The reconstruction of a once-living landscape in northern Greenland from 2 million years ago, deduced from bits of DNA bound to minerals…
Planning for the next pandemic begins with acknowledging what we did wrong for COVID-19. As the situation has calmed, experts are weighing in on what we did, and didn’t do, as the months unfolded. I’ve distilled and organized their comments from the medical literature and webinars. Several of the opinions are from Preventing the Next Pandemic: New Tools for Global Surveillance, which the Harvard T. H. Chan School of Public Health held for journalists October 17, 2022.
Next time, we should:
1. Recognize the field of ethics as practical, not just an academic discipline.
Determining the ‘right’ course of action in many circumstances proved more vexing and controversial than solving the technical challenges, such as developing vaccines and treatments, wrote Ezekiel Emanuel, Vice Provost for Global Initiatives at the University of Pennsylvania and colleagues, in The New England Journal of Medicine (“What COVID Has Taught the World About Ethics“).
Allocating resources, and carrying out mandates and restrictions, require value judgments, rather than the technical skills needed to invent vaccines. While global leaders spoke often of “fairness, “solidarity,” and “equity,” implementing these actions often proved elusive. We should have known better from tackling outbreaks of influenza, Ebola, and Zika virus, and used ethical frameworks already in place from allocating penicillin during World War II, dialysis in the 1960s, and HIV/AIDS antiretroviral drugs in the 1990s.
We should learn from the past. “Ethics cannot simply be switched on during an emergency,” they wrote.
2. Share vaccines across the globe.
Keeping vaccines mostly in wealthy nations led to excess deaths, while encouraging viral variant evolution, wrote Sam Moore, of the Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research, University of Warwick, UK and colleagues in Nature.
Discrepancies are stark. Some countries vaccinated more than 90% of adults, while others protected less than 2%. The authors modeled the impact of different potential vaccine sharing protocols, considering age and using data from 152 countries from 2021. They quantified the effects of various rollout strategies on the spread of SARS-CoV-2, the global burden of disease, and emergence of novel variants.
“Greater vaccine sharing would have lowered the total global burden of disease,” they pointed out. Interventions such as masking and limiting activities might have countered increases in infections stemming from sending more vaccines to other nations. “Our results reinforce the health message, pertinent to future pandemics, that vaccine distribution proportional to wealth, rather than to need, may be detrimental to all,” they concluded.
3. Leave COVID expertise to the CDC.
The CDC has delayed, confused, and botched some responses to the pandemic, but the agency needs to re-emerge as a leader in fighting infectious disease, said Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine, at the 2022 Texas Vaccine Policy Symposium held October 14. “I think the answer is fixing the CDC, empowering the CDC, and putting them out in front — together with the state and local health agencies. Until we do that, we’re definitely not ready for another pandemic.”
Hotez pointed out early errors that we should learn from. The CDC:
• focused on China as the source of the virus even as the first recognized mutation was already spreading throughout New York City, from southern Europe.
• botched the initial roll-out of tests.
• imposed too-late travel restrictions that conjured images of barn doors shutting after bolting horses.
• lagged in sequencing viral genomes to track and predict viral evolution.
“The last thing that should be done going forward” is to create a pandemic threat center in Washington, Hotez concluded.
4. Pay closer attention to clues in wastewater.
We don’t need only to swab noses to track COVID – the virus goes down toilets, sinks, and into the garbage. Analyzing sewage provides a larger-scale view of the spread of an infectious disease.
“If we’d had wastewater systems in place from the start, we could have looked for SARS-CoV-2. One test can capture 100,000 to a million people, whereas one test at a clinic captures one person,” said Alexandria Boehm, professor of Civil and Environmental Engineering at Stanford University.
Wastewater screening is in force now. Boehm showed a video of her grad students and post-docs collecting liters of pumped sewage, allowing the solids to settle, and then decanting the liquid. She described the process graphically:
“First the collected wastewater is boiled down into a composite that includes blood, saliva, mucus, feces, scabs, skin cells, and anything that goes down a drain. If you have a genomic sequence of the threat, old or new, you can look for nucleic acids. Whether it is influenza A that we know a lot about, or a new threat like SARS-CoV-2, or an emerging threat like monkeypox, we can look for it in wastewater. If we detect nucleic acid, we know that someone is shedding that material and is likely infected. So wastewater captures all excretions from everyone in a watershed. That can be as few as 10,000 people or 2 or 4 million, depending on location.”
Perhaps most importantly, analyzing wastewater can detect viral variants as they emerge. “Wastewater tracking can anticipate new threats and warn public health leaders. Before COVID there was little research for infectious disease surveillance, but people all over the world mobilized at the start of the pandemic to use wastewater to monitor COVID. Wastewater works well for surveying all sorts of infectious diseases,” Boehm said. But not all locations have wastewater treatment plants, she added.
5. Deploy genomic surveillance sooner.
The sequences of building blocks of nucleic acids – RNA for SARS-CoV-2 – serve as a language of sorts that can communicate the rise and spread of new mutations and the variants that they form as they recombine.
