Panic and complacency are the hallmarks of the world’s response to infectious diseases, with complacency currently in the ascendance.
This is the verdict of Jonathan Quick, chair of the US-based Global Health Council and previously a director at the World Health Organization.
Dr Quick’s recently published book, the End of Epidemics, details how the world can prevent another outbreak sweeping the globe, harming millions and crippling health services and economies. But he is not confident that the world is ready to meet the threat.
He told the Telegraph: “There is a cycle of panic and complacency. We’re currently sliding back into complacency.”
Earlier this year, the WHO published an annual report detailing the infectious diseases most likely to trigger a worldwide health emergency.
Among the diseases whose deadly potential we already know about – such as Ebola and Lassa fever – WHO also listed Disease X. The usually sober health agency warned that somewhere out there lurks a disease we have absolutely no idea about. Most likely it is hiding in an animal and is biding its time before it makes the jump to humans.
In the early 1980s AIDS was the Disease X of its time. Ebola, which swept through West Africa in 2014 killing 11,000 people, was Disease X when it first emerged in the 1970s. And more recently severe acute respiratory syndrome – better known as SARS – was the Disease X of the early 2000s.
Dr Quick details the arrival of SARS in his book. The outbreak began in rural China but was then brought to the the Metropole Hotel in Hong Kong by a doctor who had been treating patients with the disease in rural Guangdong.
Hong Kong, a global city which plays host to hundreds and thousands of travellers from around the world every year, was the perfect launchpad for the spread of the disease. The doctor later died from this new illness, by which time he had infected around a dozen others within the hotel.
“Within a matter of weeks the disease had spread to 27 countries, closing cities like Toronto and costing them a billion dollars,” he says.
He describes WHO’s stance in naming Disease X as wise in terms of communicating risk. However, it has also left the global community scratching its heads: no one knows where Disease X is going to come from nor where it will break out, he warns.
And a report from the Johns Hopkins Center for Health Security in the United States warns that scientists are looking for the disease in the wrong places: concentrating on previous outbreaks rather than trying to adapt to new threats.
Time and again, a disease breaks out and the world panics, says Dr Quick. For example, in India in the 1990s there was an outbreak of plague – the WHO realised that there was no worldwide mechanism for containing a disease outbreak it set up the international health regulations. This lays out the steps countries must take to ensure that diseases do not spread out of control.
After the SARS panic of the early 2000s the regulations were strengthened but by the time Ebola swept through Guinea, Liberia and Sierra Leone in 2014 it became clear that very few countries in Africa complied with them, says Dr Quick.
And that complacency is evident in a report by the World Bank last year which showed that the majority of countries are still ill prepared to deal with pandemics.
The report warned that many countries “chronically under-invest” in critical public health functions such as disease surveillance, diagnostics, and emergency operations centres, which enable the early identification and containment of outbreaks.
So far, just 37 countries have completed the peer-reviewed assessments, called the Joint External Evaluation (JEE), of their ability to identify their gaps and needs. This means that 167 countries have not completed the evaluations.
Dr Quick says the foundation of pandemic preparedness is “strong local and national public health systems” and front line health workers who can recognise an unusual pattern of disease. He describes front line health workers as the “canary in the global health coal mine”.
“Before the 2014 Ebola outbreak there had been 22 previous outbreaks of the disease. All of those were put to bed quickly because they took place in countries which could recognise them and quickly respond,” he says.
“What happened in West Africa was that these countries weren’t aware that the disease was there so it caught them by surprise. It had several months to get going and then quickly blow up. It was a bit like a forest fire which burns quietly and then all of a sudden the whole forest is ablaze,” he says.
He says the JEE is beginning to make an impact – but it is slow.
Richard Hatchett, chief executive of the Coalition for Epidemic Preparedness Innovations (CEPI), a new partnership set up to fast track the development of vaccines for global epidemics, says that awareness of the threat of pandemics has improved.
But he adds: “But in terms of responding to new pathogens with characteristics that make them epidemic diseases we still face immense challenges.”
He says that the experience of SARS and more recently Zika has shown that the world is still unprepared. Zika spread through South America in 2016 and led to an increase in the number of babies in Brazil born with defects, after their mothers became infected with the virus in pregnancy.
“Zika was an interesting test case. Because no one had prioritised it as a disease of concern there was very little research done on it,” he says.
The research community scrambled to react to the virus. “The aspiration was to have a vaccine ready for emergency use by mid 2018. That is not for global distribution but for emergency use. Our capability to rapidly develop vaccines and manufacture them at scale is not there yet,” he admits.
CEPI’s aspiration is to create vaccine platforms which can be used to treat a range of diseases. Zika is a flavovirus so vaccines for other flavoviruses could be adapted.
Sudan virus and Marburg haemorrhagic virus is a philovirus like Ebola. The new VSV vaccine which will be deployed in the current Ebola outbreak in the Democratic Republic of Congo could be a launchpad for the development of vaccines for these two other diseases.
Dr Hatchett worked in African communities affected by Ebola, in a New York City emergency room during the anthrax attacks, in emergency operations centers working with colleagues around the world during SARS, at the White House during the swine flu pandemic in 2009, and in the responses to many infectious disease epidemic since. So he knows about panic.
But he thinks what will really convince people is the economic cost. In 2015, a patient returning from the Middle East brought Middle East respiratory syndrome (MERS) to South Korea.
“He was treated in three different emergency rooms before his disease was correctly identified. The outbreak led to only 186 cases but the wider impact was huge. Twenty-four hospitals closed and so did 2,000 schools. It caused $10bn worth of damage to the South Korean economy. When we frame the threat in that way people understand how pandemics can have huge economic implications,” he says.
But while this talk of pandemics is sexy, Nick Herbert MP, co-chair of the all party parliamentary group on tuberculosis (TB), says there are other outbreaks which need the world’s attention. He says that the economic impact of TB is expected to be $1 trillion over the next 15 years.
“If we could mobilise the same response for TB that was ultimately mobilised for Ebola, including huge investments in R&D, we could make incredible progress very quickly.
“I would like to see more effort from all governments to align pandemic preparedness efforts with the ongoing campaigns to beat the biggest infectious killers. If you have an infectious, extensively drug-resistant disease like TB, what better way to prepare for an outbreak of a new disease with similar characteristics than to tackle the disease in front of you? ” he says.
“Everything that we will need to do for a future outbreak of Disease X we need to do today for TB,” he says.
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