Call for independent monitoring of disease outbreak preparednessBMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2269 (Published 24 May 2018) Cite this as: BMJ 2018;361:k2269
- Olga Jonas, senior fellow1,
- Rebecca Katz, co-director2,
- Shana Yansen, programme manager1,
- Katrina Geddes, research fellow1,
- Ashish Jha, K T Li professor of international health1 3
- 1Harvard Global Health Institute, Cambridge, MA, USA
- 2Center for Global Health Science and Security, Washington, DC, USA
- 3Department of Health Policy and Management, Harvard T H Chan School of Public Health, Cambridge, MA, USA
- Correspondence to: A Jha
Four years ago, a delayed and initially inadequate response to control an outbreak of Ebola virus in west Africa resulted in a devastating regional epidemic. In addition to its heavy toll of death and illness, the epidemic damaged the already fragile healthcare systems, sharply reduced economic activities, and disrupted the lives of several million people.1 The costs were borne largely by some of the world’s poorest communities. And, to contain the outbreak, external partners spent $3.6bn (£2.7bn; €3bn).
The Ebola crisis is just one example of the consequences of poor preparedness for disease outbreaks. AIDS is another, as it became a pandemic (worldwide epidemic) by the time a robust response was organised. The Ebola crisis prompted numerous expert analyses of what went wrong and why. A synthesis of the findings, published in The BMJ, found a remarkable convergence both on the failures and on what must be done to reduce the costs of disease outbreaks.2 Clearly, we need to be prepared to thwart the spread of pathogens (including drug resistant pathogens) promptly.
Persistence of poor preparedness is no surprise. How governments and international organisations deal with the risks of infrequent, predictably recurring, and high impact outbreaks has long followed a set pattern. An initial panic during the outbreak is followed by neglect once the outbreak is over. Although the recent Ebola and Zika outbreaks spurred actions to improve preparedness, neglect has set back in. Preventing the next epidemic or pandemic is no longer on the agendas of national and global leaders, though they are well aware that protecting health and economies from the effects of contagion are major national and global public goods and are less expensive than containing an outbreak.3
Breaking the cycle
How, then, do we break out of this persistent cycle of panic and neglect? We need first to understand why neglect sets in during the lull between major disease outbreaks. There are three reasons. The first is complexity: effective responses to disease outbreaks depend on the development and coordination of diverse capacities—from core national public health systems, to investment in new vaccines (in the absence of scientific ability to predict disease emergence),4 to global health governance reforms, to whole society disaster response planning. Confronted with different technical and organisational agendas, policy makers often opt to set all of them aside.
The second reason is lack of accountability: there are no reliable mechanisms to ensure that governments, international institutions, community leaders, private companies, and others are investing in preparedness. Health sector leaders often explain that the pervasive neglect of prevention is caused by the “invisibility” of its benefits.
The final contributor is competing demands. As an outbreak leaves media headlines, policy makers turn to other pressing concerns and projects with “visible” results. They do so even though public spending on preparedness yields extraordinarily high returns—including eradicating (or at the least, better managing) those diseases that policy makers tout as causing most problems.56 The cost of preparedness for a severe influenza pandemic, for example, is $4.5bn a year, which would produce estimated annual economic benefits of $60bn and $490bn benefit through averted deaths.78 Even if only one tenth of these benefits were to materialise, the returns to public investment in preparedness would still be extraordinarily high.
How can we counter the dominant tendencies to neglect preparedness? A permanent, independent, scientifically rigorous, and data driven monitoring programme is critically important. By tracking and reporting on the world’s readiness to respond to the next outbreak, we could weaken the panic-neglect cycle. Robust monitoring that is comprehensive, accessible, and independent will move this agenda forward and improve readiness in several ways.
The first is that it would reduce the perception that preparedness is too complex. Dividing the topic into its components and highlighting the critical actions should help. These recommendations should be provided in a format that is clear to political leaders, policy makers, and the public. Experts have identified the core public health capacities (both veterinary and human health) needed to detect and manage outbreaks.9 Surveillance, diagnostic laboratories (including for antimicrobial resistance), food safety systems, and emergency response protocols are among the key elements. Tracking the implementation of national action plans to fill the gaps identified in expert assessments would show what it takes to provide universal access to core public health functions.
Monitoring would also provide accountability for investments and other efforts that reduce epidemic and pandemic risks. Decision makers have repeatedly walked away from their responsibilities. Monitoring the low visibility efforts to boost preparedness, highlighting how these are extraordinarily productive investments by emphasising their co-benefits for human health and economic development, and documenting the full costs of outbreaks would help keep them on track. Documenting gaps in global governance and analysing the ensuing risks would help governments recognise the need for action. Tracking how the World Health Organization, other UN agencies, the World Organisation for Animal Health (OIE), and the World Bank are following up on stated priorities can increase public understanding of the roles of key intergovernmental organisations.
