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Experts discuss preparedness for next emerging disease outbreak

The current Ebola epidemic in West Africa is the largest in history, with approximately 25,000 cases and more than 10,000 deaths. The crisis prompted a massive international emergency response, which until recently has struggled to keep pace with the disease. Infectious Disease News asked its Editorial Board and other experts if the international community is now better prepared to handle emerging disease outbreaks as a result of the Ebola epidemic.

Read the comments from experts whom Infectious Disease News asked for their opinion. We welcome you to share your opinions.

Carlos del Rio, MD, of Hubert Department of Global Health, Rollins School of Public Health of Emory University and department of medicine, Emory University School of Medicine and Dabney Evans, PhD, MPH, of Hubert Department of Global Health, Rollins School of Public Health of Emory University:

More than a year after the outset of the largest Ebola virus disease epidemic to date, the global health community has started to reflect on the international response with the benefit of hindsight. Prior Ebola virus disease outbreaks had more or less been self-contained geographically and petered out on their own. In the early days of the current epidemic, there was no reason to think this outbreak would be any different. Actors on the ground like MSF seemed nimble enough in their response. But past outbreaks did not well inform what was about to happen, and thus the initial international response was woefully inadequate.

Carlos del Rio

Dabney Evans

Whenever a disaster or emergency impacting health occurs, there is always a period of time between the crisis and the response. Since the 2005 development of the International Health Regulations (IHR), the public health community has benefited from a structured set of operating procedures for disease outbreak alert and response. However, a Public Health Emergency of International Concern (PHEIC) has only been declared three times. In the case of Ebola, this declaration came 8 months after the first case of Ebola virus disease (EVD) in Guinea. Until the world community received this important signal from WHO, the response was mostly limited to those already on the ground. WHO must act more quickly in future outbreaks and not be afraid to declare a PHEIC when appropriate. To her credit, Margaret Chan, MD, director-general of WHO, has called for an external evaluation of the WHO response.

The global good of public health requires a rapid coordinated response in the time of a global emergency. The U.S. government response, including the appointment of an EVD coordinator, has ensured that the U.S. government actors are more or less coordinated; however coordination and collaboration on the ground among the various actors has not been optimal. In the EVD-affected countries, we have seen how a lack of public health systems, including trained health personnel, exacerbated the spread of disease and limited local capacity to respond. Investment in public health infrastructure and health care systems strengthening may be likened to establishing fire codes. It may not mean we will eliminate all fires, but we can decrease the risks and severity when emergencies occur.

More than a year in, things are better than we thought they would be. But they are worse than they could have been had we acted sooner. The same can be said about therapeutic and vaccine trials. Precious time was wasted getting them started, and as the cases have decreased in the past few weeks, the window of opportunity may have closed.

The final lesson is that international response does not stop when disease transmission stops. Complacency is dangerous and a lack of attention to building public health and strengthening health systems in affected countries is sure to lead us back to where we began. As a global community we can choose to pay now or pay later.

David L. Cohn, MD, of Denver Public Health University of Colorado School of Medicine, Infectious Disease News Editorial Board member:

I recently returned from working at an Ebola treatment center in Sierra Leone as a clinician and educator. I had the opportunity to see first-hand the death and suffering of patients with EVD, and the joy and celebration of those who were fortunate to survive. And then, all too often, a survivor quickly learned that many or all of their immediate family members had succumbed to the disease — triumph and tragedy on the same day. But I was also able to be part of a gratifying effort by many committed and dedicated providers working for a common purpose.

David L. Cohn

I also observed the coordination and collaboration between the many different organizations that were on the ground in a concerted emergency response and public health effort against EVD. Every evening the British military convened a meeting of the 27 local, national and international agencies in the Port Loko District to discuss new cases and “hotspots” in the region, contact tracing, surveillance, quarantine, community mobilization and coordination of next steps. Nothing like this existed a few months ago. At this stage of the epidemic, there is now “too much, too late.”

One of the points for discussion was about “phase 2” of the epidemic response (ie, what to do in transition as the case load diminishes while there are still cases in different areas). There were interesting presentations about “Getting to Zero,” and how challenging that will be. Importantly, there was preliminary dialogue about what’s next, when this Ebola epidemic is finally over — with more questions than answers. Who is going to be in charge? Who is going to coordinate restoring other basic health services, which have largely been ignored for the last several months? There is a need for immunization programs, maternal and child health, tuberculosis control, HIV care, malaria treatment and prevention, etc. The three affected West African countries didn’t have sufficient infrastructure; they certainly didn’t have enough health care workers before the epidemic began, and tragically, they have fewer now. Who will fund the process of rebuilding and retraining? Look at Haiti as an example of recent emergency relief. There were significant emergency and humanitarian responses after the catastrophic earthquake and subsequent cholera epidemic, but who’s there now and what has been accomplished? Ebola is a different epidemic with different needs, but the questions are similar.

