Mayo Clinic and other experts discuss COVID-19 infection prevalence, virus variants, preventive measures, vaccination status and therapies used in treating patients in Kenya and Ghana. Additionally, the impact on the prevalence of HIV, tuberculosis and malaria is explored.
Moderator: Claudia R. Libertin, M.D., consultant, Division of Infectious Diseases at Mayo Clinic; professor of medicine at Mayo Clinic College of Medicine and Science
Moderator: Prakash Kempaiah, Ph.D., associate consultant, Division of Infectious Diseases at Mayo Clinic
Featured expert: Kwadwo Asamoah Kusi, Ph.D., senior research fellow, Department of Immunology; Head Department of Electron Microscopy & Histopathology, NMIMR, College of Health Sciences, University of Ghana, Legon
Featured expert: Bernhards Ogutu, M.D., chief research officer, Kenya Medical Research Institute (KEMRI); senior clinical trialist, Malaria Clinical Trials Alliance of the INDEPTH Network; director, Centre for Research in Therapeutic Sciences (CREATES), Strathmore University, Nairobi
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The views and perspectives shared in these resources are presented based on information available at the time of recording.
welcome everyone on behalf of the Mayo Clinic School of continuous Professional development. I'd like to welcome you to the Mayo clinic Covid 19 live webinar series. I'm dr William palmer. Associate Dean of the school, your host for today's webinar Global COVID 19 pandemic updates. Part one kenya and Ghana. This webinar is accredited for one am a pr a category one credit. A record of attendance will be provided for all other health care professionals. This webinar is supported by an educational grant from Fighter Incorporated. Here are the disclosures for this activity before we get started. We'll cover a few points. The first is how to claim credit. If you'd like to claim credit after the webinar please visit c dot mayo dot e d u ford slash Covid 1116. You'll need to log into the site and if this is your first time visiting, you'll need to create an account profile after you've done this and logged in, you'll access the course to complete a short evaluation and then you'll have the ability to download or save your certificate. This link will be dropped into the chat box throughout today's webinar. The second item is how we facilitate questions. You'll see at the bottom of your screen the chat and Q and a function. If you have any questions during the webinar for today's presenters, it's important that you drop them into the Q and A channel. There will also be a helpful up vote button. So be sure of the questions that you would like to see answered here are their learning objectives for today's webinar which will be covered with that. I'd like to introduce today's moderators. Dr claudia libertine and dr Prakash. Olympia dr claudia libertine graduated from the University of Toledo Medical School and completed internal medicine, infectious disease and medical microbiology training at Mayo Clinic in Rochester. She has been on staff at Loyola Loyola University in Chicago And Yale University until she rejoined us at Mayo Clinic in Florida in 2014 she is professor of medicine, Director of infectious disease clinical research Mayo clinic florida and consulted of infectious diseases During the COVID-19 pandemic. She led the COVID 19. COVID-19 I'd multidisciplinary team And his primary investigator on five randomized controlled trials including active five. She has also already published 9 COVID-19 publications today. Dr Campagna is associate consultant at Mayo Clinic division of infectious disease in florida. Dr compare received his PhD from the Institute of Human genetics and gatting University Germany majoring in development of therapeutics for genetic diseases. Dr Campagna currently leads the drug discovery program for protozoan parasites in the division of infectious disease. More recently in COVID 19 and has established long term research and clinical collaborations based in kenya Ghana South africa, Japan, the United Kingdom South America and India to facilitate the testing and development of new therapeutics and animal models and field samples with that. I'd like to turn things over to our moderators. Dr libertine and Dr Campagna to personally introduce today's panelists. Thank you dr Palmer and thank you everybody for attending the second of our six webinars on the global um Covid 19 pandemic. We feel that the next two are very important and that they are going to be giving us the opportunity to learn the impact that the pandemic has had on african countries and then on the next one, the indian um pandemic, we'd like to first introduce dr kusi from Ghana. He is the senior research fellow department of immunology and head department of the electron microscopy and hissed a pathology, the Ghannouchi Medical Institute for Medical Research College of Health Sciences at the University of Ghana. His educational background is he's from Leiden University Medical Center in Netherlands where he received his PhD in medicine vaccine immunology. And then at the University of Ghana has gotten multiple degrees in biochemistry. His research is heavy and pathogen induced immune responses, especially plasmodium. Most importantly though, he collaborates with us as researchers at the US Naval Medical Research Center and the walter reed Army Institute of Research on similar immune responses. He is the lead immunologist of clinical trials in this country and is currently involved in assessing immune responses Elicited by the loss of fever vaccine trial. He leads the ideological arm of assessing um the benefits of prior measles, rubella vaccines on immune responses to the subsequent COVID-19 vaccine. It's a great honor to have him speak with us and I'll turn that over. So, good morning, Good afternoon, good evening wherever you may be. Um my name is called US Democracy um with the department of immunology. Um Noguchi Memorial Institute for Medical Research at the University of Ghana. And today I'll be sharing with you um what our story has been so far in terms of the covid pandemic um in terms of how we're managing the pandemic and also a lot of information on vaccines. So basically To start with and for these disclaimers um uh obviously I have nothing to disclose when it comes to this but is the outline of what I will be presenting to a bit on COVID-19 epidemiology, contact tracing and testing as has been done in Ghana um control and preventive measures as have been rolled out. Um then there's a bit on a task of two sequencing and how it's being managed. Um Then I also mentioned uh something on vaccines, vaccination and vaccine hesitancy Ghana and then end with some new government policy directions which we think are going to be very, very important for us as a country. So basically this is um Ghana's uh current covid 19 case count. Um as of 11th november we have 100 and 12 active cases, 100 and 30,000 confirmed cases, you know, 1002 100 deaths. And I know this is this pales in comparison of what is happening elsewhere in the west. But most of the disease is concentrated in the um south that's in the capital city in a crab and then also in the second largest city in terms of population in Kumasi. So these are the two main areas where you have the disease concentrated. Um This is the number of uh peaks we've had so far with Covid. The um so we had our first um peak of infections somewhere in august of last year. And then in february of 2021 we had a second one. And then just recently in in july we had a third pick and these have been due to various activities that are happening around these times. And I'll touch on this as we go. This is basically how we have done contact tracing. Um This is uh paper from uh Professor Ernest Can with the School of Public health at the University of Ghana. And um he has been in charge of the national contact tracing. And this is uh exactly what they did for the very 1st 30 cases, we had identifying a total of 1000 and nova contact but being able to follow 732 of them meaning that there was still a number who were not um we're not able to be traced and therefore not followed But it out of the 732 53 became symptomatic and then they they are contact were also followed and and so on and so forth. Uh Although this is not a perfect system. It still helped a lot in trying to identify persons who have come into contact with those who are sick from covid and these um how we have uh managed a covid situation are mostly and also because it was limited to a few cities, uh it wasn't widespread throughout the country uh that there are regions in Canada experience probably just one of under five infections over the period. Um this is a chart that is showing the same. We have shown previously by looking at the numbers that are due to routine um testing and also uh in in orange uh and then also those that are due to contact tracing. So you see that um a lot more cases have been detected through contact tracing as compared to routine testing and I want anything about my institute is um it was the first to um begin the testing uh cycle and that's the Noguchi Memorial Institute and as a december of 2020 Noguchi was testing almost 52% of all conducting, 52% of all tests that were being done in Ghana, That's quite a remarkable achievement. Um out of that, 67% of confirmed cases were confirmed by by testing the noguchi and a few months down the line by August 2021, we now have um Down to 30, almost 30% contribution because there's now hundreds and hundreds of, of labs that that were trained and facilitated to to also engage in COVID testing. But still noguchi