Publishing progress reports annually can also sustain momentum and political support. Political leadership and interest among the public are indispensable. The annual reports and other forms of outreach (such as opinion pieces, news articles, events, and meetings) will build awareness of risks and the importance of preparedness. They will communicate what needs to be done, why, and by whom.
Work to establish a comprehensive monitoring mechanism grew out of an expert workshop hosted by the Harvard Global Health Institute and the US National Academy of Medicine in April 2017. More than 50 experts from around the world discussed the options for a monitoring framework, drawing on their experience in veterinary and human public health, disaster risk management, infectious disease control, environmental risks, economics, finance, monitoring and evaluation of programs, and other disciplines. The monitoring tasks were organised in four domains: country level preparedness; improving science, technology, and access; identifying and communicating risks; and strengthening global mechanisms. Experts at the workshop agreed on these domains based on a comprehensive review of the recommendations released after the Ebola outbreak.10
Country level preparedness
Each country is its own first line of defence against microbial threats, and all countries have an interest in every country having the capacity to defend itself. An outbreak anywhere in the world could reach cities on all continents within 36 hours. Mobility is now much higher than just 30 years ago, with the fastest growth occurring in low and middle income countries. Some eight million passengers fly worldwide every day. The best way to ensure health security for all countries is to stop outbreaks “at the source.” We are far from this goal, which was formally set more than a decade ago when all WHO members adopted the International Health Regulations (2005). So far, only one third of countries have assessed their core capacities to prevent, detect, and respond to public health risks (fig 1).8
In the past two years, however, we have seen tremendous gains in the pace of completion of joint external evaluations of core public health systems, in partnership with the WHO. But most countries have not yet prepared action plans11 to close the capacity gaps identified by the evaluations, so monitoring progress is necessary.12 African countries have made substantial progress in assessing their readiness and preparing for next steps, but the rest of the world is trailing behind.13
Improving science, technology, and access
Vaccines are one of the most important advances in public health in the last century and are essential in the control of infectious diseases. Yet pharmaceutical and biotech companies face large obstacles to research and development, especially for pathogens of emerging epidemic and pandemic potential (box 1).14 Efforts to develop a universal flu vaccine have fallen short of the need, despite high economic and public health benefits (flu costs the US $10.4bn in direct medical costs annually and $87bn in total economic burden).15 This year’s centennial of the 1918 influenza pandemic is a stark reminder that without a viable vaccine or treatment, millions of people could perish, and trillions could be lost in economic output should a similarly pathogenic influenza strain emerge.7
Barriers to research and development of vaccines
High cost $750 000-$1bn for each vaccine (more for universal flu vaccine, HIV)
Long timelines (≥10 years)
Liability risks, especially worldwide (for regional or global outbreaks)
Data sharing and clinical sample sharing
Vaccine trial design in emergencies
Uncertain market potential for vaccine candidates
Unpredictability of disease outbreaks
Innovative public-private partnerships offer one solution. The Coalition for Epidemic Preparedness Innovations (CEPI) is one such example and currently supports vaccine research for three pathogens (Nipah, Lassa fever, and Middle East respiratory syndrome coronavirus) and platform technologies.
In addition, US Senator Markey recently introduced legislation calling for $1bn investment in developing a universal flu vaccine, signifying potential public investment to drive innovation in the private sector. The Bill and Melinda Gates Foundation also recently announced a “$12m grand challenge” for a universal flu vaccine.
Diagnostics and therapeutics also have a critical role in epidemic preparedness and response strategies. Progress and barriers in all three areas should be monitored regularly to prioritise resources, spur innovation, and foster international collaborations. Visible monitoring can ensure that when an outbreak occurs, viable medical countermeasures are in place, including for the most vulnerable groups.
Identifying and communicating risks
Epidemic and pandemic risks are increasing.16 This may be due to a variety of factors, including low veterinary and human public health standards, climate change, migration, growing incomes and meat consumption in emerging economies, encroachment of people and their livestock on wildlife habitats, and animal-human proximity in poor households and in many cities in low income countries.10 The emergence and spread of antimicrobial resistance is a related threat that could have similar effects to those of a severe influenza pandemic or climate change.7 Understanding of these risks, and to what extent they are caused by humans, should be tracked to inform strategies for risk mitigation and to ensure public support for preparedness (box 2). Researchers regularly conduct risk analyses and mapping exercises to better understand and prioritise risk (eg, the EcoHealth Alliance, USAID, Rand Corporation). Regular tracking and reporting on these analyses to policy makers and the public can help align financial investments with the greatest public good for our health security.
Illustrative indicators for understanding and communicating risk
Risk maps and indices: Include animal (livestock), environmental, governmental, social, behavioural, and other risk factors
Existence and quality of preparedness maps or indices—How many exist? How comprehensive and robust are they?
Economic vulnerability assessments—How and how often are they included in reports on International Monetary Fund article IV consultations, World Bank’s systematic country diagnostic and country economic reports, and similar official reviews of economic prospects and policies in countries, regions, and globally?
