVERYONE. JUST BEFORE THE EMERGENCE OF OMICRON AND WE STOPPED SWABBING EVERYONE. SO WE WERE NOT ABLE TO HAVE THAT PCR DATA ON EVERYONE THROUGH OMICRON WHICH WOULD HAVE BEEN BEAUTIFUL BECAUSE THAT WOULD BE DIRECTLY MEASURED PCR TO THE RATES OF INFECTION. BUT WE DID CONTINUE DOING EVEN WE STOPPED THAT PCR BUT WE CONTINUED THE SEROLOGIC BLOOD DRAWS SO ALL THAT YOU SEE THE SEROLOGIC BLOOD DRAW DOES CRI WITH THAT ASSAY AND THE HIGHER THE ANTIBODY LEVELS SO AS YOU CAN SEE IN THE BEGINNING VERY FEW HAVE ANTIBODIES BUT THE MORE PEOPLE ARE EXHIBITING THE ANTIBODIES. SO WE HAVE THIS SEROLOGY SAMPLES THAT EXPAND THAT OMICRON WAVE. OBVIOUSLY THERE ARE STILL DIFFICULTIES BECAUSE WE DID NOT KNOW WHAT EXTENT WE COULD USE THAT SEROLOGIC DATA SO HE USED DATA FROM THE DELTA WAVE. WE HAD SAMPLES FROM SEROLOGY AND PEOPLE WHO HAD WE INFECTIONS TO DESCRIBE DIFFERENCES SEROLOGIC RESPONSE AND ESSENTIALLY USING THE TWO DEFINED THE PATTERNS OF INFECTION THAT HE DID FROM THE DELTA TO INFER THE UNDERLYING RATES EXPERIENCED IN THE POPULATION. AND THE RESULTS AGAIN WERE QUITE STRIKING. AGAIN WE HAVE THE RURAL ON THE TOP AND ON THE BOTTOM WITH THE QUITE A BIT OF DETAIL. ANYTHING THAT IS BLUE IS NON- OMICRON. AND WHERE YOU SEE THE ATTACK GRADES EACH OF THESE DOTS ARE A DIFFERENT WAVE OF SARS/COV2. SO IN THE RURAL OF INCREASING THE TECH RATES AT 40 PERCENT AND THEN OMICRON WITH 64 PERCENT. AND THEN EACH WAVE WAS MUCH MORE SIMILAR BUT THEN AGAIN ALMOST 60 PERCENT. SO JUST TO HIGHLIGHT OR TO PUT INTO CONTEXT, YOU CAN SEE THE CUMULATIVE INCIDENCE AFTER EACH WAVES ON THE RURAL SIDE THE CUMULATIVE NUMBER PER PERSON WITH EACH WAVE AND YOU CAN SEE IT GOES UP SO BEFORE OMICRON THE INFECTIONS ARE QUITE HIGH PRIOR TO THE EMERGENCE OF OMICRON. EVEN IN THE FACE OF THIS WE STILL SEE RATES OF ABOUT 60 PERCENT SO MUCH SO THAT AFTER THE FIRST OMICRON WAVE ON AVERAGE EACH PERSON WITH ONE.THREE INFECTIONS AND ON AVERAGE THE URBAN SIDE WAS ONE.2 INFECTIONS. THAT WAS ASSOCIATED FROM THE PRIMARY INFECTIONS WITH ALL MICRON THE MAJORITY WERE BREAKTHROUGH. ON THE RIGHT YOU CAN SEE THE DIAGRAM WHICH SHOWS THE TRANSITIONS OF IMMUNOLOGIC HISTORY IN THE POPULATION. SO YOU CAN SEE IN THE FIRST WAVE IT WAS RELATIVELY LOW AND THE TECH RATES WERE SLOW THEY NEVER EXPECTED AND THEN THE SECOND WAVE MOST PEOPLE WERE DIFFERENT PEOPLE AND THOSE WE INFECTIONS ARE VERY SMALL. SO THEN WE SEE THE