Global epidemics: how well can we cope?BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3254 (Published 09 August 2018) Cite this as: BMJ 2018;362:k3254
- Jennifer Leigh, DrPH candidate1,
- Gabrielle Fitzgerald, chief executive officer2,
- Elvis Garcia, DrPH candidate1,
- Suerie Moon, director of research3
- 1Harvard T H Chan School of Public Health, Boston, MA, USA
- 2Panorama Global, Seattle, Washington, USA
- 3Global Health Centre, Graduate Institute of Geneva, Switzerland
- Correspondence to: J Leigh
The recent spread of Ebola to an urban centre in the Democratic Republic of Congo (DRC) highlights the importance of capacity to manage disease outbreaks.1 This outbreak was just one of many; already this year there have been outbreaks of Middle East respiratory syndrome (MERS), dengue, Lassa fever, yellow fever, Nipah, and cholera.2 Most of these were contained within the originating country, and so the global reforms implemented after the west Africa Ebola outbreak have not yet been seriously tested.
In January 2017, we analysed seven reports into the response to the Ebola outbreak,34567891011 identified areas of consensus, assessed progress made, and highlighted gaps, concluding that the world remained unprepared for major outbreaks.12 Here, we assess progress made since then in each of the gaps identified.
Capacity of national health systems
National capacity to manage outbreaks, including workforce development and training, was reiterated as a priority after the west Africa Ebola outbreak. As an important first step, by the end of May 2018, 77 countries had completed joint external evaluation, an assessment of country capacity to prevent, detect, and respond to public health risks.13 The World Health Organization’s Health Emergencies Programme has supported 39 countries to improve their preparedness, prioritising fragile states.14 The Global Health Security Agenda, with 61 participating countries, has also been an important driver for building national preparedness, including a $1bn US government investment.15 In addition to several regional initiatives, the World Bank committed to support at least 25 countries to develop and implement pandemic preparedness plans.16
Surveillance initiatives are working to increase capacity to detect and report outbreaks and promote information exchange.171819202122232425 Advances in risk mapping and modelling help pinpoint priorities for building capacity.262728 Several new initiatives focus on ensuring that communities partner closely with response efforts after widespread recognition that community engagement was important in containing Ebola.293031
Despite these efforts, and the development of several tools to calculate the cost of building country capacities,3233 inadequate funding remains a major barrier to increasing national preparedness. Few full-scale national action plans have been developed, funded, or implemented. Questions also remain about whether and how efforts to build outbreak capacity and universal health coverage can concretely complement each other.
World Health Organization
WHO seems much better prepared for outbreaks after heavy criticism of its response to Ebola in west Africa. It has emphasised strengthening its operational capacity through its Health Emergencies Programme, the leadership of which is highly regarded. The programme has rebuilt the organisation’s technical capacities and investigates 30 events each month.14 However, it is seen as an operational island within an organisation otherwise dedicated to policy and guidance.
In his first year of office, WHO’s director-general, Tedros Ghebreyesus, has brought high level political engagement to WHO’s outbreak response, which also features centrally in the organisation’s next five-year plan.34 Tedros says he intends to transform the WHO, focusing on impact and accountability, and overhauling core business processes.35
However, the sustainability of reform efforts is at risk because of unstable and inadequate funding for both outbreaks and WHO more broadly. Perennial questions persist about the working relationship between headquarters and regional and country offices, coordination with other United Nations agencies, and managing sensitive political relationships with countries affected by outbreaks.