contributes quite a significant proportion of the national testing. Um, this is a graph showing how much or how many tests have been done by my institute And the positivity rates indicated in red here. So at some point we're testing up to 90,000 samples within within a month and this was made possible because of the pooled procedure that we employed. Now. This is what the, the kinda health service reports in terms of covid cases in Ghana. Um, this I pulled out on this date on 7th november. And as you can see um there's routine testing, there's contact tracing and and then we also have um uh surveillance at our main um part of entry into Ghana which is through their critical international airport, luckily for us, that is the main part for most arrivals by air. So it's much easier to control and to be able to um to check for persons who might be carrying the covid virus. Uh so down here, you also see a breakdown of uh samples and where they're coming from, from routine surveillance from enhanced contact tracing and also at the airport. And obviously you see that quite a huge number having picked up at the airport or having tested at the airport with 209, 2110 being uh detected or picked up as cases at the airport. So basically this is to show how much testing has been done per million. And the number of confirmed cases and and and even even smaller number of confirmed dead from from covid. Um And if we look at this it might look disproportionate. And it's because it does look like there's a lot of exposure. Uh and we have a lot of asymptomatic cases and therefore these are not even reporting to hospitals and getting tested. Uh This is data showing um serious turbulence for antibodies against the task of two that was done in crowded places as well as in health facilities. And you see that um the marketplace uh and lori parks where you have crowds and crowds of people choose the highest levels of a serial positivity for antibodies to covid. And then if you look by age group, the 41 to 60 year age group is the most exposed. For obvious reasons. That is um um That contains quite a significant number of the working population who are always out and about. Um It seems to disproportionately um affect presents with um lower levels of education and that may be linked with their employment status in a way because a lot of those are those who also being informal employment and also being the lower income bracket. So these plots clearly show the demography that is most exposed in Ghana. And of course if we compare the number of deaths that have uh communication by COVID-19 with our neighbors, at least seven of our neighbors in West Africa. It compares very well. And this is one thing that um I would say is probably more accurate than the case counts because death should be more difficult to not account compared to um the cases and like I said, the cases are very difficult to manage because not every case actually of infection actually ends up in the intestines and our hospital to be counted. Mm Now, basically our control strategies for Covid has been what everybody else is doing mandatory face uh mask wearing uh frequent hand washing. And I must say that in this era of Covid, this has been super enhanced in in Ghana everywhere you go, there is opportunity to wash your hands and there is this um contraption here um which is enough and he described as the veronica bucket named after the inventor. Uh so this is just a normal plastic basin that is fitted with the top at the at the bottom. And this can be placed anywhere for for people to wash their hands. So in front of shops uh in front of buildings and stuff and and it's it's very came in very handy during the Covid era and it has been very, very useful. Now, physical distancing is another thing that has been employed but if you look at the graphs being shown here, um it's been more difficult, you know, enforcing the wearing of masks. So the bars in red and the proportions of persons who having shown especially in crowded places in bagels not to wear masks while the blue ones are those who are actually complying. Uh but physical distancing has been the opposite. And so that has been a very effective tool for us uh in terms of uh trying to prevent covid spread. Um and then we've had a series of uh window and Aldo uh this infections. So um we have Large companies that have been contracted to decontaminate surfaces um in various places from markets to office buildings two. And that has been quite consistent and and been very helpful and of course vaccination but that is going at such a slow pace and we look at that later. Now the pandemic has brought on some innovations but also some challenges and I'll just highlight three of these yet. The first been uh The use of uh technology for uh testing and tracking. COVID-19 zip line is an american company that has been in Ghana for a while. And the initial task was to distribute medical supplies uh to the hinterlands where it's difficult to access by road. And so they have been working for a while in Ghana. But during the covid pandemic uh, zip line has been repurposed to fly samples from very hard to reach areas to the cities for testing and the results are communicated back to health facilities there. Um and now with vaccination, they've also being involved in carrying samples uh vaccines from uh centers of distribution to very hard to reach areas for that to be used for vaccination. And then um Ghana also the Vice president commissioned uh our own local app for um uh for people to just be able to check themselves whether they have the covid symptoms and to be able to report. And also this app has been very important for contact tracing because um you are able to tell within your locality who um would most likely be infected with Covid. But of course um it has also brought hardship and this is a picture that is showing a group distributing food packs to the homeless to people who were more or less stranded because of the partial lockdowns. We had we've had lockdowns in limited places and for very limited times. But for the two or three weeks that we had the lockdown, the economic impact for so much that the government was more or less uh forced to you know, reopen the system and and try to do control. Disease control with other means. Now switch gears and talk about sequencing. And I must say that girl is um um doing very minimal sequences unfortunately because of resource constraints. But the uh sequencing that is being done a shielded quite good information. Uh My institution is doing sequencing for both Ghana and for a few other countries in the West African subregion. Um But this is data. I'm reporting from a sister institution at the University of Ghana, uh The West Africa Center for cell biology of infectious pathogens. Um and this is an app that has been developed to showcase um where the different variants that are being picked up are coming from in country. Um So as of august september uh they had done a total of 100 1000 and 40 1000 144 samples um Like I said, this is very limited but it does show us quite a good distribution of what we had in country. Um These are samples that have been collected at least since the middle of last year. And then at least have been um um selectively sampled for analysis and were able to see over time that uh sometime from november December onwards, maybe somewhere in January 2021. Uh the alpha variant has been one that has has plagued us uh and then somewhere in me june july uh This was mostly taken over by the delta strain. And so it does look like a pig in february was driven mostly by the alpha strain or the variant and peek in um in july august was driven mostly by the delta variant. Now this is a summary of the major uh receipts we've had vaccines um in country, so I think the major one has been the Astrazeneca vaccine which we have received quite a number of um from different quarters. And then to received Sputnik vaccines, the Madonna and the Pfizer biontech vaccines as well. Uh these are just rough numbers of vaccines that have come in and I've indicated at times that have come in because our vaccination has been slowed down because vaccines have trickled in in bed. Um the estimate was to vaccinate 20 million guardians by the end of December. But as of now, what is coming is less than 10 million vaccines and though the year is not over um it does look like we might not meet the target. So currently the Ghana Health Service reports having vaccinated 3.2 million persons in Ghana Out of the targeted 20 million that are supposed to be vaccinated and this is the breakdown of which vaccine has been used at what time. Um so Astrazeneca being the one that has been used a lot. And then you have the others follow in that manner And all we have 838,000 Guardians who are fully vaccinated. That's who have gotten without a double shot of all the vaccines or the single shot of Johnson and Johnson vaccines. So if you look across the west african region once again, uh Nigeria seems to be ahead in terms of the total number of persons who have been vaccinated Ghana in third position. But if you look closely at the uh this is vaccinated per 1000 persons. You see that um Nigeria is not on top of that Because they have quite a huge population, almost 300 million people. So uh in terms of this Togo and carnival head Ghana in the third position. Um we when we look at immune responses regarding um are following vaccination. Unfortunately we do not see any boosting effect. So this is data coming from our lab where we looked at post vaccination samples. Um and then uh the uh first vaccine and then the post second vaccine samples. And we do not