Epidemic preparedness in urban settings: new challenges and opportunities
Authors: Vernon J Lee, Marc Ho, Chen Wen Kai, Ximena Aguilera, David Heymann, Annelies Wilder-Smith
Journal: The Lancet Infectious Diseases (2020)

In recent decades, many emerging infectious diseases have been occurring at an increasing scale and frequency—i.e. Ebola virus disease, severe acute respiratory syndrome (SARS), avian and pandemic influenza, Middle-East respiratory syndrome (MERS), and the recently emerged coronavirus disease 2019 (COVID-19). The outbreaks of these diseases resulted in wide ranging socioeconomic consequences, including loss of lives and disruption to trade and travel. Preparedness is a crucial investment because its cost is small compared with the unmitigated impact of a health emergency. The financing gap for preparedness, estimated at US$4·5 billion per year, is miniscule compared with estimated pandemic costs of $570 billion per year.1Commission on a Global Health Risk Framework for the FutureNational Academy of Medicine, SecretariatThe Neglected dimension of global security: a framework to counter infectious disease crises. National Academies Press, Washington, DC, (US)2016Crossref Google Scholar, 2World Economic ForumOutbreak readiness and business impact: protecting lives and livelihoods across the global economy. World Economic Forum, Geneva2019Google Scholar Within urban settings, preparedness activities have the added challenge of navigating a host of disruptive determinants that demand innovative solutions, especially the way in which diseases and their human hosts behave.3Lee VJ Aguilera X Heymann D et al.Preparedness for emerging epidemic threats: a Lancet Infectious Diseases Commission.Lancet Infect Dis. 2020; 20: 17-19Summary Full Text Full Text PDF PubMed Scopus (45) Google Scholar Ensuring that urban settings are prepared for emerging infectious diseases is crucially important. In 2018, 55% of the world's population (4·2 billion people) resided in urban areas, and this proportion might increase to 68% by 2050.4UN Department of Economic and Social Affairs2018 revision of world urbanization prospects. United Nations, Geneva2018Google Scholar Emerging infectious diseases also either originate in urban settings, such as the emergence of COVID-19 in Wuhan, China, or rapidly propagate because of urbanisation once they are established, such as outbreaks of SARS in 2003 and Zika virus disease in the Americas.5Li Q Guan X Wu P et al.Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia.N Engl J Med. 2020; (published online Jan 29.)DOI:10.1056/NEJMoa2001316Crossref Scopus (10810) Google Scholar, 6Cho SY Kang JM Ha YE et al.MERS-CoV outbreak following a single patient exposure in an emergency room in South Korea: an epidemiological outbreak study.Lancet. 2016; 388: 994-1001Summary Full Text Full Text PDF PubMed Scopus (233) Google Scholar, 7Metsky HC Matranga CB Wohl S et al.Zika virus evolution and spread in the Americas.Nature. 2017; 546: 411-415Crossref PubMed Scopus (277) Google Scholar Many cities are important hubs of travel and trade; hence an uncontained outbreak would result in severe economic consequences beyond lives lost. More importantly, these urban centres risk becoming conduits of transmission to the world. As seen from the spread of COVID-19, diseases now follow major patterns of travel connections both domestically (with major cities in China connected by high speed rail) and internationally through flights.8Bogoch II Watts A Thomas-Bachli A Huber C Kraemer MUG Khan K Potential for global spread of a novel coronavirus from China.J Travel Med. 2020; 27taaa011Crossref PubMed Scopus (247) Google Scholar For example, as of Feb 17, 2020, there were 172 exported cases of COVID-19 from China to 25 countries, with 156 secondary cases in 14 countries, and these were mostly in major cities with travel connections to China.9WHONovel coronavirus (COVID-19). Situation report 28. World Health Organization, Geneva2020Google Scholar Urban settings have some common characteristics, many of which are disruptive factors that need to be addressed for effective preparedness.3Lee VJ Aguilera X Heymann D et al.Preparedness for emerging epidemic threats: a Lancet Infectious Diseases Commission.Lancet Infect Dis. 2020; 20: 17-19Summary Full Text Full Text PDF PubMed Scopus (45) Google Scholar For example, the density of people in housing, during commutes using public transportation, and in work environments is high. Inequalities, exacerbated by the rapid influx of people from rural areas, often results in poor housing, insufficient supply of fresh water, poor sanitation facilities, and ineffective ventilation systems, all of which increase outbreak risks. Rapid urbanisation might lead to encroachment into natural habitats and closer encounters with wildlife and zoonoses, and increased proximity to animals in backyard farms and food markets also provides opportunities for zoonotic infections. Both SARS and COVID-19 might have originated from food markets, and of the 335 emerging infectious diseases recognised between 1940 and 2004, more than 60% were of zoonotic origin.10Jones KE Patel NG Levy MA et al.Global trends in emerging infectious diseases.Nature. 