A Year-Long Summer: Working in the Caribbean on Respiratory Virus Surveillance

Strengthening surveillance systems for respiratory viruses is a global challenge. The Caribbean has stepped up, taking advantage of the COVID-19 pandemic.

Over the past year I had the opportunity to work with the Pan American Health Organization (PAHO) and wonderful colleagues in the English-speaking Caribbean and Haiti. The purpose was to help this region learn from the COVID-19 pandemic and strengthen its health systems. During the year, I coordinated several technical workshops at the subregional level and visited six countries to promote the internal dynamics of strengthening integrated respiratory virus surveillance systems to inform public health and health care decisions. I also witnessed the debates on new epidemiological and virological surveillance formats, the emergence of avian influenza in the Region of the Americas, and the progress made in understanding the air as a public space to be protected for everyone, also in terms of respiratory viruses and pathogens. But let's take it one step at a time: what sense did my work have?

Barbados. Photo: Scaturchio / Flickr.

In the Caribbean, the hot climate favours comfortable, ventilated and uncrowded outdoor living, making spaces less conducive to the transmission of respiratory pathogens. As a result, respiratory viruses were not considered a major problem until the COVID-19 pandemic

Integration of SARS-CoV-2 into surveillance

During the COVID-19 pandemic, countries acquired new equipment, laboratory skills, epidemiological expertise and analytical decision-making capacity. Over the past year, they have had to decide whether to stop epidemiological surveillance and control activities altogether or find ways to structure them so that they could be used to strengthen their health systems. This was one of the reasons why the World Health Organization (WHO) maintained the emergency declaration: the transition was neither obvious nor easy. In fact, much effort was put into underlining the importance of establishing structures that would be used on a regular basis, bringing value and health to the countries that maintained them and to the global community as a whole. These structures would contribute to strengthening epidemiological surveillance systems, and it was agreed that SARS-CoV-2 should be integrated into syndromic virologic surveillance for influenza and other respiratory viruses.

Photo taken by the Ministry of Health of Saint Vincent i les Grenadines.

COVID-19 puts respiratory virus control on the agenda

In the Caribbean, public health generally has a broad community focus. The urgency of outbreaks of arboviruses such as dengue and Zika, as well as natural disasters, occupy much of the effort and time of public health workers, which, as elsewhere, is always insufficient. On the other hand, the hot climate favours comfortable, ventilated and uncrowded outdoor living, making spaces less conducive to the transmission of respiratory pathogens. As a result, until the COVID-19 pandemic, respiratory viruses were not considered a problem with a high burden of disease. In reality, however, the health threat was difficult to estimate, partly because of the way surveillance is organised everywhere.

The Global Influenza Surveillance and Response Network (1952), an example of global cooperation

The epidemiological curves from the 1918 influenza pandemic included people who appeared to have influenza because they had typical disease symptoms such as cough and fever. This is known as syndromic epidemiological surveillance. At the time, it could not be confirmed that it was influenza because the virus was not yet known. It was not until 1933 that the virus was isolated. The world's first licensed vaccine was introduced in the United States in 1945. It took longer than SARS-CoV-2, but it was still record time. Two years later, however, the scientific community realised that influenza viruses were changing and that it was necessary to know what types of viruses were circulating in order to adapt the vaccines every season. This led to the creation of the Global Influenza Surveillance and Response Network (GISRS). This network started with a few selected countries and laid the foundation for global virologic surveillance, which turned 70 in 2022. It is a beautiful and enduring example of what countries can accomplish when working together on a global scale.

Surveillance systems were inadequate at the time of COVID's arrival

Let us skip a few episodes to get to 2009, with the H1N1pdm09 pandemic. Many people realised that virologic information was not enough, and little by little, countries adopted increasingly standardised epidemiological data collection systems, which provided more information on who was getting sick (Men or women? What age? Of those who had severe disease, did they have other diseases or a particular profile? Who ended up in the hospital?). This system first focused on influenza, but other viruses such as RSV, rhinovirus and classical coronaviruses, among others, have been included in recent years. However, virologic data were on one site (see the example of FluNet in the Americas) and epidemiological data on another (see the example of FluID in the Americas). Moreover, at the time of the COVID-19 pandemic, these surveillance systems were not implemented everywhere.

Many of the existing systems for surveillance of respiratory viruses at national level, even in Europe, were not ready to collect data in a more "modern" (i.e. individualised, linked and computerised) way when the COVID-19 pandemic hit

This meant that many of the existing systems for surveying respiratory viruses at the national level, even in Europe, were not ready to collect data in a more "modern" (i.e. individualised, linked and computerised) way when the COVID-19 pandemic hit. Parallel systems had to be set up and are still in place in many countries. As early as 2022, it was felt that SARS-CoV-2 should be integrated into routine surveillance for respiratory viruses so that they could be monitored together. The fact is that there are many similarities between the influenza virus and SARS-CoV-2 in terms of the type of surveillance, the type of impact and the type of measures to reduce transmission. In Catalonia, I invite you to visit the SIVIC website, where you will find information on the status of respiratory viruses each week. If the curve starts to rise, I recommend to wear a mask in closed and crowded places to avoid getting sick and infecting other people. For information at a global level, both by region and by country, you can consult the FluNET summary.

In Catalonia, I invite you to visit the SIVIC website each week, where you will find information on the status of respiratory viruses each week. If the curve starts to rise, I recommend wearing a mask in closed and crowded places

Reviewing a year working in the Caribbean

Having data for decision-making requires coordinated clinical teams in the field, with laboratories or networks of laboratories, and data analysis and dissemination capacity. Also, the work’s importance and impact on people’s daily lives needs to show in order to keep the involved teams motivated. My work this year has mainly consisted of facilitating spaces for discussion on the roadmap for each country and deepening the lessons learned from the pandemic. By bringing together the different actors in the health system through training (for example, this list), in-depth work dynamics and discussions, we selected guidelines and sought technical support for the priorities identified by the countries. If you want to take a look, you can see some new developments in the global notification of FluNet and FluID in the global and public repository for countries such as Guyana, St Vincent and the Grenadines, Grenada and Barbados, among others.

The Caribbean, forever in our hearts

My family and I are now readjusting after spending a year-long summer in the Caribbean. Despite the heat in Catalonia this past month, we wore sweaters because we feel cold when it’s below 26 degrees Celsius. Despite the fact that we came back in a ‘post-pandemic, no lock-down’ mode, we are surprised to see that in closed and crowded spaces we are among the few who still wear a mask. We now see the houses of those who returned rich from America (the “indianos”) with greater suspicion because we have learned what it meant and still means to have enslaved people for so many years to enrich our country. And we know, and we see it even more in the streets, that “the world is white no longer”, as James Baldwin said. We know that we will always carry the Caribbean in our hearts.