DELTA MAJORITY OF PEOPLE IT WAS THE FIRST INFECTION WITH DELTA AND THEN YOU SEE OMICRON AND HOW IT JUST BREAKS UP SO THESE REDLINES ARE THOSE THAT HAVE SOME FORM OF OMICRON INFECTION AND THIS IS FRAGMENTED WITH IMMUNE HISTORIES AT 5 PERCENT OR 6 PERCENT OF ONE OR 2 PERCENT THAT IS FREELY AVAILABLE. AND THOSE PEOPLE HAVING SOME COMBINATION OF INFECTION. AND WE HAVEN'T WE ANALYZED ON -- WE ANALYZE THE DATA BUT WE DO THINK TO INVESTIGATE THAT LANDSCAPE AFTER THAT. BUT NOW JUST TO COME BACK TO THE QUESTION WHAT IS HAPPENING UNDER THE SURFACE OF THAT ATTENUATION OF SEVERITY? ON THE LEFT YOU SEE THE INFECTION FATALITY RATIO BYWAYS. IT IS ESTIMATED THE RULE COMMUNITY AND URBAN COMMUNITY WE TOOK THE SEROLOGIC DATA IN THOSE COMMUNITIES THEN WE TRIANGULATED THE SURVEILLANCE DATA IN THE POPULATION WHICH GAVE US THE TOTAL HOSPITALIZATION AND MORTALITY AND YOU CAN SEE IN THE DELTA WAVE VERY HIGH AND THEN THAT MUCH LOWER RATE AND THAT'S BECAUSE WE ARE ACCOUNTING WITH A HUGE INFECTION IN THE COMMUNITY. AND THEN WE SEE THESE ARE THE THREE THINGS THAT MODULATE THE SEVERITY AND THE FIRST IS INFECTION TYPE AND YOU CAN SEE AS I MENTIONED MOST OF THE PRIMARY INFECTIONS FROM OMICRON OVER HALF WERE BREAKTHROUGH INFECTIONS AND AGE COULD HAVE PLAYED A ROLE IN THE DARKEST WERE OVER 65 AND OF COURSE THE VARIANT TYPE AND THEN TO SAY IT WAS INTRINSIC FROM THE LOWER AIRWAYS. SO THE SUMMARY WITH VERY HIGH TECH RATES WITH THE MICRON WAYS AND BREAKTHROUGHS OF MORE THAN 60 PERCENT IS A REAL SHIFT FROM THE EPIDEMIOLOGY FOR THOSE THAT WERE AFFECTED MORE THAN ONCE AND MANY PEOPLE ARE VERY NÁVE AND THEN IT WAS FRIEND FRAGMENTED IMMUNOLOGIC LANDSCAPE AND THIS IS IMPORTANT AS WE GO FORWARD INTO THE NEW ERA OF EPIDEMIOLOGY. I JUST WANT TO AND OFF THAT STEPPING ON SUNDAY PICTURE ISSUES I DON'T THINK I CAN TALK ABOUT COVID IN SOUTH AFRICA WITH THOSE INTERVENTIONS TO CONTROL THE COVID VACCINE TO HIGHLIGHT TWO IS THE NEGATIVE IMPACT ON THE HIV AND ENTER A VIRAL TREATMENT AND BASICALLY AND NOW WE SEE THE IMPACT OF PEOPLE WITH INTERRUPTED TREATMENT AND THEN CHILDREN WHO WERE AFFECTED FOR MORE THAN TWO YEARS IN THOSE POOREST AREAS THAT DO NOT GO TO SCHOOL IMPACTING FEEDING PROGRAMS AS WELL AS SAFETY AND HALF A MILLION CHILDREN DROPPED OUT IN THE FIRST YEAR OF COVID SO I MASSIVE NEGATIVE IMPACT AND API EXCEEDS AS WELL. TREMENDOUS NEGATIVE IMPACT AND I THINK THIS IS AN IMPORTANT