Very few public health officials would disagree about the need for pandemic preparedness. But sometimes the public health community is its own worst enemy in explaining the critical need for pandemic planning and preparedness and the price the world will pay for not preparing.
A report last week from a leading nongovernmental agency—which was lauded in the public health community, and rightly so, for the most part—is a classic example of misunderstanding on this critical issue.
Epidemics differ from pandemics
Last week PATH issued a report titled, Healthier World, Safer America: A US Government Roadmap for International Action to Prevent the Next Pandemic.1 PATH, a leading international nonprofit organization, is widely recognized for its work to save lives and improve health, especially among women and children. Its key to success has been its ability to accelerate innovation across five areas of critical medical and public health practice—vaccines, drugs, diagnostics, devices, and system and service innovations. Our own work at CIDRAP has benefited greatly from the tremendous public health expertise of PATH team members.
The PATH report provides a number of important issues for addressing emerging infectious disease threats, and I applaud this crucial effort. The report, however, generates some confusion about preparing and responding to pandemics versus preparing and responding to epidemics.
The report has everything to do with preventing major epidemics, or least reducing the impact of these events. But it doesn't truly address how best to prevent pandemics or how to improve pandemic preparedness.
Why does this matter? It seems we've lost an understanding of the difference between a pandemic and an epidemic and what is required to prepare and respond to each. And that greatly hinders the public health, medical, and business communities—as well as governments and philanthropic organizations—from clearly articulating and acting on meaningful preparedness activities.
The PATH report, if it commented only on epidemic preparedness, would be a home run. But by stating that the recommendations in the report will stem the risk of the next pandemic, the report ends up contributing to the ongoing mischaracterization about what pandemic preparedness truly means and what is needed to reduce any impact of a future pandemic.
Understanding the difference between a pandemic and epidemic is absolutely necessary for consequential preparedness and response planning and action to be accomplished. Let me illustrate the difference between the two and why it matters. First, a pandemic in public health terms is defined as:
- An epidemic occurring worldwide or over a wide area crossing international borders and usually affecting a large number of people. A Dictionary of Epidemiology. Oxford. 20142
- The worldwide spread of a new disease. WHO, 20103
Collateral damage, vanishing key drugs and products
A pandemic puts the entire world at risk of a markedly increased occurrence of severe morbidity and mortality.
The collateral damage from a pandemic is twofold. First, the panic and fear surrounding these illnesses and deaths can cause global governance to be severely challenged and people's behavior and activities to be unpredictable and counterproductive. It should never surprise us what we can do in the name of fear. And remember the entire world will be in the soup at the same time. The United States and other developed countries will not be sending public health first responders and medical supplies to developing countries in response to the pandemic. We will keep everything at home for our own needs.
Second, the simultaneous occurrence of the pandemic worldwide means that the supply chains for critical products like life-saving drugs and essential medical supplies will be quickly threatened. For example, with our current global just-in-time economy, most drugs and medical products that we need every day are made in China and India; there are no stockpiles of these items anywhere in the world. These drugs and products will quickly disappear or be in very short supply. Because of that, another wave of severe illnesses and deaths will occur among patients with other illnesses like cancer, heart disease, diabetes, and immunocompromised conditions and acute events like trauma.
Pandemic flu and pandemic superbugs
As Mark Olshaker and I detailed in our recent book, Deadliest Enemy: Our War Against Killer Germs,4 there are only two infectious disease situations that can be considered inevitable, serious pandemic threats: influenza and antimicrobial resistance.
An influenza pandemic will unfold quickly over a few months when the next new animal strain of influenza acquires the ability to be transmitted by humans to humans. We can only hope it won't be a repeat of the 1918 experience.
On the other hand, antimicrobial resistance is a pandemic already beginning to unfold worldwide but now occurring at a "glacial tsunami speed." Unfortunately, that speed increases each year. The 2016 Review on Antimicrobial Resistance report4 concluded that, by 2050, antimicrobial-resistant infections could cause as many as 10 million deaths per year worldwide. Yes, this type of pandemic will look and feel different than one caused by a 1918-like influenza virus, but nonetheless it will have a catastrophic impact.
It's less likely that global supply chains will be quickly and extensively compromised. But routine surgery will possibly become fatal, immunocompromised patients will face potential deadly infections daily, and previously uncomplicated puncture wounds and abrasions take on a whole new life-threatening dimension. In short, we will live in an infectious disease world more like the one that our ancestors lived in during World War I than the one we live in today.
Some will disagree with my assessment of what constitutes a pandemic and conclude that other infectious diseases also do or can cause them, like HIV. Other diseases certainly cause global, extensive damage, and other worrisome pathogens could certainly one day go global. But influenza and "superbugs" remain the two greatest looming pandemic threats.
No intent to downplay regional threats
The PATH report does highlight the critical importance of early and effective detection and response to epidemic diseases. These diseases are defined as:
- The occurrence in a community or region of cases of illness or health-related events clearly in excess of normal expectancy (A Dictionary of Epidemiology. Oxford. 20142)
Epidemic diseases, sometimes referred to as outbreaks, vary substantially in size, geographical location, and the threat they posed to human and animal health. In Deadliest Enemy, we provide an additional definition for an epidemic, discerning those that are sometimes considered as pandemic in nature and those that fit into the more conventional outbreak category. We classify diseases of critical regional importance as:
- An epidemic usually caused by a new pathogen (ie, new disease), occurring in one or more regions of the world but not a pandemic. Pathogens causing these diseases include but are not limited to Ebola virus, coronaviruses like SARS and MERS, and Aedes-transmitted viruses like Zika and yellow fever.
