Caught Off Guard: Fixing Weaknesses in the Global Pandemic Readiness

Himani Yarlagadda

In the interconnectivity of today’s world, we benefit from the free exchange of goods, technology, and ideas across borders, yet are more so than ever before left at risk of increasingly widespread, diverse, and global disease. COVID-19 might be the most glaring example, but when we consider the context in which this pandemic occurred, there have long been signs about the proliferating dangers of diseases, whether it be from the Ebola outbreaks, the emergence of Zika, or other respiratory virus epidemics. Pathogens too are benefitting from the heightened era of connectivity that marks society today, and we consequently need to shift our paradigm of infectious disease containment and control to a more sustainable, global perspective. Ultimately, the future of global health requires both the maintenance and improvement of an international alarm network for novel and highly infectious pathogens through a more equitable revision of the International Health Regulations and a focus on establishing robust surveillance networks for countries in order to mitigate long durations of propagated disease spread, as seen during the COVID-19 pandemic.

In order to understand how to address global pandemic preparedness, it is important to underscore that early detection of diseases is now more important than ever because of the way globalization changes the way diseases progress. While scientific advances and healthcare modernization have resulted in decreased morbidity and mortality rates for a host of diseases - particularly respiratory and diarrheal ones - modern society is still at a high threat of outbreaks defined by fast-spreading pathogens because of globalization.¹ Our previous understanding of virulence evolution theory suggested that horizontal transmission and the spread of an emerging disease is fastest at the onset of epidemics but slows down as the disease progresses because the pathogen depletes its pool of susceptible hosts.² Unfortunately, the increase in human mobility has forced us to reconsider this idea: globalization has not only widened the pool of susceptible victims that a pathogen can access, but it has also rapidly increased the rate at which microbes spread.³ This accelerated disease spread induces outbreaks of longer duration and heightened illness prevalence amongst many populations, with a much later occurring natural decrease of rates in infection. With billions of people at risk of global transmission, it is unreasonable to expect for all outbreaks to be self-containing geographically; therefore, it is of utmost importance for early detection of disease outbreaks, especially in the case of a novel pathogens like the COVID-19 virus where a complete understanding of the pathogen’s virulence and chain of infection is lacking. While countries create policies for domestic preparedness, we have to simultaneously focus on international initiatives that target early detection of diseases.

To spark a widespread shift in international coordination in disease detection, the guiding framework for global disease preparedness - the International Health Regulations - requires serious revisions targeting equitable resource allocation for member countries and a quicker alarm response. The International Health Regulations (IHR) were formally created in 1969, but their origins can be traced back to as early as 1851 when international discussions were held to mitigate the spread of cholera.⁴ The current IHR are the product of a fundamental revision of the previous regulations in 2005 by the World Health Assembly (WHA), which shifted its guidelines from a disease-specific model targeting diseases like cholera, plague, and the yellow fever to a more general treaty that would respond to public health emergencies of international concern (PHEICs).⁴ The tardiness of the declaration of a PHEIC during the early states of the COVID-19 pandemic emphasizes that the fundamental alarm protocol of the IHR needs to be more efficient. The first delay of PHEIC declaration resulted from late reports of COVID-19 from Wuhan: retrospective analysis of SARS-CoV-2, the pathogen behind COVID-19, revealed that the virus was in Wuhan weeks prior to China reporting the first case on December 31, 2019.⁵ Additionally, the World Health Organization (WHO) was unable to get reports from non-governmental organizations in Wuhan due to the lack of information allowed out of China, and serious questions remain as to when health officials in Wuhan first knew about the potential of a novel disease.⁵ However, rather than focusing just on China’s reporting to the WHA, it is critical to understand that countries are often disadvantaged by reporting diseases to the WHA as the body often then recommends travel restrictions or bans to the country of origin.⁴ As a result, the IHR often promotes initiatives by member states that disproportionately place economic burden on countries that take the onus to report a disease of global concern. Years prior to COVID-19, in fact, Indonesia refused to share samples of H5N1 avian influenza in 2006, a decision supported by other developing countries that found it difficult to share such information and report to the WHA without a promise to make subsequent vaccines and medications affordable for them.⁴ Therefore, without proper incentivization measures, it is unlikely that countries will faithfully uphold the reporting requirements of the IHR simply because it is not economically favorable or even feasible for them to do so. Thus, the WHA should consider adding amendments to the IHR that outline options for economic support and prioritized access to treatment and preventative therapies for diseases to countries that comply with reporting guidelines.