AREA FOR US TO MEASURE AND DOCUMENT THE NEGATIVE IMPACTS TO MAKE MORE RATIONAL DECISIONS FOR FUTURE PANDEMICS. SO NOW IN SUMMARY AND STEPPING ON -- STEPPING BACK AND THE MYTH OF COVID IN AFRICA LOOKING AT THOSE NUMBERS YOU WILL THINK THERE IS NO COVID IN AFRICA BUT THE DATA SHOW THAT MOST OBVIOUSLY FOUND SEROLOGIC DATA THAT SOME OF THE TECH RATES GLOBALLY WERE IN EFFECT IN AFRICA AND ON THE CONTINENT AND THE BORDERS. AND ALSO THROUGH THE PANDEMIC THE VACCINES CAME TO LATE AND THIS IS INTERESTING AS IT SHOWS THE 10000 PEOPLE VACCINATED IN RELATION TO VACCINES DELIVERED. YOU CAN SEE THESE ARE THE HIGH INCOME COUNTRIES THAT'S BECAUSE THEY VACCINATED EARLY BEFORE THE DELTA WAVE AND HERE MANY INCOME COUNTRIES IT WAS SUBVERTED BECAUSE THEY CAME TO LATE SO IT SHOWS THAT VERY LITTLE WAS CHANGED AND NOT A LOT OF COVID MORTALITY IN AFRICA. THE ONLY COUNTRY ON THE CONTINENT THAT HAS SYSTEMATIC REGISTRATION OF ALL DATES. 'S WE CAN DO ACCESS MORTALITY AND WHEN YOU LOOK AT THE ACCESS DATA WE HAD VERY HIGH RATES AND THEN VERY HIGH RATES SO THE ISSUE IS ASCERTAINED RATHER THAN A LACK OF BURDEN. I HAVE THIS AND HAVE A SUMMARY SIDE BUT TO PUT THE COVID PANDEMIC INTO CONTEXT THAT SURVEILLANCE SIDE IS THE RURAL SIDE CONDUCTED AT THE FIRST STUDY VERY LONG-STANDING AND WITH ITS OWN UNIQUE FEATURES BUT SUB SAHARA WITH THE VERY LONG. ALL THE WAY FROM 1990. AND THIS IS A STRIKING MORTALITY CURVE THAT COVID WAS A HECTIC YEAR AND IF YOU LOOK AT THE BROADER SWEEP OF TIME COMING IN THE FACE OF A MUCH BIGGER PANDEMIC AND EPIDEMIC AND YOU CAN SEE THIS HUGE MORTALITY WITH THE DECLINING MORTALITIES WITH THE TREATMENT PROGRAMS WITH THOSE OF HIV. THEN SEEING HOW COVID HAS REVERSED AND NOW THAT WILL THAT TRAJECTORY REVERSE AND WILL IT CONTINUE TO COME DOWN OR WILL THE HARMS OF THE DAMAGE AFFECT SOCIETY IT COULD REVERSE THE GAINS TO BE MADE IN THE PAST YEARS? SO THE VERY HIGH BURDEN OF SARS/COV2 IN AFRICA WE CAN UNDERSTAND EPIDEMIOLOGY BUT TO RELY ON THOSE CASES AND MANY THROUGH AND FOR WHAT ON -- INFLUENZA A VERY HIGH NEGATIVE IMPACTS FROM NPI THAT SOMETHING WE CAN DO FOR THE NEXT PANDEMIC WITH SCHOOL CLOSURES WE HAVE THE OPPORTUNITY TO QUANTIFY WITH OUR DECISION-MAKING IF WE DON'T KNOW HOW SEVERE AND THEN TO THAT SHIFT LAST YEAR WE HAD LAST OF THE COVID CASES AND SO NOW WE NEED TO BE THINKING OF COVID VACCINE IS IT COST-EFFECTIVE AND WHO ARE THE PRESCRIPTION