COVID-19 Social media Q&A - 25 November 2021

Overview

00:01:14

AK          Thank you for joining [?] today's live Q&A on COVID-19 with Dr Mike Ryan and Dr Maria Van Kerkhove. My name is Aleksandra Kuzmanovic. This week we changed the schedule a little bit because we have also a special session of the World Health Assembly next week so we won't be able to have this conversation. But if you have questions on the current COVID situation please ask the questions using the hashtag #askWHO if you're watching us on Twitter.

If you're watching us on other platforms please use the comments section to send your questions. Good afternoon, Maria, Mike. Thank you for your time. We have a press conference yesterday in which Dr Tedros expressed his concern over a false sense of security after being vaccinated and reducing other preventative measures and it's been picked up quite a lot in media overnight so maybe you can elaborate more on the concern and the situation in Europe, which he highlighted as being the epicentre of the transmission at the moment.

MR         Yes, and as Tedros outlined yesterday there are many factors that have driven the current situation which has emerged in Europe. Obviously in the summertime as countries began rolling out vaccines, the weather was better many countries began to roll back restrictions and public health measures on people that were in some ways affecting people's lives as well and there was an expectation that vaccination levels would probably get up very, very high.

We didn't fully understand at that time exactly for how long the vaccine would protect and whether there were going to be any issues with waning.

00:03:09

But certainly as we've entered into the winter period and as people have gone back inside and as measures have been almost completely lifted, even simple measures like masking inside - and it's happened in that way - what we see is that perfect storm of going back inside, the lack of personal precautions and that partnership we had between governments and people to maintain those layered measures, not lock-downs but that ability to continue doing some of the activities that reduce risk.

Avoiding crowded places, wearing masks inside, assuring ventilation, trying to reduce individual risks and the government helping with that. That to a great extent has reduced and on top of that, which is probably more surprising than anything else, is that while Europe and the European region has had fantastic access to vaccines there's been a lot of vaccine hesitancy in many, many countries and especially and most worryingly, I think, in groups that you would have expected would really have come out and wanted that vaccine, particularly older persons, persons with underlying conditions.

00:04:21

We've not seen the uptake of the vaccine in some countries at the same level that would be required to really protect those populations and what's happened within that is that as the virus has transmitted amongst younger and otherwise healthy people increasingly we've seen people who are older and vulnerable being exposed to the virus and then we're seeing hospitalisations and we're seeing deaths rising.

That's particularly true in central and eastern Europe, where we see very low rates of vaccination in comparison so there're two experiences. There're countries who've not achieved high levels of vaccination and they now are facing into the winter with very few public health measures in place, with a very vulnerable population and a delta variant that's spreading very intensely. They're in a very difficult situation.

But in many of the countries further west in Europe while the vaccination levels are high - and congratulations for what's been achieved in that - there are also significant numbers of people even in those older and vulnerable populations who've not been vaccinated.

00:05:26

Because the virus is transmitting quite efficiently in younger people it's eventually finding those vulnerable people and putting them in hospital and in some cases killing them. Partially that's - Maria might explain a bit more - that's been driven by all this intense social mixing.

We're back to pre-pandemic levels of mixing in western Europe and you can see that in the data. I think people had that expectation that once a certain proportion of people were vaccinated everyone could mix again and nothing could happen.

Unfortunately with the delta variant, with the fact that while the vaccines are highly protective against hospitalisation and death and they're quite effective against you becoming infected again but they're not perfect and they're actually quite effective even if you get reinfected while vaccinated, you have a lower chance of passing the virus on but again they're not perfect.

00:06:23

So what happens in this situation is that previously vaccinated people, while they won't get sick and they don't transmit as easily as potentially people who haven't been previously vaccinated, they do participate in that cycle of transmission.

If the virus is around in large enough numbers and if enough people are being exposed all the time eventually that number of people builds up and then it's almost like a wave of a certain height won't crash on the shore but sometimes the waves build up and eventually they overwhelm the defences and that's really what's happening.

It's almost as if we've sleep-walked our way into this situation where the virus has now gained an upper hand again and that's to an extent because governments and individuals have really let down their guard and I don't mean that... because we're all two years into this and we're all exhausted with all of this.

But that's the reality and that's what the DG was trying to get across yesterday, not to say vaccines don't... Vaccines are working remarkably well but what he was saying was, yes, get vaccinated and get fully vaccinated but just also be cautious once you're vaccinated that you don't become part of a transmission chain again, that you don't contribute to transmission again.