see any boosting effect in terms of antibodies. This is in the persons who had reported prior exposure or prior infection with SARS cov two and then in persons who have no prior infection. But the only thing we see that is that in those with prior infection uh quite a few of them have higher levels of antibodies. Although this is no significantly boosted by vaccination and then you have a lot of those without vaccination having very low levels of antibodies. This of course does not mean the vaccines are not effective. We are here to look into t cell responses for these vaccines. But in terms of antibodies it looks like very little is happening. And this is not surprising compared to other vaccines where it does very well in the west but when it comes to um are part of the world. Um it's the efficiencies are so much reduced probably because of a high background of uh infections. Yeah. Now if we look at attaining herd immunity which most countries are driving at, it looks like we have a long way to go because you need a certain minimum population to be vaccinated in order to come close to achieving that. And I pulled this information from a paper in vaccine where uh modeled um uh data on attaining herd immunity And that's depending on two things. One, the level of efficacy of the vaccine that you're using but also on the level of contagiousness of of the variants, the viral variants that you have in a population. And looking at these two factors. Uh it looks like most african countries who really struggle to be able to achieve herd immunity um through vaccination maybe through natural infection but through vaccination may be a very tall order. Then I look at vaccine hesitancy and how people uh either directly or not readily accepting even a few vaccine does is that we have. So this paper published recently those um that of the persons who are willing to take vaccines quite have quite a good knowledge of all the vaccines are and what they do uh in like manner to uh the same uh group who uh willing to take vaccines. So the first thing is those who are unwilling to take vaccines. Sorry. Um you have a lot of them In the 20 to 40 year group. And the for the group that are also willing to take vaccines, you still have that same age group turning up um, reasons that I've been given for whether there is willingness or unwillingness to take vaccines are listed here. So for those who are willing to take vaccines, one of the key things they've mentioned is the fact that it's a life saving medication. Uh, and they think it's good to to take it in order to preserve life. But of course, for those who are unwilling, they've given the myriad of reasons why they're not taking the vaccines from doubts about the safety of vaccines that religious believes uh to lack of information or education on what the vaccines really are supposed to do and also their perception of what the vaccines are generally. Then there's this other step in a more or less corroborates these findings. So, this study looks at reasons why people uh would be willing to take vaccines. And what comes on top is the fact that people want to protect their families, their friends, and those around them. Uh, and also the fact that some people believe the vaccines are effective Uh, from preventing them from getting COVID-19. And then if you look at those who are undecided as to whether they would take these vaccines. Um, what ranks highest in terms of their reasoning is uh, this year, that I am not well informed about the possible effects of the vaccine. So, they are looking for more information and I think this is a group that with the proper education will be, will be willing to take the vaccine and to reduce the levels of hesitancy that we have. And then we have the group that are not willing at all to take this. And there are major problem is the clinical safety of the vaccines and also the possible side effects that they have heard other people talk about more recently, there's also started taking some types of vaccines because um there were um there was information regarding some countries not accepting vaccine certificates if you were vaccinated with certain vaccines. So for example, people are a bit hesitant when they have to take a Sputnik vaccine or the Astrazeneca vaccine because they think it will not be accepted in certain jurisdictions. So that has also created a bit of a problem for persons especially who regular travelers now overall, the government in knowing how africa has suffered in terms of um or is suffering in terms of getting access to vaccines is taking steps to ensure that going into the future will become uh self sufficient. At least the ground workers started and we hope that this would be sustained. So the Ghana government has taken some steps set some short term medium term and long term goals to ensure that there is a road map for Ghana becoming self sufficient uh in vaccine production and the the short term goals are expected to be achieved within two years. And include what you see on this slide to be able to upgrade guns, food and drugs administration to a level where they can do a lot release locally. That is within the first two years. To be able to have domestic vaccine manufacturing plants that will do fill and finish vaccines And to have at least three educational institutions or research institutions to establish vaccine related development programs. Currently there are a few around but the capacity is very low. So the government is taking that responsibility to ensure that there are additional institutions that would have programs relating to vaccine development in order to build immediate human capacity. And then to establish at least two financial partnerships that will ensure the sustainability of these uh this agenda and then to establish scholarships that are attacking at capacity building still. So to train people in the west and get them to come back to contribute to um um the vaccine manufacturing process and then to implement at least one technology transfer partnership with Big Farmer out there. And then in the medium term, the expectation is that the uh gonna have, do you achieve uh wh you level for maturity uh to have a number of additional companies locally producing vaccines To establish at least three vaccine plants in Ghana to have at least five research institutions with fully functional vaccine-related research and development programs. And to establish at least three uh technology transfer agreements and in the long term to have in the next 10 years, Ghana being able to produce its own vaccines for the expanded program on immunization. Uh, Donna currently gives um Some 13 vaccines to Children between Beth and the age of five. And the plan is that in the next 10 years at least those 13 vaccines can be locally produced in China. And it is also because by 2027 Ghana we wind of Gavi support. Gavin currently supports uh the extended expanded program on immunization in Donna. But by 2027 that funding will will will be pulled. So this is also in line with making the country self sufficient in this area. And then to have uh domestic vaccine research and development programs that are capable of developing candidates for production and then to have the gotta FD fully capable of regulating the vaccine manufacturing space. So to conclude, I think Ghana relatively has fewer cases of severe Covid 19 unrelated that and that is that is um compared to what we are seeing in the west and indeed, that is also the case for most of sub Saharan africa. Um despite that, we need improved health systems because these are very important, especially as we are not sure of what the future holds in terms of the variants that are likely to come up. So uh improving health systems is one thing that urgently needs to happen. And then there's also the need for continuous education because there's a lot of people who um I'm not well informed concerning uh the collective fight against uh covid 19 and therefore a lot of education is needed to ensure that um uh even with our limited capacity and now limited uh efforts, we are able to effectively control the disease and then looking at how the vaccines are trickling in beds. Um it looks like vaccination may not be our primary strategy for controlling the disease, because even when people are vaccinated and it takes so long to get others around them vaccinated, it doesn't help for the attainment of her community by vaccination. And so um enforcing the other uh protocols, preventive protocols like wearing a face mask, social distancing, handwashing. Those are low hanging fruits that I think should be enhanced and enforced uh to be able to make sure that we keep ourselves in control of the disease. And then also um the investments that have been proposed in the vaccine production space uh will be very important, although they might not be ready. Um relevant to the current pandemic, that will be very important going into the future as we will need to prepare for any future pandemics that come on. So with this, I would end by thanking these persons who have contributed in one way or another to put in this uh package together and um I'll say thank you very much also to mary clinic for the invitation to do this presentation. Thank you. Yeah, yeah thank you very much Doctor cozy for providing the war review of uh pandemic and the covid pandemic in Ghana as well as the West African. Uh reason moving on to the second presentation, it's my great honor and pleasure to introduce our speaker. Dr Bernard's ago too. Uh in the reminder of the session, Dr. Bogota will be covering the COVID-19 pandemic situation in Kenya and Bradley address uh in Eastern