After undue delay, much of the response to the Ebola epidemic has been impressive and a great deal has been learned. For the international community to be fully prepared for future EVD outbreaks and epidemics due to other pathogens, it will ideally need what Bill Gates has recently recommended: coordination by a global institution with authority and funding, rapid decision making, expanded investment in research and development, improved early warning and detection systems, a reserve corps of trained personnel and volunteers, strengthening of health systems and preparedness exercises to improve responses. We are not close to meeting these aspirations.

J. Glenn Morris, Jr., MD, MPH&TM, director of the Emerging Pathogens Institute at the University of Florida and Infectious Disease News Editorial Board member:

J. Glenn Morris Jr.

This outbreak underscored the lack of appropriate infrastructure at multiple levels. The question is, will there now be the political will to put into place such an infrastructure? This will require money and a willingness to invest in infrastructure (training of public health and medical personnel, construction and equipping of laboratories, and development of surveillance systems) so that underdeveloped nations have the capacity to identify and control outbreaks at an early stage. We need to move away from a purely reactive approach, toward a proactive focus on how we build, long-term, the necessary public health infrastructure within these countries so that they can deal with and contain problems locally, even before the international community can mobilize. The question is not how we target an emergency response, but how we make sure that we don’t need an emergency response the next time around. The problem: this costs money, and it is not exciting enough to get CNN coverage. There will inevitably be savings if we can prevent or minimize future outbreaks, but putting in place the tools to accomplish this may be a hard sell in the current financial climate.

The outbreak also highlights the need to work on our own research infrastructure. The scientific response to the Ebola outbreak has been outstanding. However, it remains difficult, outside of government labs, to get funds from NIH or CDC to move forward quickly with critical research projects in outbreak or other emergency settings; the government labs do a great job, but there is tremendous talent in academia which is often untapped in this setting because of a lack of funding. There also is a need for long-term support of global health research. Funding levels at NIAID are at record lows, and prior to the epidemic, key projects on diseases such as Ebola had languished without adequate financial support. We need to think about the way we are currently funding research on some of these agents, and to identify ways to get more funds into the research environment. We also need to better highlight priority areas for research on emerging pathogens outside of the traditional, NIH peer-reviewed systems, particularly in the current setting of very low funding levels.

Reference:

Gates B, et al. N Engl J Med. 2015;372:1381-1384.

Disclosures: Cohn, del Rio, Evans, and Morris report no relevant financial disclosures.

The current Ebola epidemic in West Africa is the largest in history, with approximately 25,000 cases and more than 10,000 deaths. The crisis prompted a massive international emergency response, which until recently has struggled to keep pace with the disease. Infectious Disease News asked its Editorial Board and other experts if the international community is now better prepared to handle emerging disease outbreaks as a result of the Ebola epidemic.

Read the comments from experts whom Infectious Disease News asked for their opinion. We welcome you to share your opinions.

Carlos del Rio, MD, of Hubert Department of Global Health, Rollins School of Public Health of Emory University and department of medicine, Emory University School of Medicine and Dabney Evans, PhD, MPH, of Hubert Department of Global Health, Rollins School of Public Health of Emory University:

More than a year after the outset of the largest Ebola virus disease epidemic to date, the global health community has started to reflect on the international response with the benefit of hindsight. Prior Ebola virus disease outbreaks had more or less been self-contained geographically and petered out on their own. In the early days of the current epidemic, there was no reason to think this outbreak would be any different. Actors on the ground like MSF seemed nimble enough in their response. But past outbreaks did not well inform what was about to happen, and thus the initial international response was woefully inadequate.

Carlos del Rio

Dabney Evans

Whenever a disaster or emergency impacting health occurs, there is always a period of time between the crisis and the response. Since the 2005 development of the International Health Regulations (IHR), the public health community has benefited from a structured set of operating procedures for disease outbreak alert and response. However, a Public Health Emergency of International Concern (PHEIC) has only been declared three times. In the case of Ebola, this declaration came 8 months after the first case of Ebola virus disease (EVD) in Guinea. Until the world community received this important signal from WHO, the response was mostly limited to those already on the ground. WHO must act more quickly in future outbreaks and not be afraid to declare a PHEIC when appropriate. To her credit, Margaret Chan, MD, director-general of WHO, has called for an external evaluation of the WHO response.

The global good of public health requires a rapid coordinated response in the time of a global emergency. The U.S. government response, including the appointment of an EVD coordinator, has ensured that the U.S. government actors are more or less coordinated; however coordination and collaboration on the ground among the various actors has not been optimal. In the EVD-affected countries, we have seen how a lack of public health systems, including trained health personnel, exacerbated the spread of disease and limited local capacity to respond. Investment in public health infrastructure and health care systems strengthening may be likened to establishing fire codes. It may not mean we will eliminate all fires, but we can decrease the risks and severity when emergencies occur.