00:07:41

Because while the vaccines will protect you against being hospitalised and dying they won't perfectly protect you against becoming infected or infecting someone else so therefore to maintain those at least small precautions so that you don't become part of the transmission chain.

I've probably spent too long explaining that but I think it's important to get across what the DG was saying yesterday. Maria.

MK         I totally agree. I think this idea that you're completely safe once you're vaccinated... I think we all want that but the vaccines aren't perfect at everything. They're incredibly effective at preventing severe disease and death and they are very positive in terms of preventing infection and onward transmission but they don't prevent all infections and they don't prevent all transmissions.

That's why it's really important that you as individuals, leaders when they're setting policies, they also have measures in place that reduce transmission. So it's increasing vaccination coverage but critically focusing on the people that need those vaccines most.

00:08:42

It's not just about 40% of a population. It's the right 40% in that country, the right 70% in that country and what we mean by that is focusing on people who are at risk of developing severe disease first in all countries.

That's what's really, really important so we've been trying to speak a little bit more about not just who is vaccinated but who's missed by vaccination because that's where we will see the success in this.

But it isn't vaccines alone and I think that's also this false sense of security that if you just get to a certain percentage of vaccination the pandemic will be over and I'm afraid that's not where we're at. We need to get vaccination coverage up to the right individuals but we also need to drive transmission down.

That's because we have the possibility that the virus will evolve. It is evolving and this has been happening since the beginning. We have the risk of future emergence of new variants and we have to do everything that we can.

In most parts of the world it is quite simple now to wear a well-fitting mask, to clean your hands, to keep your distance from others. It doesn't mean lock-down and I think we will continue to say that every single time we say public health and social measures.

It's a combination of measures, of distancing and even in the buildings where we live, where we work, where we study there needs to be more investment in ventilation, which will not only benefit COVID but it will benefit other infectious diseases, other contaminants and it's a layered approach.

But as you put those layers in you have to be very careful as you peel those layers away. If you take them all up at once the virus will take advantage of that regardless of how much vaccination is there.

So we're advising to increase vaccine coverage but also decrease transmission and this is something we can do because we have tools in our toolbox. Maybe we'll go back to our toolbox analogy. All of us have tools at hand. Leaders need to provide policies and support to people to be able to use those tools and so they can get on with their lives.

00:10:45

I think many countries are finding some kind of a balance for this but unfortunately this surge that we are seeing in Euro began in June. It's not in recent weeks. It's been steadily increasing for many weeks now and we're entering our third winter of this pandemic in the northern hemisphere.

Myself I can't even believe I'm saying that. In the last week alone there was an 11% increase in Europe, more than 2.4 million cases from Europe out of the 3.6 million reported globally. That's two-thirds of all cases and we are seeing not only increasing cases but we're seeing increasing deaths and this is incredibly tragic because we have tools that can prevent that.

I just want to make one last point. When we report cases it's also imperfect because we're not able to say how many of those cases were vaccinated or how many of those deaths were vaccinated as well as we would like to, as Mike and I are speaking and rattling off these numbers right now.

But we do see on an individual country basis that those who are vaccinated, the proportion of people are hospitalised - more people are unvaccinated than vaccinated, significantly. So vaccines work, that's my point, vaccines work even against the delta variant and so when it is your turn please get vaccinated and make sure you receive that full course.

00:12:16

Whatever you can do, please fight for vaccine equity around the world so that those who are most at risk in all countries get their first and second doses.

AK          Thank you, Maria. Maybe we can take a follow-up question from Gopal Sharma because you mentioned some data from Euro region but also overall and he's asking what's the present situation regarding COVID so maybe you can also update us on other regions.

MK         Yes, I can give a go. I'll try to keep it short. We do publish our weekly sitrep every week and that's where I get most of the information from that we have here. We did see a decline in cases in south-east Asia, our eastern Mediterranean region and across Africa but we did see increasing deaths in the western Pacific, in the Americas, almost a 20% increase in deaths in the Americas as well as a 3% increase in deaths in Europe.

00:13:10

It's dynamic. We have hot-spots in all regions. Some countries have brought the virus to a low level and for those countries we would advise to continue to keep that transmission low, do not let your guard up so that we can drive that transmission down while you get your vaccine coverage up.

But it is quite dynamic around the world. Europe really is a hot-spot right now and it is a warning. The situation in Europe is similar to the situation we saw last year in Europe. Let's not do this again. Let's learn from each other.