Although WHO has responded rapidly to a series of outbreaks, it remains unclear whether its progress is adequate for a major global epidemic.36
Research and development of health technologies
Research and development of technologies for outbreaks has received extensive attention. WHO’s research and development blueprint is the main source of global guidance, identifying 10 prioritised pathogens, each with roadmaps and target product profiles.37 The Global Research Collaboration for Infectious Disease Preparedness is working to set a research agenda and tackle scientific, legal, ethical, and financial challenges to facilitate a rapid and effective research response during outbreaks.38
Vaccine development has emerged as a clear priority. The Coalition for Epidemic Preparedness Innovations (CEPI) was launched in 2017 and began funding vaccine projects in 2018.39 Although many are enthusiastic about the rapid pace of CEPI’s development, concerns persist about sustaining the engagement of major vaccine producers and the appropriateness of its priorities (MERS, Lassa, and Nipah viruses).40 Adequate vaccine stockpiles also remain a challenge, even with the United States’ September 2017 award of $84m (£64m; €72m) towards development and procurement of the Merck and Janssen Ebola vaccines.41
During the Ebola outbreak in the DRC, an investigational vaccine was used in the early stages of a response for the first time. Gavi, the Vaccine Alliance, supported the delivery of 7560 vaccine doses, donated by Merck, to health workers and contacts at high risk through a ring vaccination strategy.424344
Therapeutics, diagnostics, and non-biomedical interventions have received far less attention and public financing than vaccines. In June 2017, CEPI and the Foundation for Innovative New Diagnostics launched CEPIdx to facilitate the development and uptake of diagnostics for outbreaks.45 Despite this start, more action and funding are needed for these other critical technologies.
Sharing knowledge and data on outbreaks is critical. Although no overarching frameworks exist for sharing knowledge across priority pathogens, numerous pathogen-specific platforms have been set up to facilitate the free exchange of epidemiological and research data.464748495051 It is too early to assess how widely these platforms are being used, their effect, or whether they are sufficient. WHO52 and GloPID-R53 are working to tackle the many inherent challenges, including a lack of incentives and inadequate infrastructure.
Despite substantial political attention to sharing influenza viruses, ensuring that all relevant samples (or genomic sequencing data) and resulting benefits are shared between countries remains challenging. There are no clear governing frameworks to facilitate such sharing beyond influenza, and information on actual sharing practices is limited. Complex regulatory, legal, and ethical questions for both data and sample sharing also remain.
Travel and trade restrictions
Restrictions on travel and trade can deepen and lengthen outbreak related crises.54 Minimising unwarranted restrictions is critical for public health, humanitarian, political, and economic reasons. However, there is no governing framework covering the wide range of relevant public and private stakeholders. Norms and reasonable expectations for private firms during outbreaks remain undefined.
WHO has strengthened monitoring of trade and travel restrictions, and Chatham House and the Graduate Institute developed a set of indicators to monitor travel and tourism reactions.51 The World Economic Forum is working to improve coordination and communications between the public and private sectors to minimise disruptions to travel and trade.55 Further research is needed to understand better their causes and effects, as well as greater political engagement to strengthen accountability for their negative consequences.
Humanitarian aid system
When outbreaks overwhelm the capacities of the health sector or develop into complex emergencies, the broader humanitarian aid system becomes critical. Reviews after the west Africa Ebola outbreak highlighted the importance of strengthening the capacity and coordination of the humanitarian sector to respond to outbreaks.
Efforts to improve coordination include WHO’s revised emergency response framework.56 The UN’s main humanitarian coordination body, the Inter-Agency Standing Committee, released and tested a new protocol for serious outbreaks.57 Several other preparedness and response simulations were also conducted in 2017 by the World Economic Forum, the G20, and the World Bank and International Monetary Fund.585960 However, managing outbreaks in conflict settings remains a major political and operational challenge because of security concerns, restricted access, and a limited number of organisations with capacity to act. Furthermore, the international aid system is already under heavy strain, with multiple ongoing complex emergencies that require resources that might otherwise go to reform.