African region. Dr Okamoto received this medical degree MD. And as well as the PhD from the inner city of Nairobi in kenya and uh atrocities pediatrician and trained in clinical pharmacology. And he is a pharmacologist uh by training and uh it's a certified physician investigator as well. So he currently serves as a uh chief research officer at Kimberly which is kenya Medical research institute um similar to the city, see what we have here and uh also a scientific team, leader of the center for research in therapeutic senses. Uh strathmore University in kenya and uh Dr Alberto ah uh yeah currently he leads is a lead clinical trial trial list of several product evaluation protocols including recently approved in other artists as malaria vaccine uh in Children. Uh His research area includes studying disease pathogenesis primarily in the malaria. Also conducted clinical trials as well as you know uh involved in capacity building in Africa with that place. Welcome Dr Alberto, Thank you very much uh dr Bernard, somebody from kenya and I would want to share with you what the Covid situation out in. Okay. Yeah. And thank you for the opportunity to be with the audience at my clinic and the other places that we are watching this presentation vigil is possibly to see that this uh COVID-19 is just part of the epidemics that we have seen in the last couple the last two decades. And this has been possibly one of them. The thing that was really shipping the way medical care and medical medical research is being conducted around the world. And this physically, if you look at the last two decades where we had, you know, fema, we had zika influenza and then we had Ebola and now we have, we had Moscow and then withdrawn. We've had cholera now have uh south for one. And I think this is some of the things that possibly we need to look out and what is really happening in the last two decades. And what are going to possibly some of the things that uh looking at what might be considered as the biological pandemics that possibly is going to shape the way we react to health executions around the world in this world that has become more of a Villager communication and the flow of information is basically in a matter of seconds from one end of the block together. So we know that there's a, there's a high prevalence of under long information period of the symptoms of the covid 19 and this is what has really cleared there the world by having several people getting infected infected across the law. And this is what leads there covid pandemic as announced by the lecturer in 2019. So some of the key components of this virus that I think has really being the target of a number of developments, especially when we are looking at developing drugs and vaccines has been physically the spike treated physically there components of the vaccine that it used to large onto the host cells and that also is the entry of the virus into the host system. And then another key component is basically the envelope that covers the virus And this basically allows the viral assembly and release into the the hotels and possibly in the extra cellular space. Then we have the membrane proteins. We basically help to stabilize the sale of the of the virus. And I think bodies have been targets for when you're looking for interventions that possibly and drug and vaccine targets. And then you have the nuclear has been proteins which are basically the RNA replication which are between involving RNA replication and also messenger RNA in also the viral budding And as he tried to propagate once within the host. So in the last couple of months we have seen the mhm mm hmm audience and physically these kids are there the genetic code of these various fairly versatile that we've seen a number of variants that are basically trying to eclipse one another. Now we know that the delta variant has become the predominant variant from the time it was first reported in India 2020 October and now it has become the most dominant variant closed the globe. And yes, a rather worrying that have been reported in there. It's a matter of time before you know which other barrier becomes much more the predominant one and possibly uh going to cause more havoc depending on whether it is more transmissible or the way it possibly will evade some of that control strategies the drugs and the vaccines that have been put for us the key interventions for the control of Covid 19. Currently, basically the vaccines and then they're supportive care for those who are severely ill. And basically the treatments that which are also currently not very clear, we can work together than we are physically anti virus and anti inflammatory agents which have basically supporting pair once you more or less to tame the hyper immune reaction that possibly might be the Reason behind severe disease in COVID-19. So this this line are just possibly looking at the major milestones that have happened in the period that we've had covid from December 2019, the current situation, what has happened and somebody that have been put in place uh one of the things that has happened is basically the fact that within the time period within a a couple of months, less than a year were able to get a get a functional and effective vaccine that has been deployed within the last one year. And we've seen but ramped up uh deployment of the vaccine across several countries and territories across the world to basically help to tame the pandemic. And this has been one of the most important things that have happened because that would not have been the case because with the fatalities must have been fairly large over the period of time. If you look at some of the places like East Africa where I come from, we look at the number of cases that have been reported and these have been fairly high, not as hard as we have been seeing from the West. And this possibly also reflects the extent of diagnostic capabilities within those countries and within the region as well because some of these, you only report what you're tested and if the diagnostic capability is not that great, then you might not report many cases. And I think so, most of these that you see the number of cases that have been reported and even the deaths are related to what can be tested. And you know that they're testing rates in most of the sub Saharan Africans were fairly law now over time, you realize there have been a shift from community straining and targeted testing much more to health facility based testing where the focus has been much more on the those who are severely ill or those who are able to seek help from health facilities rather than yeah, multi moderate courses that will not possibly require hospitalization that might not report hospital. So in a place like kenya, this has been fairly the trend and the number of the waves we have seen this also just looks at the number of waves that you've seen me now more or less to go around For peak transmission periods that we've seen over the last period from the time that can you reported the first case, it was in March 2020 and this also has seen the interventions interpose that some of the things that have been possibly interventions put in place in kenya by the time we started doing much more though, of the deployment of the vaccine the last one year as well. So what can one get away from this? Like that in kenya? Physically, a majority of the cases have been a symptomatic and there's basically one of the trends that we see across ups are in africa that most of our cases are reminders in committee with a few that have been severe but despite that the health system has been fairly straight that the capacities of being able to manage the severe disease have been quite stretched, that sometimes you totally cannot get bed space in some of the health facilities and during this time, some of the things that were done in the president kenya of course, it also coincided with the time that we're trying to launch the universal health coverage, health care for all the population and we get a savage just to see how well the health system was ready for universal health care. And you can see that a number of counties which is basically shown in the, In the different color shades, just shows how well prepared those areas were for universal health care because that mirrored how will the countries we're basically going to be ready to possibly tackle some of the things around COVID-19. And you also looked at the COVID-19 preparedness which was basically whether they had quarantined units. They had the bad space that we could isolate the People suffering from COVID and at the beginning of the pandemic, which was basically around the maid of 20 Uh towards the end of 2020, a number of counties were not very much fully prepared for the money the the cases of COVID-19 and this was basically related to in terms of the health facilities that had the necessary equipment and the bed space that will take care of the, of the patients that are having severe disease. So some of the framework that had been put in Kenya basically was set up with the National Emergency Response Committee for COVID-19 which was chaired by the Cabinet Secretary, which is the head of the Minister of Health. And then that brought in a number of government departments so that they could be able to raise the resources, ensure, ensure that the security system of the country took a good look at what was happening around Covid. And then the technical bit of this was basically National Covid Task Force which was chaired by the principal Secretary of Health and and the director of the directorate, you know, of the mid uh medical