There was a question, I think, at the press conference yesterday which I don't know if we actually answered. What can we learn? I think we should be learning from every country's experience, every country's response because it's about that combination and getting that balance right.

But I do want to recognise that while we have increased testing around the world it's still not strong and in many countries they've reduced the amount of testing for COVID-19 and we need testing to continue.

We need strong surveillance not only for COVID-19 but now for influenza, for RSV, for other respiratory pathogens that are circulating. We need testing linked to public health action so that people know what to do.

00:14:33

If you are infected with COVID, what do I do, how do I get into the clinical care pathway, or if I'm mild or asymptomatic how do I make sure that if I'm infected I don't pass the virus to others? All of that public health work, that infrastructure of surveillance, testing, good clinical care, strong workforce.

That also needs to continue so we are advising countries to even surge their capacities now even as we enter the third year of this because it will benefit COVID and all future infectious threats that we have.

AK          Thank you, Maria. You're now mentioning testing and there is also a question from Maureen Adams, also watching us on Facebook. Is it still recommended to wait five days for testing after seeing someone with COVID? Maybe you can remind, when is the right time to test if we've been a contact.

MK         That's a great question. We don't actually make a recommendation on which day is best. I think it depends on the system in country. If you are a contact of a case there is national guidance that will come out that will give you a recommendation.

00:15:40

You have to remember that there's the incubation period from when you are exposed to when you may develop symptoms. People can transmit this virus even before they develop symptoms and most transmission is happening right around the time that people develop symptoms so that's like a day zero.

If you think about the symptoms of COVID, it could be anything from extremely mild - you could have a loss of taste, a loss of smell - all the way through fever and really developing severe disease quite quickly.

I think there're a variety of days that can be tested. There's the PCR tests that are typically done in labs and clinics. There are also antigen-based RDTs, rapid diagnostic tests that are now widely available. Some people do those at home and that gives you an indication of whether or not you are infected at the time that you take the test.

There is no golden set rule of when the best day is but it is important that you do get tested if you are a contact of a confirmed case and that you quarantine so that if you are infected the virus stops with you and you don't pass it on to others.

00:16:46

AK          Thank you, Maria. Mike, here is a follow-up question for you coming from Thomas. He says, since Dr Mike confirmed that you can contract the virus and transmit COVID if you're vaccinated then wouldn't it be true that the variant would become vaccine-resistant, hence why we constantly need boosters? The virus will always outpace the creation of vaccine.

Maybe you can clarify, Mike, on this comment.

MR         Yes, I went into it last week a little as well. We don't see vaccines commonly associated with the development of that, what we call vaccine escape, that the viruses evolve to evade the... It can happen and we keep a very close eye out for it but that's driven more by natural and random evolution of the virus, not driven by the presence of the vaccine but just the way the virus evolves.

We're always watching to for any new variant that emerges that might be, in a way, not resistant to the vaccine but where the vaccine might become less effective and that's called immune escape where, in a sense, the virus is able to evade the immune response that's been generated due to having had a vaccine.

So we don't generally see that and the fact that you become reinfected is... In general people are being reinfected by the same strain they were infected with the first time so it's not that they've become - people use this word - resistant to the vaccine.

It's that very often in some people, in a small proportion of people the vaccine doesn't take properly and another proportion of people might be immunocompromised, they don't get a full immune response.

In some people immunity might wane more quickly than in others so there's a whole range of different factors that might determine your risk to be reinfected and that's hard to predict in any given individual.

So this idea of needing to be boosted all the time - no, that's not the case. Also when we talk about very often waning immunity and people measure antibodies, we're measuring this neutralising antibody and this what they call sterilising antibodies and sometimes that gives a false sense of immunity waning.

You see these antibody levels drop, drop, drop and everyone says, oh, God, immunity is waning. That's not necessarily the case because in effect what happens is the signal that says, I've got this much antibody in my system, that wanes, the amount of antibody in your system wanes.

00:19:16

But the memory is still there. It's almost like the way our memory works. Soon after an event you might forget all the details but at some point in the future someone reminds you and all of a sudden all of the details can flow back and that's essentially what happens.

The system doesn't carry around as much antibody all the time but what it has deeply embedded in the system is the memory of that infection and that's built into the system. Then the system can react very quickly when the virus arrives and build up its immunity again.

So in other words there's a tremendous focus on just measuring antibody levels, neutralising antibodies and they're very important, and sterilising antibodies but it isn't the full story of immunity. There's a much broader-based immune response that happens when you get vaccinated and that immune response is sustained for a very long time in your system.

