Preparedness for emerging epidemic threats: a Lancet Infectious Diseases Commission
Authors: Vernon J Lee, Ximena Aguilera, David Heymann, Annelies Wilder-Smith, Vernon J. Lee, Ximena Aguilera, David L. Heymann, Annelies Wilder-Smith, Daniel G. Bausch, Sylvie Briand, Christianne Bruschke, Eduardo H. Carmo, Sean Cleghorn, Lalit Dandona, Christl Donnelly, Ibrahima Socé Fall, Jane Halton, Richard Hatchett, Felicia Hong, Peter Horby, Chikwe Ihekweazu, Michael Jacobs, Kamran Khan, Yijun Lin, Gabriel Leung, Constance Low, Bethan F. McDonald, Ziad A. Memish, Ryan Morhard, Deborah HL Ng, John Nkengasong, Junxiong Pang, Stephen C. Redd, Karen Tan, Wen Qing Yeo
Journal: The Lancet Infectious Diseases (2019)

At any time, an emerging, lethal, and highly transmissible pathogen might pose a risk of being spread globally because of the interconnectedness of the global population.1McCloskey B Dar O Zumla A Heymann DL Emerging infectious diseases and pandemic potential: status quo and reducing risk of global spread.Lancet Infect Dis. 2014; 14: 1001-1010Summary Full Text Full Text PDF PubMed Scopus (119) Google Scholar, 2WHOGlobal Preparedness Monitoring Board. A world at risk: annual report on global preparedness for health emergencies. World Health Organization, Geneva2019Google Scholar Emerging epidemic threats are occurring with increasing scale, duration, and effect, often disrupting travel and trade, and damaging both national and regional economies.3American Veterinary Medical AssociationOne Health: a new professional imperative.https://www.avma.org/KB/Resources/Reports/Documents/onehealth_final.pdfDate: 2008Date accessed: November 28, 2019Google Scholar, 4The World BankFrom panic and neglect to investing in health security: financing pandemic preparedness at a national level (English).http://documents.worldbank.org/curated/en/979591495652724770/From-panic-and-neglect-to-investing-in-health-security-financing-pandemic-preparedness-at-a-national-levelDate: 2017Date accessed: November 28, 2019Google Scholar Even geographically limited outbreaks such as the Ebola virus disease in Africa might have a global effect. Preparing for epidemic threats is not a static or binary (prepared or unprepared) exercise, but a dynamic state reflecting the constantly changing world. Countries prepare in different ways based on their interpretation of disease risks and international agreements such as the International Health Regulations (IHR). The IHR were introduced in 1969 to prevent spread of specific serious diseases between countries and set out preparedness measures at international borders to stop disease spread. The 2005 revisions to the IHR reflect changes across multiple dimensions, requiring countries to develop preparedness capacities to detect and respond to outbreaks where and when they occur, supported by international partners to respond when outbreaks cannot be contained locally.5WHOInternational Health Regulations 2005.https://www.who.int/ihr/publications/9789241580496/en/Date: 2016Date accessed: November 28, 2019Google Scholar However, disruptive factors have emerged at a greater pace over the past decade, creating a new ecology that requires novel strategies for preparedness. These factors include dealing with the increasing human population density and connectivity, harnessing novel data streams and new technological advances to manage epidemics, mitigating false information on social networks, to creating informal technical networks that can work together when political forces fail to do so. Do the recent outbreaks of Ebola virus disease, Middle East respiratory syndrome coronavirus, and yellow fever reflect this changing context of disruptions requiring dynamic responses? These outbreaks show that countries are at various stages of preparedness, and many have underdeveloped preparedness plans and response capabilities with weak or non-existent strategies to mitigate disruptive factors.6WHOGlobal Health Observatory (GHO) data.https://www.who.int/gho/ihr/en/Date: 2019Date accessed: November 28, 2019Google Scholar, 7Global Health Security AgendaImplementing the Global Health Security Agenda: Progress and Impact from U.S. Government Investments.https://www.cdc.gov/globalhealth/healthprotection/resources/pdf/GHSA-Report-_Feb-2018.pdfDate: 2018Date accessed: November 28, 2019Google Scholar Many countries face severe difficulties in providing universal health coverage, for example, and might overlook timely investments for threats that demand greater health-care facility or workforce requirements.8Oshitani H Kamigaki T Suzuki A Major issues and challenges of influenza pandemic preparedness in developing countries.Emerg Infect Dis. 2008; 14: 875-880Crossref PubMed Scopus (147) Google Scholar, 9Kluge H Martín-Moreno JM Emiroglu N et al.Strengthening global health security by embedding the International Health Regulations requirements into national health systems.BMJ Glob Health. 2018; 3e000656Crossref PubMed Scopus (78) Google Scholar Other challenges include shifts in within-country and between-country cooperation, the evolving need for transdisciplinary, cross-sectoral approaches and social participation,2WHOGlobal Preparedness Monitoring Board. A world at risk: annual report on global preparedness for health emergencies. World Health Organization, Geneva2019Google Scholar, 3American Veterinary Medical AssociationOne Health: a new professional imperative.https://www.avma.org/KB/Resources/Reports/Documents/onehealth_final.pdfDate: 2008Date accessed: November 28, 2019Google Scholar, 8Oshitani H Kamigaki T Suzuki A Major issues and challenges of influenza pandemic preparedness in developing countries.Emerg Infect Dis. 2008; 14: 875-880Crossref PubMed Scopus (147) Google Scholar, 9Kluge H Martín-Moreno JM Emiroglu N et al.Strengthening global health security by embedding the International Health Regulations requirements into national health systems.BMJ Glob Health. 