services. And this was basically the technical arm which brought all the experts from the public sector and the private sector and academia uh to make sure that they had all the people that would Cover all the aspects that they're areas that needed to be covered around COVID-19 containment. And these were done within several subcommittees. Those who are in fun resource mobilization and those who are in the clinical care and those those who are the public response and emergency response. So all these committees met every week and sometimes several times a week depending on how syria the situation is and report back to the main task force and then was filtered out to the National Emergency Response Committee which reported directly to the head of State. So basically what some of the things that were being addressed were enhanced surveillance, basically a community health facilities and the points of entering the country basically the airports and also the border points so that we could take good control of those who are coming in. The number of cases that campaign coming in and those who are leaving the country and also increasing the, the testing capacity through the national uh laboratories and those are the kenya Medical Research Institute that was initially running most of the testing across the country and then the regional labs and the and and also introducing new tests, testing capacities that platforms that needed to be done. And initially there was mandatory quarantine and testing of everyone arriving from outside the country. And also with the time it was much more of the testing and not quarantine and possibly tracking down those who are coming to the country within the last 96 hours. And this was also full by aggressive contact training and then we have court case management what was being done quite with. And then we also had a lot of coming to quarantine isolation facilities in every country that has made sure that there is a facility that we have those who are, oh it was isolated them. And also at the same time making sure the health workers were trained on how to harden those cases of COVID and one of the things that we had for quite a long time till October 2021 was the National Nationwide Curfew. We restricted the movement, sometimes it's still the movements across certain counties and also movement during the night. And this helps possibly to tame the spread of the virus across the different countries. And then the other thing was the deployment of the vaccine, which was a new committee that was set up to just make sure that we deploy the vaccines rapidly and mobilize more vaccines for the country. Yeah. So some of the things that we used to do is basically had a daily update which was initially led by the cabinet Secretary for Health and then and the technical leads of the Minister of Health. And this was just to update the population to tell them the gravity of the problem, telling the number of cases that we're seeing the number of deaths also have been recovered from the disease. And and this was done daily so that everybody is in tandem and everybody across the country knew what was going on so that you can do a bit of public education. There's not much time and they're just looking at the distribution of the the deaths which had occurred by the time of to this presentation, which is basically Uh, 2021. And you can see that majority of the deaths were still in the older age group but we're still not missing. We're still having some people say the younger elegant that we are seeing a number of deaths. So this also informed some of the way the interventions were being deployed, like targeting the older age group with vaccination as we started off and also ensuring that those who are vulnerable were tested to make sure that if they had innocent and they can be tested so that appropriate care can be taken and also they need inpatient care. They should be given priority. So currently the garden government targeted possibly two Vaccinated around 10 million People by December 2021. And we hope that by that time we might get around 26 million 20 vaccinated by the end of 2022. And I think these are some of the things that currently most of the the activities are geared towards and trying to expand the vaccination framework to make sure this can be done. And currently there are multiple vaccines that have been deployed across the country and that's both from Astrazeneca Moderna Pfizer. Yeah, johnson and johnson and those cells in a farmer. And this has improved over time because initially access to the vaccines was a problem and we couldn't go flat out as a country inform the place or where to go and get the vaccine because the numbers are limited. But this has improved over time and we have quite a number of people that you hope will be able to get The juices that possibly they need by the end of 2022 and this basically the road map of what the government hopes to achieve in Kenya. So with time now that we have more vaccine, there's a bit of expansion of the priority brooks. Initially it was those who are with comorbidities and those who are older than 58 years old, that were the initial target. But now this has been expanded and we hope that we are going to get more people especially there, the other population over time and also looking at those who are the front line workers, especially those working in the health sector, in the security and also in the education sector. And there's basically to make sure that we can cover the most likely people that are going to possibly with the super spreaders or are going to be at risk of possibly coming down with the disease. And this, making sure that now has remote was january 2022. Then we are going to look at a person's greater than 18 years old and possibly to make sure that we get this population covered and that's basically under group. But you can see that this team leaves there the the younger age group, which is quite a big population in the country that knowing that we have a very young population in kenya. So these are some of the vaccines that currently we possibly have in the country and what is being possibly received. And we know this gets updated on a daily basis depending on when new vaccine, those arriving country and this is just the way they have been coming in from august when we received the first but of the vaccine in the country in the country which is basically the Astrazeneca vaccine. And now we're more or less how the whole area of the other vaccines that have come into the country. And this is the main thing that we possibly should be able to reach the population that we want to reach with this vaccine coverage. So if you look at the people who have been vaccinated over time and you can see that the older, the all the age groups, quite a good portion had been captured. But we also never see the younger age group about the Bible 18 two being also vaccinated. And this is something that the government is really trying to ensure that more people get the information and possibly attend to the vaccination center so that they can be vaccinated. There have been a bit of literally and possibly hesitancy and a number of people coming in and there's also, it's affected by when the waves go down and then people feel like oh there might be supposedly that things are getting better and we might want the vaccine And also they have been quite a lot of false information which is flowing around through the social media set. Uh again it's the vaccine and that is how the information that the government is trying to deal with in form and positive to make sure that people get the right information so that they can go for the vaccination. This is just also to look at them now, we have currently have Kenya has 47 counties and we also send this out to make sure that the counties can see how they are performing in terms of vaccine coverage. And some of the counties that are in more difficult to reach areas, the ones that possibly having lower vaccine coverage, but a number of them are doing fairly well and these are the areas that are easy to reach and also the area that are having low recovery that also the areas where we have a number of the pastoralist communities and these are areas that are saying arab and the populations are far apart and number of modalities are now being used to possibly make sure that most of the people in these areas are reached by those, the health workers to make sure that they get vaccinated and I think this helping strategizing and seeing where the attention needs to be paid so that we can cover as much of the adult admission as possible. So there are several things that have been put in place to make sure that We reached the numbers that are currently targeted by 20 by December 2022. This is basically to increase the vaccination point which from The initial 800 And 3000 by December and by June 2022 we hope to have achieved more or less, like Almost 8000 vaccination points so that financial that most people are covered. And also they acquired outreach programs for mass vaccination center, starting all the areas where the population's provide and any time that have other activities going on, there must have vaccine station so that people can be vaccinated easily. Uh we access the vaccine and also expanding the collagen to ensure that we can take care of all the vaccines, even though those who are requiring minus 70 or minus 80 like the Pfizer vaccine. And this has been done within the short time possible to ensure that that and then ultimately there's a real drug possibly start local manufacturing through the fill and finish as an initial component and then