CAN WE AFFORD ANNUAL VACCINATION? WE NEED TO ADDRESS HESITANCY -- HESITANCY SO LASTLY JUST TO ACKNOWLEDGE THE FIRST STUDY AND THE FIELD TEAMS THAT ARTICULATED THE DATA AS WELL AS THE PARTICIPANTS IN THE FIELD WORKERS AND THE TEAMS AND ALSO MANY PEOPLE TO THE RESPONSE AND OFFENDERS WHO FUNDED THE NUMBER OF STUDIES THAT I HAVE PRESENTED. THAT IS IT. THANK YOU. >> THANK YOU. THIS WAS GREAT WITH THE DATA COLLECTED ANALYZED AND DISSEMINATED AND IT WAS USEFUL GLOBALLY. SO ANTICIPATING THE IMPACT OF THIS VARIANT IT IS MUCH APPRECIATED SO A REMINDER TO SEND YOUR QUESTIONS SO VACCINATION CAME TOO LATE AND IS DIFFICULT TO DO ANNUAL VACCINATION WITH ADULTS IN THIS SETTING BUT IT'S NOT THAT CLEAR FOR COVID YOU GET THAT HIGH SUBMISSION FROM CHILDREN SO WHAT YOU SEE IS THE LONG-TERM STRATEGY, IF ANY? >> THAT'S A GREAT QUESTION. I THINK THE FIRST PART IS THAT FOR FLU WE ESTIMATED THE BURDEN OF MORTALITY AND HOSPITALIZATION AND WHAT YOU GAIN AND THE COST AND WHO SHOULD BE VACCINATED NOW AND THE PANDEMIC WHEN IT WAS SO SEVERE BUT NOW IT SUGGESTS WE SEE FEWER FOR COVID. SO THE FIRST IS IN THIS PHASE TO PROPERLY ESTIMATE AND THERE ARE OTHER FEATURES THAT MIGHT TIP THE SCALES. AND THEN PROBABLY GO THROUGH RISK VACCINATION AND MODERATELY SUCCESSFUL AND BASED FOR COVID AS IT IS FOR INFLUENZA. I WOULD BE SURPRISED IN FACT IF IT DOESN'T SHIFT TO BE DRIVEN BY CHILDREN IN THE SAME WAY AND I THINK SOME DATA SUGGESTS SHOWS THAT IS WHAT IS HAPPENING. IN AFRICA THE DISTRIBUTION OF THE HIGHEST IN THE INFANTS AND IN THE ELDERLY. SO TO BE OBSERVED WITH OTHER VIRUSES COMING IN WITH NO IMMUNITY AND THEN MULTIPLE THE INFECTION SO NOW YOU DO SEE THAT DISTRIBUTION THOSE THAT DRIVE THE INFECTION BUT WE DON'T HAVE THAT DATA. AND IT STILL NEEDS TO BE DEMONSTRATED. >> WE HAVE A QUESTION ABOUT OTHER COUNTRIES IN INDIA WITH THE INFECTION RATES WE HAVEN'T SEEN THAT MANY CASES. SO THE QUESTION IS HOW COULD WE MEASURE THE MORTALITY IMPACT FROM THOSE STATISTICS QUICK. >> IT IS VERY DIFFICULT. AND THE YOUNG POPULATION HAS A HUGE IMPACT AND SEROLOGIC STUDIES ARE THE SIMPLEST TO CONDUCT ALL THE SEROLOGIC STUDIES HAVE PREVIOUS HIGH RATES EVERYWHERE ON THE CONTINENT IN TERMS OF INFECTION. BUT MORTALITY IS MUCH MORE DIFFICULT. THOSE STUDIES DONE WITH RSV BUT WITH ADULTS IT IS QUITE DIFFICULT TO MORE COMPREHENSIVELY COLLECT THE DATA THAT IT IS DIFFICULT. ONE ANOTHER WAY WE