It's the diseases of critical regional importance that the PATH report is addressing in terms of the urgent need for additional preparedness and response capability. These diseases have the potential to cause rapidly increasing morbidity and mortality, as well as economic and sociopolitical disruption, but only at the national or regional level. Current examples of such diseases include those noted above.
At no time was there a measureable risk of a pandemic caused by diseases such as Ebola, Zika or MERS. Critical product global supply chains and international trade and travel were never at risk. Yet all countries need to have the laboratory, trained workforce, surveillance, and emergency operations capabilities to prevent, detect, and respond to these disease threats.
GHSA support is crucial
This is the heart of the Global Health Security Agenda (GHSA) launched by 29 countries, the World Health Organization, the United Nations Food and Agricultural Organization, and the World Organization for Animal Health in February 2014. Today GHSA is now a collaborative effort of more than 60 nations and organizations designed to help build countries' capacity to elevate global health security.
In December, the US Centers for Disease Control and Prevention (CDC) will publish a supplemental issue of Emerging Infectious Diseases (EID) detailing the important accomplishments of the CDC and its many international partners in addressing the GHSA agenda. Unfortunately, the US government investments in GHSA-related activities have relied primarily on supplement funds, which are slated to end soon.
In an introductory commentary for the EID supplement titled, "Global Health Security—an Unfinished Journey."5 I strongly support increasing US investment in the GHSA and the consequences to the international public health response to diseases of critical regional importance if we don't invest.
In the Path press release to its report last week, Carolyn Reynolds, vice president of policy and advocacy at PATH, said, "US leadership and funding has catalyzed significant global progress on pandemic prevention since the Ebola crisis, and has mobilized more than 60 nations to strengthen preparedness through the Global Health Security Agenda."6
This is factually incorrect. GHSA support, as essential as it is to addressing diseases of critical regional importance, will not begin to touch the most minimal of required preparedness activities for a pandemic. Confusing these two requirements—preparedness for a pandemic versus an epidemic—is a costly mistake for public health.
Pandemic clocks are ticking
To prepare for a potentially catastrophic influenza pandemic we need an immediate "Manhattan-like Project" to develop and manufacture new game-changing influenza vaccines (also referred to as universal vaccines) and vaccinate billions of people with them before or very shortly after the emergence of the new pandemic virus.
We detailed this urgent priority in our 2012 Center for Infectious Disease Research and Policy (CIDRAP) report, The Compelling Need for Game-Changing Influenza Vaccines: An Analysis of the Influenza Vaccine Enterprise and Recommendations for the Future.7 Very little has changed since then to suggest we are taking this priority seriously.
Based on our ongoing surveys of private sector, philanthropic, and government support, we estimate that last year only about $35 million was invested globally in this effort. Meanwhile, more than $1.1 billion was invested for the eighth straight year in HIV vaccine research and development, an amount commensurate with its public health priority.
Until we prioritize the influenza vaccine effort, nothing we will do with GHSA-related activities will make us better prepared for pandemic influenza.
Early detection and rapid response of an emerging pandemic flu virus is often cited as a step in stopping the next pandemic. This is simply a pipedream. Influenza virus, because of its infectiousness, will be around the world before we detect and identify it. In 2009, the H1N1 pandemic virus was retrospectively recognized to be in 27 countries before it was first identified in Mexico and the United States.
A similar case can be made for why GHSA activities will not make a dent in the evolving crisis of antimicrobial resistance. Infection surveillance by itself will do little to slow down the development and spread of antimicrobial-resistant infections. Nor will GHSA-related funding support major international antimicrobial stewardship programs for humans and animals, new vaccines to prevent resistant inflections, new antibiotic development, or the research and development necessary to identify ancillary treatments using such agents as phages.
The influenza and antimicrobial resistance pandemic clocks are ticking; we just don't know what time it is. Misunderstanding and misrepresenting what we need to do to be better prepared takes an understanding of what a pandemic is and what it isn't.
To date we are not doing a very good job of understanding that point and responding accordingly. The PATH report is a clear reminder.
- PATH. Healthier world, safer America: A US government roadmap for international action to prevent the next pandemic. Oct 24, 2017 [Full text]
- Porta M (ed). A dictionary of epidemiology. Oxford, 2014 [webpage]
- WHO. What is a pandemic? Feb 24, 2010 [Full text]
- Osterholm MT, Olshaker M. Deadliest enemy: our war against killer germs. Mar 2017 [webpage]
- Osterholm MT. Global health security—an unfinished journey. Emerg Infect Dis 2017 (published online Oct 12) [Full text]
- PATH. US leadership and sustained funding urgently needed to prevent pandemics. Oct 24, 2017 [News release]
- CIDRAP. The compelling need for game-changing influenza vaccines: an analysis of the influenza vaccine enterprise and recommendations for the future. Oct 15, 2012 [Full text]