ultimately possibly have vaccine manufacturing facility in country. And I think this just the realization of lack of access to vaccines during the initial stages. So some of the things that have been with Scully is to address the issue of access and these are antiquity through the covax uh system or that basically has been one of the things that have been used. So that kenya can access the vaccine and we have used that and also direct procurement from the manufacturers to make sure that we can access much of the vaccine that possibly the country needs. And we hope that that is going to possibly improve over time and we should be able to get now vaccines for the the country. And as we move on to possibly talking about manufacturing uh well current patent holders to make sure that if we start manufacturing in kenya, they should be havoc said the A. P. S. And also see that they might be put into with us and also look at the storage and administration and distribution network that is being put in and also rapping in the private sector to make sure that we have the body in the shared and everybody plays their role to ensure that there's enough vaccine and possibly read the population that is needed. Um, you know, there are currently, there's quite a bit of sharing on donations of vaccines that are coming in into the country from the different partners and that has been quite useful. So with that as a kenya is a country has been looking at through a number of collaborations in the country and then looking at technological transfer with the different partners and improving the regulatory framework and the quality control mechanism and looking at all this and the building a business case and also getting the human resource and the personnel that are needed to possibly get into the distribution and also asking gear afterwards manufacturing Ultimately this also just to possibly show you how a number of countries in terms of the total vaccination that have been given across a number of countries in africa. We're still doing fairly not well because we steven Morocco which is possibly doing where there's still 31% of the population, which means they're still way way behind possibly getting closer to the hard immunity that because that could be protecting the entire population. So we have gone a long way but there's still a long, long way that needs to be covered if the population is to be protected by ensuring that we can achieve hard immunity. Uh He's just looking at south there countries and comparing where the African countries are and you can see that we are fairly still at the bottom of the scale but I think there's just possibly help people understand that we need to get more people vaccinated and also keep the population aware or where we need to go. So this just to say that some of these things are more or less looking at possibly our country's getting isolated because we now possibly having low vaccine coverage and the issues that are going to happen globally in terms of traveling. But some countries we isolated that people can't visit them or the members of those countries cannot travel to other places. And I think these are some of the things that we are going to come up as time goes by depending on how these pandemic behaves. And this will definitely bring in new travel regulations that possibly might get some people getting isolated. One of the things is that as we're all aware especially in the sub Saharan africa where we have a very young population, this need to get vaccine in today adolescents and also the Children. Because if we don't get this done, then possibly a good part of the population is still remaining vulnerable and they can become basically they spread us and the they are going to define the number of waves are going to get. And the only way to do this is to make sure that we can get a number of these vaccines evaluated in the pediatric population so that we can start vaccinating Children and this because there's and I know this has been slow because of the low fertility that have been seen in this age book. But I think we need to be not look at that but look at possibly them as possible group of population that are going to drive the waves that we're going to see and also sustain the pandemic. So there's need to start moving into this population and they need to optimize the diagnostic tools for this population as well. Despite they are, the focus has been marked with the other population because I think they're fairly different. And after we will evaluate more the vaccines then we can know which of the vaccines might be much more attuned to the pediatric population so that we can also monitor really and the term possible effects of the long term effects of covid on Children because that is something that you do not look at very well. And I think the scientific community owns the Children that we need to know. Even if the Children don't come down with severe disease, What might be the long term consequences of being exposed to COVID-19? And these are some of the things that we might not answer now, but we need to make sure that we can protect the Children and ensure that possibly some long term effects might be lingering after being exposed to Covid 19. We should possibly about this by ensuring that they get what mm get vaccinated earlier. So some of the issues that we possibly can see that are going to emerge from the sub Saharan region is basically access the vaccine and therapeutics and diagnostics which has been a problem. And I think these are some of the lessons that have been learned and we need to see how to tame this for the future. Uh this basically should be looking at working with the manufacturers and possibly see how best to position the region and the country is to make sure that they can get access to all the Interventions that come up that are available for COVID-19. And this has been creating the right temple for local vaccine, bonfire and drug development in the region which has been, that's something that nobody has been paying attention to. But I think this has also helped bring this to discussion much more than we thought we have seen before and we hope we don't lose that momentum and there are several before that are going on to start to make sure that we repurpose a number of grounds. Even in the sub Saharan region and also developed the african pharmaceutical industry is sure that it can be revamped so that we can produce all these vaccines locally and there's also, they need to look at to devote some resources internally to ensure that we can get into the product development more aggressively than has been left before in the region. And this is great difficulty going to look at building the capacity and the infrastructure as a way of response to the pandemic that are going to happen because most of our health systems are basically caught unawares when the pandemic hit because if you look at the ICU bad space that was available in most of the countries but negligible and they seem to even supply of oxygen and also being ready to ship in things and out was not as easy as should have been. And I think that has affected the way people reacted to this pandemic as well. So what are some of the things that have come as a result of the COVID-19 what you're known. It does increase the demand of the health system that was already fragile And there is more or less almost broke out the health systems with their needs and there's now been the need that we need to have started production of some of the communities like in kenya now you can produce a number of them. Pp is the mask that sanitizers and the strangers which initially this we're not being given much of attention but I think now the infrastructure has been put in place and some of this coming there and also, yeah, one of the things that came out because of the pandemic for the, the discussion and the academia and the policy makers coming to the table together to, to provide answers to what was happening. And I think we need to maintain this as we move on to the future for the health sector and now there's a big club for the vaccine manufacturing and a bit of awareness on the need of revamping the clinical trials infrastructure in the region and I think these are some of the things that we might gain from the pandemic and whisk early one thing that has come out but globally and within the region is the role of public sector and product development for public good. Because you're there various government didn't come on God as early as possible, possibly would not have more, very fast in terms of the intervention development like the vaccines that we have seen during this time. So what are some of the key challenges that have been brought back to the fall, They have been there, but I think they have become more glaring and this basically affecting vaccination is the limited resources that we realized that we could not jump start this even the health system that were well developed still possibly reeling in a lot of difficulties to ensure that they can vaccinate the other population in large numbers and then still the complete competing health priorities is a problem that we need to deal with and possibly see how we compare it as pandemics. They come without definitely interfering with the other uh programs within the health sector that needed not to be interfered with so that we we stopped losing the gains that have been made. Some of the things that have come in the form of payment of the health systems which I think is something that has been pampering vaccinations. And I think some of that now became more clearer and also the inadequate monitoring and