HAVE DONE FOR FLU WITH HOSPITAL SURVEILLANCE THERE YOU CAN ESTIMATE THE INCIDENCE AND HOSPITAL MORTALITY BUT EVEN FOR THE FLU THOSE AHEAD MORTALITY ESTIMATES. >> WE HAVE ANOTHER QUESTION. SO HOW DO WE SEPARATE WITH THE EFFECT OF PRIOR IMMUNITY OF DIFFERENT VARIANTS? SHOWING THE RISK OF HOSPITALIZATION WAS LOWER BUT SO HOW DO YOU SEPARATE THROUGH THAT VARIANT. >> I DON'T THANK YOU CAN. AND THEN WE DESCRIBE THE PREDICTORS AND THEN WITH ALL THOSE TO BRING THAT TOGETHER IN A MODELING FRAMEWORK AND THAT IS BODY OF WORK AND I DO THINK THERE IS A LOT OF MISSING DATA THAT YOU CANNOT DISENTANGLE NECESSARILY. >> I CANNOT RECALL FOR INSTANCE. >> EXACTLY AND WITH THAT BELIEF YES. >> SO ON THE TRANSMISSION IF THERE WAS CONTACT TRACING DONE FOR TESTING OR ISOLATION. >> I HAVE A LOT TO COVER IN A LITTLE TIME. THAT WAS ONE OF THE DIFFICULTIES OF FIRST IT WAS CONDUCTED IN THE RECOMMENDATIONS WERE TO DO CONTACT TRACING AND IT WAS ONE OF THE REAL CHALLENGES OF THE STUDY BECAUSE AS YOU SAW FRICTION WAS LOW AND WE WERE DIAGNOSED ALL THESE PEOPLE WHO HAD NOT BEEN DIAGNOSED LOOKING AT THEIR LIVELIHOOD AND MOST PEOPLE IF THEY DIDN'T GET THE FUNDS THEN GOING TO THOSE MEASURES THE COMPLEX ETHICAL ISSUES TO WITH THE PUBLIC HEALTH AND IN AFRICA CONTACT TRACING WAS PUT FORWARD AS A POLICY BY THE WHO AND WE TRIED AS MANY COUNTRIES DID BUT IT WAS APPARENT THAT IT WAS NEVER GOING TO BE FROM THE PUBLIC IT WOULD NEVER BE IMPLEMENTED IN THE CITIES JUST BECAUSE OF THE RESOURCES. WHILE THERE WAS THE ATTEMPT TO BE INFORMED BUT CONTACT TRACING WAS VERY LIMITED RESOURCES TO IMPLEMENT AND WE DIDN'T CONNECT DATA IN ANY WAY BUT FROM SUCH AN INTENSIVE STUDY LOOK AT THE KEY SYMPTOMS AND NOW IT'S VERY DIFFICULT TO ANALYZE. >> ANOTHER QUESTION THE DIFFERENCE BETWEEN PCR TO SEE THAT ANTIBODY RESPONSES? >> YES. I DON'T HAVE THE ACTUAL NUMBERS IN FRONT OF ME BED N-95 PERCENT WITH MAYBE BETWEEN 90 N-95 PERCENT THAT WERE CONVERTED SO WE HAD A GOOD CORRESPONDENCE AND THAT IS BECAUSE SARS/COV2 WENT A BIT LONGER. WE THINK FOR FLU WE MISSED MORE INFECTIONS WITH PCR BECAUSE THE FLU IS JUST A LITTLE SHORTER SO IT WAS A GOOD CORRELATION BUT THERE WERE SOME PEOPLE WE MISSED WITH PCR. >> TALK ABOUT THE NEGATIVE IMPACT WITH CLOSING SCHOOLS THE IMPACT OF CHILDREN A MENTAL HEALTH SHOULD WE NOT DO SCHOOL CLOSURE AS PART OF ECONOMICS IN THE FUTURE? >> IN THE COVID SCHOOLS THERE WAS ALL