2018; 3e000656Crossref PubMed Scopus (78) Google Scholar and effective leadership, coordination, and financing of local national and international partners.10Jain V Duse A Bausch DG Planning for large epidemics and pandemics: challenges from a policy perspective.Curr Opin Infect Dis. 2018; 31: 316-324Crossref PubMed Scopus (27) Google Scholar Against this backdrop, the Lancet Infectious Diseases Commission on Preparedness for Emerging Epidemic Threats was formed in mid-2019 to examine the importance of this new ecology and its disruptive factors that have resulted in an underprepared world, whether current planning assumptions still hold, and what mitigation measures need to be introduced. A sample of the new ecology, its disruptive factors, and how they manifest are shown in the table. Preparedness plans must take these factors into account to succeed and those that do not will not have the resilience and capability to fully respond. These factors are political and institutional factors that include influential stakeholders and decision-making forces; social factors that link individuals and communities, through exchange of goods and information, and building relationships that ensure societal cohesiveness; environmental factors that influence pathogens and hosts, contribute to biodiversity and how diseases emerge and spread, these factors affect interaction between humans, vertebrate animals, and arthropod vectors, and influence human development and health systems; and pathogenic factors that define the biological basis of epidemic emergence and antimicrobial resistance, host–pathogen interactions, and available interventions to address these epidemics.TableExamples of disruptive factors and their manifestations that require mitigation for effective preparednessDisruptive factorsExamples of manifestationsPolitical and institutionalNational governments; international agencies; non-governmental organisations and charities; corporate entities; academic institutionsWeakness in behavioural change guidance from national and international organisations; scarcity of sustainable leadership and financing in failed states leading to neglected or uncoordinated health systems; increasing duration and frequency of insecurity or conflict zones hindering efforts to recognise and respond to health threats; failure of countries to report disease outbreaks because of fear of economic consequencesSocialTravel patterns, migration, and interconnectivity; trade; technology and digital revolution, including those that affect human interaction; expansion and control of information; patterns of communication including social media; expectations and definition of expertise; social conflict and privacyFailure of host countries to protect the health of refugees and migrants; epidemic of devastating rumours and fake news on social media due to increased digital connectivity; emergence of social influencers exerting influence on politicians and institutions; increased resistance and hesitancy within communities to health interventions because of opposition by local expertsEnvironmentGeography affecting biological diversity; planned and unplanned urbanisation; climate change; interaction between humans, animals, and vectors; human development; state of the economy; state of health systemsClimate change resulting in increased flooding with failed sanitation and safe water; altered distribution of zoonotic disease reservoirs and vectors; emerging zoonosis with increased agricultural production and human encroachment into animal environments; changing national priorities resulting in sharply reduced investment in health systemsPathogenesisChanging disease biomes; relationship between hosts and pathogens; pathogen evolution and changes; technologies such as synthetic biology, and the risks of manufacturing pathogens and their accidental or deliberate release; characteristics of a population such as underlying disease conditionIncreased opportunities for mutation or reassortment of infectious agents; increasingly reduced effectiveness of conventional vaccines and therapeutics for prevention and treatment of diseases; failure of conventional control measures to break the chain of transmission of infectious agents Open table in a new tab The Lancet Infectious Diseases Commission will discuss disruptive factors and how preparedness planning must consider this new ecology by exploring current preparedness platforms and their vulnerability to disruptive factors; by addressing key disruptions, identifying possible solutions, and providing recommendations for countries to strengthen preparedness; by developing a multidisciplinary approach including a strong role for social sciences and innovative technology; by challenging leaders and stakeholders to create sustainable preparedness platforms through collaborations and investment in established and novel recommendations; and by creating a community of practice to share new ideas and monitor outcomes. To tackle the wide-ranging issues, the Commission has brought together experts from academic, public health, policy making, international, non-governmental, and corporate institutions. They bring local and global knowledge and experience, including policy-making and field response, human and animal health (including One Health) approaches, and novel developments in communications, information technology, analytics, public health, diagnostics, and therapeutics. The Commission aims to deliver the report by 2021 and will include key recommendations for countries and international stakeholders, and monitoring indicators to evaluate the effectiveness of preparedness initiatives over time. The Mok Hing Yiu Charitable Foundation is the sole sponsor for the Lancet Infectious Diseases Commission meetings and travel for some commissioners. The foundation is not involved in the technical discussions, data analysis, and drafting of the report. This Comment was written on the behalf of the Lancet Infectious Diseases Commission on Preparedness for Emerging Epidemic Threats; see appendix (pp 1–2) for the Commissions author list. Download .pdf (.11 MB) Help with pdf files Supplementary appendix