In January 2020, news outlets around the world reported a disease outbreak in China caused by a new pathogen. For a while, the now all-too familiar disease called COVID-19 appeared to be mostly contained in China–at the start of the final week of January, there were 2,700 confirmed cases in the country and only around 40 cases elsewhere. The rest of the world ignored the headlines and failed to see the danger.
Tom Inglesby is a doctor and director of Johns Hopkins Center for Health Security at Bloomberg School of Public Health, Baltimore, Maryland. However, he recognized some alarming signs from China. The rising number of sickly health-care workers, young and healthy, was leading to the construction of large temporary hospitals. Officials ordered the closing down of a larger city than any in the United States. Inglesby understood that any disease spreading to such an extent in the global community was everyone’s business. He started to push for an acceleration of pandemic preparedness, including COVID-19 testing, in the United States.
At the same time, Jennifer Nuzzo, an infectious-disease epidemiologist, was hearing similar alarms. In the months that followed, she became more disillusioned at the rising rates of morbidity in the world due to a lack of preparedness for possible disease outbreaks. In April, she was appointed to the position of director of the Pandemic Center at Brown University School of Public Health, Providence, Rhode Island. She wanted to work to ensure that the world is never again left unprotected. She believes governments and other international organizations must act now to ensure that when the next pandemic occurs, health-care professionals are able to prevent it from spreading earlier and limit its effects.
Curbing infectious diseases relies on several medical pillars. It is crucial to be able to detect outbreaks in the first line and share that information with other institutions. It is crucial that health-care providers are prepared to respond to pandemics when they do occur. This includes having well-planned plans of action, secure access to vaccines, and clear access to essential medical supplies. Not just for certain countries: The world’s ability find and stop the next pandemic will depend on its weakest link.
Pathogens that can cause disease outbreaks include bacteria, viruses, fungi, and parasites. To identify a pandemic pathogen, you must first test the people who are ill to determine which pathogen is causing their symptoms.
Cecilia Sorensen is an emergency medicine physician and director at the Global Consortium on Climate and Health Education at Columbia University. She describes hospital emergency rooms as “sentinel system” for infectious diseases because they are often the first place people go to when they experience unusual symptoms. She says, “That decision point in emergency departments sets the stage for everything that happens next.”
It is often the emergency medicine physicians that decide what information to collect from a person via laboratory testing, at minimum initially. Sorensen stresses that emergency medicine professionals must be careful about diagnosing patients in a world that is aware of the potential pandemic. They should also be alert for symptoms that are not typical for the area. She says that emergency providers must have a high index of suspicion. It is possible to prompt diagnosis by ensuring that frontline health-care professionals are aware of what might be spreading in other regions, as well as what is endemic within their own region. Sorensen believes that the supply of this information to front-line health-care professionals is inconsistent.
The ability of medical personnel in diagnosing an infection correctly depends on the capacity of hospitals to perform disease testing. Inglesby pushed for testing in the early days of the COVID-19 pandemic, so that medical teams could find out for certain whether they were dealing with the new pathogen that was spreading around the world. Although the test was developed by the US Centers for Disease Control and Prevention (CDC), Inglesby believes that it didn’t make it into clinical labs quickly enough.
At present, the diagnoses in any hospital reflect the most common illnesses they encounter. Health-care workers are often not able to access tests that would confirm unusual illnesses in their area, as might be the case during a pandemic. Sorensen believes hospitals should develop relationships with laboratories that can test in other areas of the country for diseases such as those that are not within their control. This will allow them to be able to call on these labs quickly when they are needed. For example, in the United States, a hospital in Colorado might not test for tick-borne Lyme Disease. Instead, they could establish a relationship with a laboratory located in the northeast.
Senjuti Sha, a molecular biologist and director of the Child Health Research Foundation, Dhaka, said that there are not many diagnostics available in hospitals in low and middle-income countries. This means that doctors often encounter illnesses they can’t diagnose. This not only reduces the chance that people will receive the right treatment, but also masks outbreaks. It is still unclear if illnesses in a particular area are caused either by multiple pathogens or one.