THIS SOCIAL ACTIVITY AND THEN THE TEACHERS IN THE SCHOOLS. BUT IT HASN'T BEEN PROPERLY ACCOUNTED BUT IT IS POSSIBLE AND IN SOUTH AFRICA NOT THAT MUCH RESILIENCE IN THE SYSTEM THAT IF YOU COMPOUND THE NEGATIVE AFFECT MISSING THAT GENERATION OF ALL THAT SCHOOL 60 PERCENT UNEMPLOYMENT AND THEN THE NINE ECONOMIC EFFECTS WITH SOCIAL DISRUPTION IT MAY NOT PAN OUT BUT OF COURSE IT IS VERY DIFFICULT YOU DON'T KNOW THE SEVERITY OF THE VIRUS YOU ARE DEALING WITH AND IN THE BEGINNING WITH THE ROLE OF CHILDREN IN TRANSMISSION THAT IS A VERY SEVERE WITH A MAJOR NEGATIVE IMPACT AND FOR ME IT WAS NOT UNDERSTOOD TALKING ABOUT POLICIES FROM THE FLU THOSE THAT HAVE A MUCH BIGGER IMPACT. >> AND THE RISK FACTORS ESPECIALLY IN CHILDREN DO YOU KNOW OF ANY STUDY OF NUTRITIONAL DEFICIENCIES? >> IT'S VERY INTERESTING IT'S NOT DOWN TO THAT BUT WE WERE THE FIRST TO PUBLISH ABOUT MALNUTRITION AND THE FLU. SINCE I'M NOT AWARE OF ANYONE THAT WE ARE CURRENTLY ANALYZING THE SENSE OF SURVEILLANCE STATES WE MAY HAVE SOME RESULTS AS A SIGNAL IN THE NEXT YEAR. >> AND THE LAST QUESTION TO GO BACK WITH HIV AND RESPIRATORY VIRUSES WITH THAT ERA THAT IS RESPECTED FOR FLU MAYBE NOT AT QUITE THE SAME LEVEL SO INCREASED SUSCEPTIBILITY OR SEVERITY AND WHAT WOULD YOU DO? >> I DON'T KNOW THE ANSWER ONE IS THE EVOLVING PANDEMIC THAT NOW WE HAVE DONE THE ANALYSIS OF THE TWO YEARS AND STILL SEE THAT ASSOCIATION AND WE ALSO SEE IT THE DATA IS 50 TIMES WITH THE FLU IT IS LIKE FOUR TIMES. SO IT SEEMS TO BE THERE IS A DIFFERENTIAL PROPENSITY BUT I DON'T KNOW THE MECHANISM I'M NOT THE IMMUNOLOGIST OR A SPECIALIST I DO THINK IT'S INTERESTING. SOME OF THAT IS CERTAIN THE TREATMENT IS A PROFOUND EFFECT MODULATING THAT SEVERITY BUT IT MUST BE SOMETHING OF THE MECHANISM AND THE IMMUNOLOGIC COMPONENTS THAT MAKES IT MORE SEVERE OR NOT. >> THE EFFECT OF VIRAL EVOLUTION? >> AND PEOPLE WITH HIV. HIM SO BAD WITH NAMES BUT WE DO HAVE A PROJECT OF PEOPLE LIVING WITH HIV AND SEEING A HUGE AMOUNT SOME PEOPLE HAVE PUBLISHED BUT THERE IS A VERY BEAUTIFUL WAY TO DETERMINE THE DIFFERENCE OF THE SUBPOPULATION PRECISELY AND TO QUANTIFY THEM IS VERY HIGH LEVELS AND OF COURSE IN ANY IMMUNOCOMPROMISED PERSON FOR IT TO BE AN HIV SPECIFIC ISSUE. >> THANK YOU SO MUCH FOR SHARING THIS GREAT DATA. IT WAS A GREAT TALK AND WE ARE AT TIME NOW BUT THANK YOU AGAIN. >> THANK YOU FOR HAVING ME. >> GOODBYE EVERYONE.