00:20:13

And we don't know, we're really only a year and in many cases six months into our experience of these vaccines and the studies are being done constantly to see how the vaccines are still performing. I'm encouraged with how well the vaccines are holding up in preventing severe disease and preventing hospitalisation.

It's incredible to think that we have so many vaccines that are still performing and doing that despite the emergence of variants. So on the one hand we're lucky in that sense but we're always aware that there could be a variant around the corner that could evade our vaccines and that would be not a good thing.

But I don't believe that the vaccines themselves are driving the evolution of the virus to escape the effectiveness of the vaccines. It's a much more general process of viral evolution. That's different if we end up with therapeutics and tablets that treat the virus because when you're immune, when you have vaccine immunity you have no virus in your system and then the virus arrives in small numbers and then your immune system can attack it.

00:21:16

When you use a drug there's loads of virus in the system because the person is very sick and now you introduce the drug into the body and there are trillions of viruses and amongst those trillions of viruses there may be one or two that have some resistance to the drug and that's how resistance emerges.

The drug kills all the viruses that are susceptible and the few that are left end up living and then they reproduce and then the next generation of viruses is more resistant to the drug than before.

So it really is a matter of numbers. I know I'm not explaining it very well but I am not as concerned about - resistance is the wrong word but your listener had asked about that. I'd be much more concerned about the emergence of resistance if we overuse antivirals or if we use antivirals in an unintelligent way by just distributing them everywhere.

We'll have to be very careful when we get these new antivirals in place. They could be game-changers and they can probably make a huge difference in the long run but we're going to need to use them very prudently so that we can maintain their benefit. But I'm not concerned about vaccines right now.

00:22:35

MK         Can I say one thing on that last point? One of the things we're trying to ensure is when we're doing testing and we're looking for cases we want to help people who have COVID and give them the right treatment, they need to enter that clinical care pathway wherever they live as soon as possible.

Earlier clinical care saves lives and what we've been trying to talk about is, especially as new antivirals come online, it's about the right patient getting that right test, getting the right treatment at the right dose. It's not just that a new drug will become available and then everybody can take a pill whenever.

We need to make sure that people are receiving appropriate clinical care by trained medical professionals and that they're using these therapeutics the right way because some therapeutics are focusing on earlier in disease severity and others in late.

I think what Mike said is really, really critical but it's the right patient, the right test, the right dose, the right therapeutic and we're working with so many partners around the world.

00:23:30

We have an amazing clinical management team here led by Dr Janet Diaz, working with clinicians around the world to get the data, understand the clinical trials so that we can get that guidance out as quickly as possible.

That's a huge amount of work but we're working very hard to get more therapeutics assessed properly, robustly so that those can be used but used appropriately, as Mike said.

AK          Thank you so much to both of you. Actually you covered a few more questions that others were asking but I see that there are more questions coming in on vaccine resistance so I would invite our viewers maybe to rewatch this as we have quite a lot of questions coming in, so that we don't repeat.

But for those who just joined, we answered that questions. Maria, here is a...

00:24:17

MR         One thing we could do is get Kate and Annamaria and others... This is obviously something that is concerning people and it is not easy sometimes to... I find it confusing at times. The vaccine prevents hospitalisation but it doesn't stop infection?

These aren't intuitive things, these are not directly intuitive so I don't blame anyone out there for feeling, hang on, what's happening here? So I think it is important that we engage and find better ways to explain this and engage with people.

So maybe we need a masterclass with Kate and yourself and Annamaria to do a special Facebook Live around this specific issue. I think it'd be worth it because this is something we really do need people to get and to understand. We're not saying that vaccines don't work. Vaccines work, they're saving hundreds of thousands, millions of lives around the world.

It's just that in the specific area around transmission they're not 100% effective in stopping that so therefore we still need to keep taking basic precautions.

Then this whole issue of losing vaccine efficacy. Everyone's concerned about that, I'm concerned about it. I've had vaccine and I want to know it's going to work for as long as possible so maybe it would be good, Aleks...

00:25:35

AK          To have a special session on it.

MR         To have a special session on that, as I say, maybe with Kate, Annamaria, yourself, Maria, and others to go through that.

AK          Thank you, Mike. We'll make sure that we offer that masterclass as well to our followers. Maria, there is a question now about the new variant that we are reading about in the news so what do we know about this new variant and how concerned are you about it?

MK         Thanks. I think what you're referring to is some of the recent media reports about this E11529 so this is a variant that has been detected and reported to us from our colleagues in South Africa.