supervision that we need to really bring to the form especially when it comes vaccination because and this possibly has much of the of the vaccination program because vaccination has been focusing on the vulnerable group that don't have a voice and that is the pediatric population. But now when you realize the other population is getting much more involved because of this pandemic than some of these things come to the fore. And I think this might be the time to possibly fix them. And the political instability is also have not been very good in some of the countries in africa area experiencing this and this is really going to hamper the way those countries can respond to the pandemic and possibly ensure that they seem to get into the country and possibly get to the people that needed. And also with the stability possibly leader vaccination doesn't become a priority. That there are more things people starving and these I think that's something that we need to make sure that we need to have a priority given strengthening the routine locks nation globally so that when the pandemic scam we can be much more ready to face it. Like the global vaccine action plan had put in some students since strategic objective from 2013 and we realized some of these became much more clearer that still all countries need to commit to vaccination as a priority as most of them were grappling and they didn't spare even the west or the low and middle income countries. And we still need to really get to understand the value of vaccination and the demand for immunization as a right and a responsibility. And this has been seen by the number of the anti vaccine groups that are still spreading quite a lot of false wood to make sure that people don't get vaccinated. And we need to make sure that the benefit of managing equitably extended to all the people. And we need to make sure that we have strong immunization system which are which are integral part of any functional health system. And there's no better time this became blaring us. Unlike this time when you have the pandemic And should we make sure that that possibly the immunization programs that were sustaining boxes to funding and colleges, supply of communities and also the new technologies because we can see new technologies came in by the health systems where some of them are not ready to possibly adopt this. And this caused a delay on when some of the countries can start vaccinating and we need to make sure that this but call wasn't possibly to ensure that the new innovations that are being developed uh for immunization are put in place. And I think this is something that also has been featuring quite a lot of the global vaccine research forum That gets held held over two years and I think COVID-19 more or less brought this to the phone and I think we just need to make sure that the global research and development boxing by the benefits of immunization by bringing more platforms into this place. Thank you. Well doctor um Qc and dr o go to, we really appreciate your insight and all that you have done in preparing for these presentations. I think it gives us a greater perspective of what is happening in the african content continent. We have quite a few questions. The first one I'm going to ask you is doctor or go to and I think it's um could compare us to um Ghana but in kenya, have you measured the efficacy of the vaccines in the Kenyan population or have you done anything? Yeah. Mhm. Thank you very much. And uh one of the, this has not been done fairly well. But one of the things that we are currently doing, we are doing uh going to start a national sample survey and one of the things we are going is to look at the antibody status that has been generated from people who have been vaccinated and those who have been exposed to the disease. And this is one of the things that we are currently looking at and also because we have not had a provide much of the population covered. So it might not be to see the impact on Inpatient battle. So looking at the people who are possibly being admitted with severe disease, whether they have been exposed to the vaccine or not. And that's the initial results are showing that possibly almost 80-85% of people who are coming down with severe disease and those who have not been vaccinated as opposed to those who have received as a single those are completed their two doses. And from the serial survey we possibly know because they're going to be a bit of qualitative and quantitative us to start seeing what sort of reaction that the population had so that we can see whether there's a good just so that we might see the same pattern. We have seen some of the initiative uh like what Uh, cause he presented from Ghana. But I think you won't see when we do. We are looking at the entire population across the country. There were about 5000 people. And possibly this will help us understand this. We might have this data really by first quarter 2022. That is also our experience here in the States is that the primarily those who are non vaccinated are the ones who develop severe illness and require intensive care type of management. Um, and I'm gathering that you're saying something very similar to that. Okay, dr kusi there is a question for you and it's from Terrence who states I work in the F. Q. H. C. That serves mostly immigrants and refugees. A good portion of them are from Ghana as well as Nigeria and they tend to be culturally conservative and have brought into the brought into misinformation. They say there is no covid in their home countries and that anyone can get a vaccine and that most in their home country choose not to get the vaccine. Can you address either both of you, Can you address briefly the situation in Nigeria and other suggestions on dealing with African immigrants and refugees who may be coming to our country. Okay, thank you very much. I think it's a mixed bag really. Um, you have very deep seated um, perceptions of what this is all about. You speak to people on the streets and uh, telling you some are telling you that uh, there's nothing out there. You are free to do whatever you want. Uh, there are those who tell you wearing of masks is too difficult. So although they know their diseases out there, they don't really care. Um, initially it was um, something that people responded to because of the magnitude of the deaths that were reported from from elsewhere. But um, I think six months into and seeing the numbers that were dying, probably more people die of uh of road accidents uh, than than has been recorded to die from from covid. So it almost became uh something that is, well, not not something we should worry so much about. Um, so that that really has been the situation. So that that is, that is not far fetched. Um, the other side of this is also that um, you have people who um, like uh photography said out there. You know, spilling a lot of uh mis truths or let's just putting out information that is not accurate regarding what what the vaccines even are for. Uh, I've had interactions with people who will tell you that. It's a way that the West wants to track them. And then I would have to tell you that probably people can track you through your mobile phone even better than a vaccine. I don't see how vaccine which the biological preparation will be used for tracking. So there's all of this information out there. Uh, and we we have said, I think I've had a lot of people say that we have to epidemics or two pandemics ongoing. There's one of covid and one of misinformation. So really that is the case. Yeah. So your answer also would include then that we need to re educate the people that are coming in that are immigrants and stressed to them. The importance also of vaccination here in the United States. Thank you for that information. Thank you for that information. Another question is how active is the gagne M. O. H. G. H. S. Involved in getting vaccine to the individuals considered to be essential workers such as those in shopping malls, the elderly and in banks. Okay, so the M. O. H. Does the Ministry of Health and they're gonna health service. Um, so this I mean, there was a strategy for vaccination rollout of vaccine rollout when when we started getting vaccines in March. And the first group that would be vaccinated where the age at the top government hierarchy, uh and a few other such groups. And then the second group where those who are actually running the economy and I must say that health workers were put in that first group as the front liners who are interacting with persons who are likely to have covid. So that has been the strategy um to vaccinate setting groups of people first and health care workers were among that first group of people who were supposed to be vaccinated. Um unfortunately we've even had health care personnel who have refused to take vaccines, although they were supposed to send them out. We've had instances where people in health care have rather not opted to take these vaccines. So it is a real problem and that we have to deal with. Yeah. Okay. Uh huh. There is a question from uh Sarah spent nearly um for both of you uh since you know, um A lot of resources have been allocated and used for the COVID-19 how how how are you are, you know, the government is allocating to take care of other endemic disease. You know, those are like you know, being there like you know, tv HIV malaria and other infectious. This is a first, you don't have to go to thank you very much. And uh that was something that initially when there was the chronic at the beginning of the the pandemic, when literally everything was shut down. Then people realized if you shut down