International financing for outbreak management has started to flow. The World Bank has several channels for financing responses to health crises, including loans, insurance, and cash disbursements.6162 The philanthropic sector has been an important contributor to new initiatives, including CEPI. WHO’s new Contingency Fund for Emergencies has made 46 emergency allocations totalling $36m, with more than 80% released within 24 hours.63 Although donors pledged an additional $15.3m in March, total contributions fell far short of the fund’s $100m goal.64 Despite the renewal of the Global Health Security Agenda to 2024, the US (its largest funder) has not made any financial commitments beyond 2019.65 The announcement of deep cuts to the US Centers for Disease Control and Prevention’s global outbreak prevention work raise doubts about future US financial support.66 The fate of the G7’s 2016 pledge to fund capacity building in 76 countries remains unclear as no follow-up has been announced.67
Despite these investments, only a fraction of required funding seems to have been mobilised. An estimated $4.5bn is needed annually.8 Detailed tracking of financing is extremely difficult. No aggregate estimates are available of global investment in outbreak management, and data on national investments are especially difficult to find. Without such information, it is impossible to track whether global financing is increasing or decreasing over time, or to estimate the financing gap.
Leadership and monitoring
Although political attention to outbreaks rocketed after the west Africa Ebola crisis, it has since declined. Nevertheless, there has been leadership from governments, multilateral organisations, foundations, non-governmental organisations, companies, and researchers to strengthen various aspects of global outbreak capacity. Many global initiatives are being implemented, but there is no governing framework to ensure these efforts sum up to a functional, adequate global system.
Reviews of the Ebola response emphasised the importance of system-wide leadership extending beyond the health sector. With a new UN secretary general in 2017, however, it remains unclear what kind of leadership the UN will provide. The Global Preparedness Monitoring Board, a new initiative created by WHO and World Bank Group, was announced during the 2018 World Health Assembly, after several years of discussions.68 Although it is an important step forward, key questions remain about its independence, membership, and operational methods.
Many new initiatives have been started to improve global capacity to manage outbreaks (table 1). The multiplicity of projects is encouraging but raises broader questions about fragmentation, coordination, and adequate financing.
We believe that there are three priorities for attention:
Funding—Substantial investment is needed to strengthen capacity to manage outbreaks but thus far only a small fraction of required funding seems to have been committed nationally and internationally. The large number of initiatives, the scope of funding required, and decreasing political attention have all contributed to this gap. In order to achieve adequate progress, more funding, and better tracking and coordination of those funds are required.
Monitoring—Meaningful assessment of overall global capacity to manage outbreaks requires in-depth investigation of implementation efforts and specialised expertise. Ideally, the new Global Preparedness Monitoring Board will provide an independent global mechanism to ensure regular in-depth, system-wide tracking and assessment.
Leadership and a clear governing framework are needed to ensure that individual efforts for each initiative and pathogen are coherent and sum up to a functional, adequate global system. The overall system requires stewardship beyond WHO, as the actors and issues extend beyond the health sector. We believe this role is best played by the UN. Without adequate leadership, momentum cannot be sustained, and the world will fall short of what is required to manage a major outbreak.
Overall, it is unclear how much better prepared the global system is today for a major outbreak than it was a few years ago. The evidence suggests that efforts have been considerable, but have not progressed far enough, fast enough, or with enough financing.
The west Africa Ebola outbreak in 2014-5 highlighted deficiencies in global capacity to respond
This year’s Ebola outbreak in the Democratic Republic of Congo showed that some of those deficiencies have been addressed
However, more progress needs to be made related to preparedness, monitoring, and knowledge sharing
Overall leadership is lacking, leading to numerous unlinked initiatives rather than a functional global response
Stewardship beyond WHO is needed
Many funding promises have not been met as epidemics have fallen down the political agenda
Contributors and sources: JL, GF, and SM contributed to the conception of the analysis. JL, GF, EG, and SM contributed to research. JL wrote the manuscript. GF, EG, and SM reviewed and edited the manuscript. JL and EG prepared the table. GF led and coordinated the project. All authors approved the final manuscript.
Competing interests: We have read and understood BMJ policy on declaration of interests and declare that Wellcome Trust funded the research for this paper. It made no input into its findings or conclusions, which are the authors’ own.
Provenance and peer review: Not commissioned; externally peer reviewed.