There are ewer than 100 full-genome sequences that are available. We don't know much about this yet. What we do know is that this variant has a large number of mutations and the concern is that when you have so many mutations it can have an impact on how the virus behaves.

00:26:35

So right now researchers are getting together to understand where these mutations are and the spike protein and the furin cleavage site and what that potentially may mean for our diagnostics, our therapeutics and our vaccines.

What we need people to understand who are watching this, who are reading those news articles is that these types of variants being detected - it's good that they are being detected, it means that we have a system in place.

I do want to thank our colleagues in South Africa who are doing incredible genomic sequencing, doing incredible research and they're planning to do, right now, neutralisation studies. It will take a few weeks for us to understand what impact this variant has on any potential vaccines for example but there's a lot of work that is underway.

Our technical advisory group on virus evolution is discussing this with our colleagues in South Africa. We're also meeting again tomorrow, we're calling a special meeting to discuss this, not to cause alarm but just because we have the system in place. We can bring these scientists together and discuss, what does it mean, and also set the timeline for how long it will take for us to get those answers.

00:27:47

So right now it's a variant that is under monitoring. The virus evolution working group or the TAGVE will discuss if it will become a variant of interest or a variant of concern and if that's the case then we will assign it a Greek name.

But it is something to watch and I think besides the C11529 we need to understand, everybody that's out there needs to understand that the more this virus circulates the more opportunities the virus has to change, the more mutations we will see.

So given that so many people, a quarter of a billion people have been reported to have been infected with this virus - and we know that's a gross underestimate - if we look at seroprevalence studies around the world, which capture unrecognised infections, past infection, that number is far higher.

But the virus has a lot more room to go so we need to drive that transmission down so that we reduce the possibility of having more variants emerge. But this is one to watch. I would say we have concern but I think you would want us to have concern and I want the viewers to know that we have people who are on this, who are making sure that the right people are having the discussions and as soon as we have more information to share we will.

00:29:04

But don't forget, we still have the delta variant which is also evolving and there are at least 30 sublineages of delta that we are tracking. We have reported on the delta sublineage AY4.2, which has been reported from the UK and in this sublineage there's a suggestion that this variant has increased transmissibility, slightly over the delta variant.

So this virus has a lot of room to change. This is why every single one of you watching has a role to play in driving transmission down as well as protecting yourself against severe disease and death so get vaccinated when you can, make sure you receive the full course of your doses and make sure you take steps to reduce your exposure and prevent yourself from passing that virus to someone else.

AK          Thank you, Maria. Mike, would you like to complement, please?

MR         No, I just would like to emphasise what Maria said regarding the work done in South Africa. Work over the last two years in South Africa on surveillance, on integrating genomics in this network for genomics surveillance in South Africa and the way in which that's driven public health policy and work, it's truly outstanding.

00:30:16

I know the Science and Innovation and Council in South Africa, I think the Medical Research Council, the National Institute of Communicable Diseases, a whole range of universities, Stellenbosch and others, and others have been involved in this.

This is hugely responsible science. It's aimed at providing insights and information that can drive public policy and being able to pick up signals like this early and we saw that same in the United Kingdom, two very good examples of countries that have build their public health surveillance systems, expanded their genomic surveillance, made sure that that genomic surveillance feeds back in to good decision-making at the government level.

This is exemplary use of science for public health good but I'd just also caution people. As these signals generate, they're generated because these countries have in place these systems. There could be all kinds of things happening in other countries where we don't know.

00:31:09

So it's really important that there are no knee-jerk response here, especially in relation to South Africa. South Africa's picking up interesting and important signals for which we're doing the proper risk assessment and risk management.

Because we've seen in the past if there's any mention of any kind of variation then everyone is closing borders and restricting travel. It's really important that we remain open and we remain focused on understanding and characterising the problem and not punishing countries for doing outstanding scientific work and actually being open and transparent about what they're seeing and what they're finding.

So I think it's really important at this point that we have that approach, that countries like the UK, countries like South Africa who do this work openly, share it openly and transparently, are supported in doing that because that's what we need.

If we're going to beat this virus we need good information and good information will only come when people feel that they may share that information without being punished for having done so.

00:32:12

So I think this is a really good example where we just need to be really, at this point, cautious and we need to be grateful to our colleagues in South Africa for giving us this opportunity to understand further virus evolution.