Genomic test can be a useful tool in these cases. Saha’s team used a genomic sequencing facility in order to analyse meningitis cases in the local community. This was done to identify unknown pathogens. Researchers were surprised to discover that some cases of meningitis in children were caused by an unnoticed mosquito-borne virus. The group was able to develop a test to detect the pathogen that could be used by the nearby hospital’s diagnostic laboratory in the future to detect the outbreaks of the virus more quickly.
Others want to replicate Saha’s setup. A report from the World Health Organization (WHO) in March laid out how to use genomic data as part of broader surveillance of pathogens with epidemic and pandemic potential1. The Africa Pathogen Genomics Initiative is backed by several governmental organizations and philanthropic organisations. It supports efforts to increase the use genomic sequencing for disease surveillance on the continent.
Sharing and comparing
Obtaining accurate information on the occurrence of disease in a single hospital or area is the first step to preventing future pandemics. Next, ensure that data from different health-care providers and testing laboratories is shared and collated to enable health officials and government officials to see the whole picture.
Although the International Health Regulations, signed by 196 countries, include a commitment to share information about extraordinary disease outbreaks with the rest of the world, individual countries sometimes struggle to coordinate even their own internal data. Early in the COVID-19 pandemic in the United States, for example, health officials in many states collected information from hospitals but were not required to send the disease data to the federal government. This hindered efforts to build a picture of all cases in the country. Congress later passed laws requiring hospitals and states to share data with federal officials, but this is COVID-19-specific and not expected to be permanent. Inglesby believes that a better federal authority should be given to obtain information about infectious-disease outbreaks in the United States. He says, “We must be prepared for the next pandemic” and that we don’t have to wait for new legislation.
Tieble Traore, technical officer for emergency preparedness at the WHO’s regional office emergency hub in Dakar, says that after the Ebola outbreak in West Africa between 2014 and 2016, the WHO has led efforts to strengthen information-sharing practices in Africa. Under a strategy adopted in 2016, health officials now encourage robust community participation to improve data sharing about threats to public health. Health-care workers and volunteers, which include local religious and political leaders as well as birth attendants, can identify potential health problems in their community and send the information to their nearest health facility by text message. If a serious public-health problem is suspected, the health facility is required to report data on disease cases to the district, regional or national level within 24 hours for further scrutiny.
Data integration and sharing is being improved worldwide. The Rockefeller Foundation is a medical research foundation based in New York City. They are collaborating with Wellcome in the United Kingdom to create an independent early-warning system that can detect emerging pathogens or new variants of existing pathogens. The technology used to pull together disparate data sets is the basis of the system. In partnership with the WHO, the UK government launched the Global Pandemic Radar surveillance network to monitor disease outbreaks wherever they occur. This initiative expands the surveillance infrastructure and data sharing agreements for other infectious diseases such as HIV and tuberculosis.
A state of readiness
In the best case scenario, a local outbreak of disease is quickly detected and managed. However, if a group of diseases spreads around the globe, it should be quickly detected and controlled.
Nuzzo believes that practicing drills for infectious diseases crises is crucial for pandemic prevention. Exercises like earthquake or fire drills can help to create a culture of preparedness and educate medical professionals that there will be outbreaks and that a total shutdown is not an option. Nuzzo states that hospitals and government health agencies need to not only prepare for pandemics but also “regularly practice those plans so they’re not dusty or unknown when an outbreak occurs”.
Taiwan, for example, conducts a vaccination drill every year in the form of a seasonal influenza mass vaccination campaign2. Contrary to other haphazard flu vaccination strategies in certain countries, which might lead to a shortage of vaccines, or slow distribution of vaccines over a season, this exercise simulates a rapid medical countermeasure in the event that there is a pandemic. In which vaccines or medicines need to be distributed rapidly and widely, it is not like the more chaotic approaches to vaccination. It not only teaches the public where to get vaccines in an emergency but also establishes relationships between different stakeholders involved in emergency medical preparedness. Traore states that staff from the WHO African region emphasize the importance of training or simulation exercises in order to maintain operational readiness.