2008; 451: 990-993Crossref PubMed Scopus (5266) Google Scholar Ensuring better preparedness in urban settings will require a fresh emphasis on strengthening capacities to deal with outbreaks and other health emergencies. Many of these efforts are applicable across all settings, urban or otherwise, such as having a good understanding of the local socioeconomic and cultural milieu and an active involvement of communities and local leaders in both planning and implementation. However, urban settings also offer new opportunities (table), such as securing the commitment of local leaders and strengthening public health networks to prevent, detect, and respond to disease threats early. Businesses can be appropriately engaged to manage employees in an emergency, and risk communication can be pushed through prevalent social media networks. Many lessons will also be learned from the city-wide community containment measures in Wuhan—the largest community quarantine exercise in history—and other containment measures rolled out in other Chinese cities and in Singapore.TableChallenges, and opportunities for epidemic preparedness associated with characteristics of urban settingsChallengesOpportunitiesHigh population density and high volume of public transportationA larger population to be managed; ease of disease spread between humans in congested areas; difficulties in contact tracing, especially causal contact in public areas; inequalities resulting in poor housing environments that might hinder outbreak prevention and control efforts; closer encounters with wildlife via food markets or because of expansion into previously untouched ecosystemsUrban planners can consider epidemic preparedness in their designs and implementation; transport networks can be used to rapidly move supplies to outbreak epicentres; harnessing advancement in technologies for more effective contact tracingInterface between animals and humansAreas of poor sanitation with rodents and other animal vectors; live domestic and wild animal markets; animals raised in backyard farms or industrial agricultural facilities in close proximity to humansImproved sanitation and rodent control around humans and animal communities; vaccination of domestic animals for common zoonotic infections; precautions at slaughter to prevent contact with blood; regulating live animal markets to phase out sale of live animals or to ensure that those for sale are raised on commercial farms and have been verified to be disease freeGovernance by local authoritiesCompeting interests within a finite local budget; insufficient authority to institute response measures promptly; insufficient epidemic preparedness capabilities or capacities at a subnational and local level; difficulties in accessing national capacitiesLeaders in cities would be better placed to develop and implement effective and contextually appropriate solutions; consolidated local surveillance data can improve sense-making at the national level; local leaders can be engaged to advocate for greater investments in local systemsHeterogeneous subpopulationsA wide range of cultural factors, including modes of social interactions and acceptable control measures; some subpopulations might be difficult to reachCommunity leaders can be mobilised for targeted approaches to preparedness and response; innovative solutions can be shared and adapted across culturesHigh connectivity to other urban centres (domestic and international)High likelihood of multiple importation events; risk of rapid export of disease to other parts of the country or to other countries; fear might lead to restrictions on travel and tradeEvidence-based points of entry measures and exit screening measures can be implemented; trust can be built through strong diplomatic relations to allow for better collaborationCentres of commerceGreater disruption to economic activity, stability, and growthBusinesses and corporations can be engaged in business continuity plans that also prevent further spread, as part of a whole-of-society approachUnconventional communications and interactionsMultiple information sources leading to misinformation; false information might spread quicklyUnconventional but reliable information channels and social media can be used for risk communication Open table in a new tab Many urban settings now have substantial expertise and experience in preparing for and dealing with health emergencies. Having had large outbreaks of infectious diseases, authorities in some urban areas have developed purpose-built surveillance systems that make use of digital and web-based information.11Tang L Bie B Park SE Zhi D Social media and outbreaks of emerging infectious diseases: a systematic review of literature.Am J Infect Control. 2018; 46: 962-972Summary Full Text Full Text PDF PubMed Scopus (150) Google Scholar Other local authorities have established surge capacity and contingency plans, including strong links with health-care facilities and national coordination bodies.12Tay J Ng YF Cutter JL James L Influenza A (H1N1-2009) pandemic in Singapore—public health control measures implemented and lessons learnt.Ann Acad Med Singapore. 2010; 39: 313-412PubMed Google Scholar In some urban settings, complex simulation exercises have been run and disease spread has been modelled to determine the most effective public health actions to control the spread of infectious diseases.13Ahn I Heo S Ji S et al.Investigation of nonlinear epidemiological models for analyzing and controlling the MERS outbreak in Korea.J Theor Biol. 2018; 437: 17-28Crossref PubMed Scopus (9) Google Scholar There is room for sharing of best practices and measures in urban settings. Having an assessment and evaluation tool that is tailored for urban settings might also be useful for preparedness planning. The ongoing pandemic of COVID-19 is a strong reminder that urbanisation has changed the way that people and communities live, work, and interact, and the need to strengthen systems and local capacities to prevent the spread of infectious diseases is urgent. As a global community, we must collectively invest in and build strong preparedness systems that are better adapted to increasingly urbanised settings. We declare no competing interests. Correction to Lancet Infect Dis 2020; published online March 27. https://doi.org/10.1016/S1473-3099(20)30249-8Lee VJ, Ho M, Kai CW, Aguilera X, Heymann D, Wilder-Smith A. Epidemic preparedness in urban settings: new challenges and opportunities. Lancet Infect Dis 2020; published online March 27. https://doi.org/10.1016/S1473-3099(20)30249-8—In this Comment, Ximena Aguilera's affiliation should be "Faculty of Medicine, Clínica Alemana Universidad del Desarrollo, Santiago, Chile". This correction has been made to the online version as of April 20, 2020, and will be made to the printed version. Full-Text PDF