But we have not fully assessed any threat or risk associated with this variation. That remains to be seen and the studies need to be done so I'd just caution everyone to be... This happens, viruses evolve and we pick up variations. It's not the end of the world, the sky is not falling in because there is this idea that we're just waiting for the next variant and I don't want people to spend their lives worrying about that every day.

Scientists need to worry about that and we need to characterise those risks and you need to trust that we will tell you if there's a significant change in risk and then to rely, as I said, on the superb network of genomic surveillance in South Africa and the institutions that make up that network.

MK         They're also helping the region so the researchers in South Africa are also helping to improve sequencing across the continent and that's something that is also to be commended.

00:33:15

We do need better sequencing around the world. We need intelligent sequencing, not just more but intelligent and better geographic coverage. If you look at some of the maps that we produce in our sitrep you can see where for example delta has been reported in the last 60 days.

But I think that's more a reflection on where those sequences have been shared rather than where delta is circulating. So there are a lot of partners around the world that are helping to improve sequencing, especially focusing on regional capacities, building regional and national capacities and we need that to continue.

This is really an important moment in terms of surveillance, there's a lot of attention to this and now is the time to build those systems, support those systems so that they're good for SARS-CoV-2 and helping to track and monitor this virus as it evolves but also for any future infectious pathogens that will come our way.

AK          Thank you, Maria. I'm aware that we don't have too much time left but we have a good, I think, three or four questions that we should really address today. The first one is from Jonathan, watching us on LinkedIn. Is it time to join dots here? If different countries are choosing different testing or public health measures and vaccination regimes then we do not need to review the evidence and encourage adoption of one system worldwide.

00:34:38

I think the question is, shall we actually revisit the evidence and adopt one regime?

MR         I understand the instinct but my experience... I think we need one approach. We need to look at the tools and actually understand the tools we're using so, yes, we need one toolkit, one set of tools that we all recognise and understand and support.

But then the tools we use will depend on the situation in each country so that needs to be applied. You can't take an approach here in Geneva and say, this is going to work everywhere every month in every geographic situation and every social situation.

That's not true but we need to commonly understand the value of mask-wearing and when it's useful, the value of ventilation and when that's critical, the value of restrictive measures if they're needed.

00:35:30

So we need to have the same understanding of the public health value and impact of those things so that we then are communicating in the same way to people. So I understand the question but I think a global approach to vaccine equity has been badly needed and we need more equity and we can do that at global level.

I think the research and development that has been done has been done in a very co-ordinated way. We can have a common understanding of what's happening in the world and we really do thank everyone and all the people around the world, all the governments, all the institutions that share with us every single day data on the pandemic.

We have, as you said, the weekly epi report and other products that push that information back to all our partners around the world, including the public. But no, I don't think you can say the solution here is just to impose one...

For example some countries have populations that are quite young and not too many people in the vulnerable age groups. Some countries have many, many older population with many, many of the older population in long-term care facilities. That's a time bomb in some countries if you don't have high vaccination levels.

00:36:42

So the priorities also change and differ and, as Maria said, we need to focus, I think, in terms of, rather than bringing in that kind of draconian approach, what we need to fix in each country. I would say you said it earlier. We need to find every single person who's unvaccinated, particularly those individuals in older age groups with underlying conditions, and try and convince those people to be vaccinated.

We should be doing that worldwide, no matter what country we're in. We should be ensuring that all health workers are vaccinated and that every health worker has access to proper protective equipment. That should be a worldwide principle.

We need to have worldwide surveillance that continues to look for genetic differences in the virus so genomic surveillance everywhere and to share that technology everywhere so we have a common understanding of what's happening in the world.

00:37:31

Yes, if it's a global regime, that kind of thing but the idea that we can have one approach everywhere all the time, I don't think so, Maria.

MK         No, I think you're exactly right and I think what we're trying to support countries in doing is having a tailored response based on the situation in terms of the epi in their population, the social contract that leaders have with their communities as well as their capacities.

That needs to adjust because the virus is very dynamic. Once the virus is circulating it doesn't mean that it's going to circulate at that intensity all the time so the layers, as I was mentioning before...

As you apply certain layers of response those can be adjusted and lifted but that has to be done slowly and what we also advise is it isn't just a... You need a national plan but it needs to be implemented at the most local level possible.

So we know what tools work and we know vaccines work against preventing severe disease and death. We know that masks work against preventing onward transmission. We know that improving ventilation helps prevent the spread in enclosed settings.

00:38:38

We know that physical distancing reduces the opportunity for me, if I were infected, to infect you and so on and so on - cleaning your hands. But we know when you add those in combination with each other you're adding more and more protective layers.