More than a year in, things are better than we thought they would be. But they are worse than they could have been had we acted sooner. The same can be said about therapeutic and vaccine trials. Precious time was wasted getting them started, and as the cases have decreased in the past few weeks, the window of opportunity may have closed.

The final lesson is that international response does not stop when disease transmission stops. Complacency is dangerous and a lack of attention to building public health and strengthening health systems in affected countries is sure to lead us back to where we began. As a global community we can choose to pay now or pay later.

David L. Cohn, MD, of Denver Public Health University of Colorado School of Medicine, Infectious Disease News Editorial Board member:

I recently returned from working at an Ebola treatment center in Sierra Leone as a clinician and educator. I had the opportunity to see first-hand the death and suffering of patients with EVD, and the joy and celebration of those who were fortunate to survive. And then, all too often, a survivor quickly learned that many or all of their immediate family members had succumbed to the disease — triumph and tragedy on the same day. But I was also able to be part of a gratifying effort by many committed and dedicated providers working for a common purpose.

David L. Cohn

I also observed the coordination and collaboration between the many different organizations that were on the ground in a concerted emergency response and public health effort against EVD. Every evening the British military convened a meeting of the 27 local, national and international agencies in the Port Loko District to discuss new cases and “hotspots” in the region, contact tracing, surveillance, quarantine, community mobilization and coordination of next steps. Nothing like this existed a few months ago. At this stage of the epidemic, there is now “too much, too late.”

One of the points for discussion was about “phase 2” of the epidemic response (ie, what to do in transition as the case load diminishes while there are still cases in different areas). There were interesting presentations about “Getting to Zero,” and how challenging that will be. Importantly, there was preliminary dialogue about what’s next, when this Ebola epidemic is finally over — with more questions than answers. Who is going to be in charge? Who is going to coordinate restoring other basic health services, which have largely been ignored for the last several months? There is a need for immunization programs, maternal and child health, tuberculosis control, HIV care, malaria treatment and prevention, etc. The three affected West African countries didn’t have sufficient infrastructure; they certainly didn’t have enough health care workers before the epidemic began, and tragically, they have fewer now. Who will fund the process of rebuilding and retraining? Look at Haiti as an example of recent emergency relief. There were significant emergency and humanitarian responses after the catastrophic earthquake and subsequent cholera epidemic, but who’s there now and what has been accomplished? Ebola is a different epidemic with different needs, but the questions are similar.

After undue delay, much of the response to the Ebola epidemic has been impressive and a great deal has been learned. For the international community to be fully prepared for future EVD outbreaks and epidemics due to other pathogens, it will ideally need what Bill Gates has recently recommended: coordination by a global institution with authority and funding, rapid decision making, expanded investment in research and development, improved early warning and detection systems, a reserve corps of trained personnel and volunteers, strengthening of health systems and preparedness exercises to improve responses. We are not close to meeting these aspirations.

J. Glenn Morris, Jr., MD, MPH&TM, director of the Emerging Pathogens Institute at the University of Florida and Infectious Disease News Editorial Board member:

J. Glenn Morris Jr.

This outbreak underscored the lack of appropriate infrastructure at multiple levels. The question is, will there now be the political will to put into place such an infrastructure? This will require money and a willingness to invest in infrastructure (training of public health and medical personnel, construction and equipping of laboratories, and development of surveillance systems) so that underdeveloped nations have the capacity to identify and control outbreaks at an early stage. We need to move away from a purely reactive approach, toward a proactive focus on how we build, long-term, the necessary public health infrastructure within these countries so that they can deal with and contain problems locally, even before the international community can mobilize. The question is not how we target an emergency response, but how we make sure that we don’t need an emergency response the next time around. The problem: this costs money, and it is not exciting enough to get CNN coverage. There will inevitably be savings if we can prevent or minimize future outbreaks, but putting in place the tools to accomplish this may be a hard sell in the current financial climate.

The outbreak also highlights the need to work on our own research infrastructure. The scientific response to the Ebola outbreak has been outstanding. However, it remains difficult, outside of government labs, to get funds from NIH or CDC to move forward quickly with critical research projects in outbreak or other emergency settings; the government labs do a great job, but there is tremendous talent in academia which is often untapped in this setting because of a lack of funding. There also is a need for long-term support of global health research. Funding levels at NIAID are at record lows, and prior to the epidemic, key projects on diseases such as Ebola had languished without adequate financial support. We need to think about the way we are currently funding research on some of these agents, and to identify ways to get more funds into the research environment. We also need to better highlight priority areas for research on emerging pathogens outside of the traditional, NIH peer-reviewed systems, particularly in the current setting of very low funding levels.

Reference:

Gates B, et al. N Engl J Med. 2015;372:1381-1384.

Disclosures: Cohn, del Rio, Evans, and Morris report no relevant financial disclosures.