Burial practices, food norms, and hygiene practices can all affect pathogen transmission during outbreaks. Communications about zoonotic diseases can be harmful when health officials (or the media) mislead the public about the source of the risk and also influence behaviour.10 Research on risk perception, behavioural reactions, and media incentives can improve containment strategies. Reporting on economic effects may also help economists integrate these risks into macroeconomic assessments and other economic studies. The World Bank and International Monetary Fund reports do not include risks of disease outbreaks, although the effects of a severe influenza pandemic or antimicrobial resistance are considerably greater, on an annualised basis, than other risks included in these assessments.
Strengthening global mechanisms
A high level UN panel recognised in 2017 that we need an independent (non-governmental) and evidence based mechanism to monitor activities related to health security in key global institutions.12 International organisations have a vital role in managing epidemic and pandemic risk, because cooperation from all countries is needed to make progress. As a neutral convenor (based on its near universal state membership), WHO is well positioned to advise on public health and support governments in coordinating resources during the response to an outbreak.13 Expert reports about the responses to the Ebola outbreak in west Africa outlined how performance fell short of intentions.
Member countries have so far failed to hold intergovernmental organisations accountable. We need increased transparency about this essential global public health programme, since the ability to respond quickly and effectively to outbreaks is important for current and future generations. Without independent monitoring, preparedness is more likely to be neglected and the next outbreak could expand, again, into a costly crisis.
Proposals for monitoring governance
Global monitoring efforts have influenced policies and funding in public health for decades. Alcohol and tobacco use, HIV/AIDS, diet, and non-communicable diseases are a few such examples.1718 Recently, WHO and the World Bank announced the launch of a global preparedness monitoring board, a signal to the world that global monitoring can and should facilitate greater preparedness. The Nuclear Threats Initiative along with the Johns Hopkins Center for Health Security and the Economist Intelligence Unit are also developing a global health security index, as a form of global monitoring at country level.
Although the structure of the WHO-World Bank monitoring board has yet to be released, international experts, including those who contributed to our framework for global monitoring of disease outbreak preparedness,19 have set out recommendations for governance. Members of the board should be independent and knowledgeable, to ensure objective evidence based assessment. It also requires participation from a range of sectors and all regions of the world. In particular, researchers from low income countries should participate in collecting and analysing data. A coalition of independent experts covering all four domains of monitoring included in the framework should create and disseminate annual “report cards” to the global community to describe progress and gaps. Health security can be achieved for all if two aspects of sound governance are recognised and supported: multisectoral coordination (notably, One Health approaches and public-private cooperation) and accountability for preparedness by multiple stakeholders. The monitoring framework discussed here was designed around these fundamental principles.
Consensus is emerging in the global health security community that regular, independent reporting on disease outbreak preparedness can help to increase risk awareness and encourage appropriate action nationally and globally. Our framework is a starting point and can succeed if driven by a coalition of independent experts and key institutions (fig 2).19 The most recent outbreak of Ebola in the Democratic Republic of Congo highlights the importance of building on, amplifying, and coalescing existing research and data collection efforts.20 Having an independent, diverse group of experts track and share progress through a shared framework is our best chance at breaking the longstanding cycle of panic and neglect.
Lack of preparedness to respond quickly and effectively to infectious disease outbreaks gives rise to high (avoidable) health and economic costs
The cycle of panic and neglect that characterises our disease outbreak management to date must be broken
Consensus is emerging in the international health security community that regular, independent reporting on progress can help to increase risk awareness and encourage action nationally and globally
A coalition of independent academics and experts from all regions of the world are ideally suited to monitor progress, issue reports, and sustain momentum among policy makers and the public for disease outbreak preparedness
Contributors and sources: The monitoring framework discussed here came out of an April 2017 meeting held at the National Academy of Medicine with 50 international experts and a comprehensive review of published post-Ebola recommendations. OJ, SY, and RK coauthored the framework report with substantive input and direction from Peter Sands, AJ, and technical reviewers. OJ brings 33 years of experience as economic and policy adviser at the World Bank, including coordination of its avian and pandemic flu responses. RK is a leading expert in global health security and the International Health Regulations. SY manages HGHI’s epidemic and pandemic preparedness portfolio and was a coauthor on the monitoring report noted herein. KG is a Harvard fellow conducting research on intellectual property law, global access to medicines, and health security. AJ is a leading scholar in US healthcare quality, senior author on The BMJ analysis on post-Ebola reforms, and directs HGHI’s work in global health security, climate change and health, and healthcare quality. All authors contributed to the design of the manuscript. OJ, SY, and KG drafted the manuscript. All authors then reviewed and provided comments including redrafting. OJ, SY, and KG received comments and updated the manuscript, after which all authors reviewed and provided feedback and, finally, approval.
Competing interests: We have read and understood BMJ policy on declaration of interests and have no competing interests to declare.
Provenance and peer review: Not commissioned; externally peer reviewed