So it really does depend on the circulation around and then we tailor that approach as necessary.

AK          Thank you, Maria. We know that Dr Mike Ryan has another commitment.

MR         I have to run, if I can jump out, and I'll leave you with Maria and I can do it without making too much noise. Is there any last question you'd like to ask me?

AK          Maybe just the last question is because it's related to the special session of the World Health Assembly that we'll have. Jaya Kumar is asking, can you confirm, what are the precautionary measures to be taken by every country for any future pandemic through different sources of viruses, what are the most effective preventive systems that can be made by countries well in advance to protect people from any type of future pandemic?

00:39:34

MK         Easy question.

MR         That's a good question and I wish I had 14 hours to talk to you and not four seconds. Maybe we need a special session on that. It's the right question and that's what the member states are coming together for the first time... It's only the second time in the history of WHO in 70 years that there's an extraordinary World Health Assembly and all the nations of the world are going to get together on Monday and they're going to talk about exactly that.

How do we put in place a framework to prepare for and prevent the next pandemic? Number one, we can stop some of these things breaching the species barrier so some of the management of risk we have to do is in the animal side, in the environment.

In fact our best protection may not be on the human side. Our best protection may be on the other side of that barrier in terms of managing our planet better, managing our biome better, identifying risks in nature so they don't cross over the barriers, protecting those barriers so that we don't create holes in that natural barrier by what we do in terms of trade and everything else.

00:40:41

We can do a lot more to increase our ability to detect early and contain these diseases early, to share information, biologic samples. We can do a lot more to accelerate research, development and innovation and share the results of that more equitably.

So in each and every one of those phases we can make our health systems much more ready and resilient and fast and flexible. All of that can be achieved but it can't be achieved unless the member states and organisations around the world come together and define, how are we going to do that, what's the plan, how are we going to govern that, how are we going to finance that and what are these priority systems we need to develop.

00:41:20

We need a roadmap, we need a game plan and we need a new game plan and we need it quickly because the next pandemic may not be that far down the line and that's what that meeting is about next week.

My quote of the day and I've used it a couple of times today because I think it's so profound. Abraham Lincoln once said - a great leader historically in the world - if you want to predict the future you must create it. So the best way to predict the future is to create it. I think that's exactly what he said, the best way to predict the future is to create it.

So if we want control of the future, we want control of our health, control of the risks that we face then we need to create a future in which those risks are reduced and we have control over viruses and not them over us.

That's not just going to take a week or a month. It's going to take a decade, it's going to take a generation to do that, no more than with climate but there are things we need to do now, like with climate change, and there are things we need to do over five years and over ten and over 20.

My fear is if we don't take the first steps, if we say, ah, well, we'll come back to this next year or the year after, then we'll have forgotten.

00:42:30

So next week is really important. This is really the biggest chance that our member states, 194 states from all over the world, are going to come together and discuss one topic only, this topic. So citizens out there, time to tell your leaders what you want from this meeting next week because it's an important one.

AK          Thank you, Mike. This was a great way for you to end this conversation and we're also inviting everyone to watch the discussion. It will be live-streamed on our website, Monday to Wednesday if you want to see what the health leaders of the world will be discussing and what will be their agreement for the way forward.

But I think, Maria, you had something to add as well.

MK         Just very briefly to say that we really do have an opportunity right now, as Mike was saying and I think you've heard us talk quite a lot before about... The world is going through something incredibly traumatic right now and incredibly painful and difficult and now is the time to make those changes.

00:43:25

Now is the time while that trauma is fresh - and of course we hope that this ends as soon as possible - now is the time to make those changes because if we don't make those changes now we will move on to the next crisis and there are plenty of other crises that are out there.

But for COVID-19 this is a global problem and we need global solutions but there are solutions and I think people worry and I understand the worry but I think they should also be hopeful because we have those tools.

We have vaccines as part of our toolkit but they have to reach everybody who needs them, particularly those who are most at risk. We have masks that are widely available now that prevent the onward spread. People have access to good hand hygiene, they can clean their hands, which does help for COVID-19 but also other infectious pathogens that are out there.

We know that distancing works, we know that we can get kids back to school by making sure that the right provisions are in place, that we can support people to work from home. We know that surveillance and testing and good clinical care...

These are tools that are part of our toolkit but we need to strengthen them now. We can't wait for this to be over and then say, okay, what should we do? I don't want to hear any more lessons learned, we have books and reports of lessons learned and we're grateful for those, don't get me wrong.