Sikhulile Moyo, who discovered Omicron and is laboratory director for the Botswana Harvard AIDS Institute Partnership, relates how RNA sequencing enabled its detection:
“Genomic surveillance in public health has showed us the value of intervening, even when a variant is not seen in other parts of the world. Omicron was in Botswana in mid-November 2021 and swept across the world, bringing a new wave of uncertainty about the future of the planet. We learned the speed of its spread in terms of sharing data and making sure the world had time to prepare with near real-time genomic surveillance. Many scientists, when Omicron was just in southern Africa, told the rest of the world that a surge was coming because of the nature of the changes in the genetic makeup of the virus. A large number of mutations were characterized that could drive transmissibility. That prediction was correct and led to interventions like renewed social distancing. And we saw a sudden uptick in vaccination programs and government response in days, not months – all of which were important in trying to slow transmission.”
Moyo also credits the value of analytical dashboards that link mutations and variants to epidemiology, clinical outcomes, and vaccine efficacy.
More recently, genomic surveillance has revealed a settling down of the mutational hotspots in the SARS-CoV-2 genome. Convergent evolution is selecting and amplifying genomes that benefit the virus – and, fortunately, are less deadly to us – for now.
6. Consider social determinants of health (SDOH) in different parts of the world.
Satchit Balsari, assistant professor of Global Health and Population at Harvard, pointed out a “lack of imagination at all levels” in considering how people live:
“Not everyone has the luxury of space to do social distancing; most of humanity doesn’t live in an American suburb. Lockdowns deprived millions of workers of their livelihoods, resulting in extreme food insecurity. There was schooling by zoom for households that barely had a phone, let alone a cell phone, where families had worked for decades to be able to put their kids in schools.”
“We learned so fast that infectious diseases are a societal issue. A virus doesn’t have a passport. We needed to make sure global health is connected and nations respond together, not in tandem. Responding in silos exposed major societies in poor settings ravaged by the virus. We raised the bar in vaccine production, but the inequality that arose in distribution exposed the weakness in the global health system.”
At the CDC, Marc Lipsitch leads the Center for Forecasting and Outbreak Analytics, which addresses social determinants of health to help predict how an epidemic or pandemic will unfold, and “to make sure all levels of society are prepared and to break down pandemic science to allay fears and reduce hesitancy. In Africa we need to foster solidarity among countries to align pandemic preparedness,” he said.
7. Use mobility data.
Epidemiologists recognized the value of data from cell phones and apps early on, after years of using remote sensing and closed circuit TV. “In early 2020 we realized the capability to interpret streams of aggregated mobility data in a desperate attempt to respond to the pandemic,” recalled Balsari.
The COVID-19 Mobility Data Network started in March 2020. “It is a volunteer partnership of more than 70 researchers. Teams communicated daily with local, state, and national agencies to interpret mobility data in their jurisdiction. For example, the data indicated mobility increased in Manhattan but not in the Bronx. The correct response was to provide more support to the Bronx,” said Balsari. Data are aggregated and anonymitized before they’re shared, using existing methods.
Researchers can parse situations with mobility information. “If you restrict freedom does it impact transmission and spread of the virus. Commuting? Getting together? How much is enough social interaction to impact epidemiology?” Balsari asked.
8. Combine data sources.
Tracking the spread of COVID became more complicated once people began testing at home and rarely reporting positives to public health authorities, said Lipsitch. “Combining data sources is more important than ever” in foretelling waves of infection, he said. He suggested measuring viral load, which indicates how much virus is in a person, and therefore how infectious they are. If sneezes eject significantly more virus, then a resurgence or wave is forthcoming.
9. Nix travel bans.
Viruses do not adhere to human-created borders – biologists realized the futility of restricting air travel immediately. But politicians persisted, thinking they were acting, or reacting, swiftly. “Travel bans, when we look back, were not the best way in southern Africa and did more harm than good in slowing the pandemic. Viruses move as people move,” said Moyo.
Lipsitch concurred. “We were watching Omicron in southern Africa and it was clear that a new wave would sweep through the world. What was less clear early was how severe the cases would be.” Within a month, by mid-December 2021, researchers at Kaiser Permanente and Berkeley had compared a sufficient number of cases of Omicron and Delta to determine that the newbie was milder, he added.
10. Train eclectic types of public health professionals.
The COVID pandemic found physicians suddenly having to be experts in genomics, data science, communication, sociology, and more. They can’t do it all. “We must rethink our training in public health to ensure people graduate as not just doctors, but also masters in public health and other types of training that enable appreciation of how different types of data can be combined to produce a big picture of what’s going on,” Lipsitch said.
Viral genomes are undoubtedly already brewing the next pandemic. With the many lessons learned from the no-longer-novel coronavirus that burst into existence in late 2019, perhaps we will be faster to contain the next outbreak destined to go global.