A good response to a pandemic requires more than being well-trained. It also requires the ability to manage a spreading disease, which is a problem in places with limited resources. Desiree LaBeaud is a paediatric infectious disease specialist at Stanford University in California, who collaborates with researchers from Kenya. “Capacity comes down to access.” “Access to knowledge, access diagnostics, treatments and vaccines, as well as training individuals and social capital are all essential.” Without these capacities, local health professionals could quickly become overwhelmed by a disease outbreak, making the population vulnerable.
Researchers have called for further investigation of best practices for building capacity in the most challenging global settings, such as places with protracted conflicts or political instability3. However, global partnerships and relationships can help to build this capacity for many low- or middle-income countries if they are established long before a pandemic.
Vaccines are a crucial part of capacity-building. It is crucial that vaccines are developed and manufactured quickly in order to combat emerging pathogens. Efforts are under way to streamline vaccine development and production: for example, an international foundation called the Coalition for Epidemic Preparedness Innovations is spearheading a campaign for research that will allow vaccines to be developed for new pathogens within 100 days of identification. And researchers have proposed a 10- to 20-year investment in leveraging knowledge of ‘prototype’ viral pathogens from each known family or genus to develop vaccine candidates in case they are needed.
Inglesby states that once a safe and effective vaccine has been developed for a pathogen it is essential to have systems in place to allow production at scale around the globe. This would require collaboration with industry to ensure the right financing and partnerships for technology transfers. He says, “It shouldn’t be the case where one or two countries has the most access to vaccines because the vaccine was produced in those countries.” LaBeaud concurs, and points out that if COVID-19 vaccines had been distributed more equitably, we might not have had to deal with variants that subsequently arose.
There have been efforts to establish multi-disciplinary international health teams that can quickly respond to an outbreak anywhere in the world. The WHO-led Global Outbreak Alert and Response Network is made up of more than 150 organizations committed to tackling pandemics in their early stages4, although it relies heavily on volunteers. Bill Gates proposed a similar network that would employ a group fully-paid international pandemic responders. Saha supports building local, decentralized capacity in Bangladesh and other countries to reduce dependence on others who might disappear in times of crisis.
For her, capacity building means reducing “parachute science”, in which researchers from resource rich countries enter resource-limited areas and “get their shoes wet for an afternoon”. She says, “The samples are taken out of the country, the analysis is done elsewhere, and we lose ownership.”
Saha would rather local scientists learn the technologies and get excited about solving their problems. Saha states that passion is the key to a lot of what we do as scientists. “If you don’t have passion and haven’t done the sequencing yourself, it’s unlikely you’ll be able explain it to a policymaker .”
or advocate for change.
Nuzzo is optimistic that COVID-19 can create an awareness of, and commitment to, pandemic preparedness. She compares the situation with the horrific fires that erupted in American cities around the turn of 20th century, which prompted a shift in fire safety in the country. Fire departments are vital in preventing uncontrolled fires from destroying lives. Continued funding for pandemic preparedness could help with infectious-disease epidemics. The World Bank approved in June the creation of a global fund for pandemic preparedness, prevention, and response activities. This fund is intended to close any gaps in capacity.
Inglesby emphasizes that to keep an eye on infectious diseases, all health-care providers must take responsibility. This applies to international organizations, governments, states, regions, hospitals, and even local hospitals. He says that “sustained leadership commitment is and awareness is what makes everything possible.” And as the COVID-19 pandemic has made abundantly clear, the whole world must be prepared. LaBeaud says, “We are all together on this little planet, working together.” No pandemic response, no matter how well planned or funded, can be effective if it is only applied in one part of the globe.
World Health Organization. Global Genomic Surveillance Strategy for Pathogens with Pandemic and Epidemic Potential, 2022-2032 (WHO, 2022).
Meyer, D. et al. Am. J. Public Health 108, S188-S193 (2018).
Saleh, S., Mansour, R., Daou, T., Brome, D. & Naal, H. Confl. Health 16, 31 (2022).
Mackenzie, J. S. et al. Glob. Public Health 9, 1023-1039 (2014).