00:44:44

But now let's make those changes and let's make those course corrections now. So next week is a huge opportunity for health leaders to come together, led by Dr Tedros and brilliant people like Mike - thank God for him.

But we really, really do need to make these changes because if we don't do it now, when will we?

AK          Thank you, Maria. I'm glad you brought back the precautionary measures because we got a few questions on that and I couldn't finish this conversation until we clarify. Marc Tressiser, who is watching us on Facebook, is asking, is it safe for fully vaccinated people to gather without wearing masks or social distancing?

MK         It depends on where you live. As vaccination increases it does reduce the opportunity to get infected and pass the virus on but we still recommend even if you are vaccinated to wear a mask when you're indoors and when you're with other people.

00:45:37

If you are indoors with other people make sure you have good ventilation, good cross-flow, open those windows, try to physically distance as well. I know that becomes very hard and it's Thanksgiving in America so I do want to say happy Thanksgiving to my family and to my friends who are celebrating. We really wish we could be with you but one day we will celebrate again Thanksgiving.

But yes, there are precautions that need to be put in place. Vaccines alone are not enough so what we recommend is vaccines and, not vaccines only so please continue to just be cautious and take measures to keep you...

It's not just about you so even if you are vaccinated you may be with other people who aren't and if that person is in a vulnerable category they do have a higher risk of dying if they were to be infected.

So get vaccinated for you, wear your mask for you but also for others.

AK          Thank you, Maria. I will just join in saying happy Thanksgiving to you, your family but also to everyone celebrating today and I hope you are taking the precautionary measures to celebrate safely.

00:46:48

There was another question as well from someone else asking about mass gatherings and whether we still, despite vaccination, should be, if we go to a sports match or other mass gathering, be all wearing masks to reduce the risk as obviously people are crowded in such settings.

MK         Yes, we advise when there are gatherings taking place to do a risk assessment. Where is the event, how many people will be there, what precautions are in place in terms of distancing, is it indoors or outdoors, will there be a test requirement, are you requiring vaccination, will people need masks?

Again the comment is really about the fact that vaccines don't prevent all infections and don't prevent all transmissions so that's why we continue to advise even if you are vaccinated to continue to wear your mask when you're with others.

This is for now, this is not forever. It won't be like this forever, I promise it won't be like this forever but we need to get through this together and putting that mask on, keeping that distance, avoiding those crowds where you can will help get us towards the end of this pandemic.

00:47:57

Unfortunately we have quite a ways to go with the current situation that we are in and so we need everyone to play their part.

AK          Thank you, Maria. Some were asking why we here in this room are not wearing masks so we are in a quite well-ventilated room. We are also keeping the distance so this is not a crowded environment and yes, we are fully vaccinated but that's not the only reason. It's other precautionary measures that we are putting in place.

Maybe a last note to end on today - this is why I'm wearing orange. It's International Day of Elimination of Violence Against Women. One in three women around the world experience violence, domestic violence and we've seen many reports that during the pandemic there were even more experiences faced.

Maria, maybe as a last message today, how can we all be part of the solution to support survivors and also to help end violence?

MK         I think you even answered it as you asked the question. I think we all have to stand up to end violence. The statistic that you read that one in three women globally experience violence, that has increased during this pandemic with women having to stay at home, with the stay-at-home measures that are in place not only for women but for partners and also children.

00:49:18

So it's been quite a dangerous time for many and we cannot lose sight of that. There are support systems that are in place if women can reach out there are systems. We need more systems within countries to support women in this and we have to stand up against violence against women no matter where we live on this planet.

We need to support those systems in place that help those women get out of those situations and stand in solidarity. I didn't wear orange today. I don't own anything orange. I'll have to buy myself something orange.

AK          There are 16 days of activism to orange the world, to express solidarity with victims but also to call for action to end violence so you still have time.

MK         I have time.

00:50:06

AK          I thank all our viewers from Rwanda, Bangladesh, Pakistan, Switzerland, Serbia - my country - Spain, Cuba, Peru, Slovakia, Costa Rica, Argentina, Turkey, New Zealand, Belgium and many other countries for watching us today, for all great questions.

We apologise for not taking them all but we do our best to provide you with answers or to organise more special sessions, as Mike suggested, to go maybe into a deep dive on a particular subject.

Follow our channels next week in particular for the special session of the World Health Assembly and also for any updates on new variants or any other health issues. Thank you and goodbye.

00:50:53