Furthermore, a second major delay in PHEIC declaration came from the WHA itself. Under the IHR, the Director-General of the WHA has the sole authority to declare a PHEIC after considering submitted country reports and corroborated information from non-governmental sources.⁴ In the case of COVID-19, the Director-General and organization was reluctant to declare a PHEIC, saying doing so would have been “too early”.⁵ However, the definition of a PHEIC under the IHR does not necessarily require a disease to already have been spreading concerningly but rather calls for consideration of diseases with the potential to spread.⁵ The entire purpose of declaring a PHEIC is to proactively alert countries to reduce rapid disease proliferation from occurring, meaning that a PHEIC for COVID-19 should have been called earlier. The delay in designating a PHEIC leaves countries vulnerable to the disease without proper signaling about the gravity of the pandemic. While various countries across the world handled COVID-19 differently and much more effectively than others, a timely PHEIC declaration would have provided all countries with international awareness about a potential health threat and signaled to domestic healthcare agencies to prepare for COVID-19. Thus, considering the delays in COVID-19 alerts, the IHR should also be revised to emphasize the proactive nature of a PHEIC declaration by the organization itself and also define the qualifications of a disease having proliferation potential, especially in terms of the pathogen’s biological capabilities, mode of transmission, and infectivity. Finally, the international community also needs to prioritize the construction of stable surveillance systems in order to promote timely reporting to the WHA and in order for countries to address the emergence of diseases within their borders. In particular, it is important to prioritize surveillance systems in countries that do not have robust healthcare systems equipped to handle disease outbreaks because it reduces the burden on their healthcare systems by potentially decreasing the number of patients that will become infected and require treatment. Having less stable health systems leaves fewer health workers and therapeutics available to populations, often causing disease spread in a less controlled manner without sufficient diagnostic and treatment capabilities.⁶ In the context of COVID-19, a study from Imperial College exemplified these trends by predicting that the average-mortality rate in the pandemic was pushed up nearly 33% in low- or middle- income countries (LMICs) compared to high-income countries (HICs) due to substandard health care; this statistic does not even begin to account for a lack of access to healthcare in the first place, which is greatly exacerbated in LMICs.⁷ Therefore, establishing stronger surveillance systems allows earlier pathogen detection and localized containment of the disease, mitigating the use of resources for large-scale shutdowns or widespread epidemics and reducing the burden on fragile healthcare systems, which is critical when approaching disease spread in LMICs.⁸ Thus, the WHA should also prioritize agreements that target surveillance in LMICs by bringing developments in surveillance technology into these regions, tailored to each country’s population and context. There are many fronts in which these changes could be implemented, such as mobile health syndromic surveillance, allowing active participation of community health professionals to send symptomic data to centralized health agencies.⁹ In addition, allowing for the flow of rapid diagnostic tests that HICs have access to into LMICs allows for quicker detection of disease by increasing the diagnostic capability of these countries.⁹ Ultimately, combining targeted disease detection and general symptom surveillance allows LMICs to be better able to address and contain disease outbreaks on a smaller scale. All countries have an active stake in investing in LMIC surveillance - beyond just furthering global health - because researchers believe novel pathogens have an increased potential to emerge from areas, especially rural and tropical communities, with limited health care.^9,10 Having surveillance systems in place for disease detection increases the likelihood of detecting novel pathogens and containing any subsequent outbreaks earlier, prior to their global spread.

Ultimately, coming off the heels of the COVID-19 pandemic and its predecessors, the international community needs to prioritize a global approach to pandemic preparedness that targets early detection across countries equitably. In order to do so, the IHR needs to be fundamentally revised to promote quick and accurate reporting and declarations of PHEICs, while also working to establish strong surveillance measures in LDICs, which are disproportionately affected by the spread of global disease. Furthermore, we are positioned at a unique point in time where infectious disease readiness is on the forefront of the global community’s mind. As the debate on IHR reform continues until the 77th WHA meeting next year, we have the opportunity to seriously reconsider and elevate the world’s capability to better handle the next big pandemic.¹¹

References

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