there, the facilities and that means those who require their drugs, the people who are on long term treatment with chronic illnesses and even those who get acutely ill, especially the rennes even started and we have those who get malaria. Then there was a big dr that we need to open up, especially the health facilities to take care of this group. No, this affected the health seeking behavior because initial it because it it was, yeah, the, the, what I think that had a bit of re education and ensure that there was a bit of revamping the system to make sure that the vulnerable groups were taken care of innovative ways came up where they, some of the people didn't need to come to hospital and then get the community health workers to possibly deliver what they needed to have and then ensure that they are visited and possibly taken care of. And also one of the things that came up, the global fund came up with a rapid response where they, they brought in some resources to support the global fund funded programs like Tv malaria and HIV to ensure that the pandemic does not impact the gains that have been made in the control of HIV TB and malaria. And this also brought in some of the things so that they supported some of the procurement for communities for management and containment of covid so that they don't impact these three diseases. So, and the government also started looking out seeing how much are these disease problems affected to see so that the mitigation measures were put in place to take care of themselves. It is a realization that was made and yes, they have been in kenya, we thought that was going to be a big problem, but we realized that when he did the malaria indicator survey, our malaria cases case law actually did not increase in that period of time. So the closure was for a shorter period that it didn't depart the bigger picture. Mhm. Okay. So I would say the picture is very similar in Ghana. Um I think aside what the government contributes to control of these diseases, a lot of the funding for control of these diseases also comes through uh donor partners uh and these are dedicated funds for managing these conditions. So uh we've not seen very huge impact although when it comes to things like for example, hospital attendance for maybe people with special conditions that has been impacted because uh at some point uh probably been going to the hospital was even more dangerous. That's staying at all. So in terms of of that, that there's been some kind of impact because there are disease groups that um you would have people uh either have been afraid of going to the hospital for care and therefore we prefer to stay at home. And if there is no option for care at home then then it means they go without without their treatment for for a period of time. But in terms of funding, I think it's it's been very limited because most of the funding for most of these other disease areas is specific. And it's channeled into those areas. Can you both comment on the number of deaths that are potentially not being counted or missed? Doctor. You got to do you want to go first. Mhm. Uh No we currently are given that this was because not that several people that die away from hospital. And there's there's been a big tried to look at the excess deaths that might have happened during the pandemic and this has not been fully rivaled. And I think currently there's a lot of data collection trying to get through the registries. Especially there the death registries and also the notification that come from the administration side of things that of those who died at home really see whether they are accessed that. I think there's some that we've been traveling with and there's a big drought really see so that we can quantify those who are dying outside the health facilities to make sure that because one of the things that happened with that most of those people who also died even in hospitals because of the scare the post models are not being done. So it was very difficult possibilities. And what might be the actual cause of death Even if you assume discovery and then that and is that the same for you dr kusi. Uh huh. More let's so uh that's especially the okay in the hinterlands probably you don't you know having any autopsy ato um you have situations where um persons uh die and you're not sure what happened but most of these will happen outside of the big cities and I think that the dead count in sub Saharan africa probably will be more accurate measure of the impact of covid than the case count like I mentioned in my presentation because you have a lot more people who are asymptomatic some of them uh do not even feel anything and you pick some of these up especially in travelers who just need a report to be able to travel. So they're healthy. They just came to test because you want to travel and they are positive and they didn't know. So the symptomatic cases uh woefully underestimated. I mean it's it's it's more much more than than has been reported. And uh some of the data represented show that clearly in terms of the zero prevalence uh in in in very crowded places where you have so many people up to 30% showing uh Covid specific antibodies to so death. Yes you will definitely miss some. But I think relatively that that those numbers are more accurate compared to to to the cases. And dr kusi there are a couple of underlying questions among several people as to could you give a reason as to why people do not respond to the vaccines. Um So let me say that in the data I presented that is a very limited number of samples analyzed so far. We are still collecting and we are also looking at uh analyzing this new samples for t cell responses. So we do have uh not just samples to do serology but we actually also story in um cells to be able to do t cell analysis later. Um for a viral infection. I think T cells would have quite an infant role to play in terms of immunity. Um one thing that you realize across board is that for most vaccines uh you test them in a population that has very low infectious disease background and they work quite well. Um but you bring them to an area where there is a lot of infectious disease and yeah you have very limited responses to it. So that that is a very standard phenomenon that is known uh I work in malaria typically and that is a very typical thing for for malaria. Okay. Um I think that's also answers the question as to what is the lack of the antibody response for the vaccination. I'm hearing that it's the background endemic infectious diseases that may also exist. What measures are being taken to improve the education of the local populations to dispel the false information that's out there. Let's go to thank you very much. And this is one thing that we have quite a rolled out but a bit of uh health education and campaigns and really trying to address the specific targeted groups of people and possibly some of the falsehoods that are being spread across. You think the social media, there are a number of things that we do both on the both on the tv radio and also getting out people to possibly have one on one and health education and health facilities just to make sure people have the right information about the vaccines, about the different interventions and I think there's some of the things that are being uh driven to the population and there's a bit more realization that the health communication is a major component of public health than we thought before. I think it's got a bit of like in kenya, the Minister of health is revolving the communication department and I think that has really has a lot been brought around because of the things that have happened around the vaccines dr kusI in gotta. Yeah, so there is um, uh education that is going on on various um media unfortunately it is small less linked with whenever we have a rise in cases immediately the cases go down, it almost small less goes silent on, on, on on our media space. But from time to time you have um education on various types of media uh, that, that like I said that has not been consistent because immediately cases go down and you think, oh everything is back to normal then those ones also sort of subside. But there is a drive to have the, the information services department probably um, make more forceful, you know, announcements of of um what people need to do when there are other, especially because like I said, I think social distancing has been one challenge. We have uh it works well where there is enforcement um online covid mask wearing because for mask wearing it's very difficult even when you need to enforce the rules, there are people who tell you they just can't breathe and there's very little you can do about it, so it's it's been easier and sharing social distancing especially vehicles or if you're on the street. Uh There are instances where people have just you know master for one reason or the other and uh unfortunately those ones there's nothing you can do about as well, there's been a few instances of people who have been taken to court for gathering when they were not supposed to. Uh that's more or less has uh you know gotten some people to be more aware of uh some of the things they need to do and not to do under another circumstances. Well dr copia and I thank both of you for superb presentations and participating in this webinar, I want to remind all the um people who have been listening that we have a part two of Global health that will involve India. Um and that will be on December seven. So we thank everybody for participating as asking their questions and to both of you for excellent presentations. Thank you, thank you very much very much