Pandemic preparedness enables countries to recognize and manage a pandemic (when an infectious disease becomes prevalent over an entire region or the world) through the use of established plans, preparations, and protocols. According to the “Checklist for Influenza Pandemic Preparedness Planning,” prepared by the World Health Organization (WHO) in 2005, the goals of pandemic preparedness are to “help reduce transmission of the pandemic virus strain; to decrease the number of cases, hospitalizations, and deaths; to maintain essential services; and to reduce the economic and social impact of a pandemic.”
Pandemics are unpredictable but recurring events that cause severe social, economic, and political stress. To mitigate the severity of that stress, advanced planning and preparedness are crucial. In the 21st century, this concept primarily has concerned existing and potential global outbreaks of the deadly influenza A strain, such as H1N1 (swine flu) and H5N1 (avian flu). However, historically a variety of diseases have gotten out of control and led to pandemics including measles, tuberculosis, plague, smallpox, human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), and cholera.
A pandemic occurs when an infectious disease, such as a new subtype of a virus, emerges for which no one has an immunity. This typically triggers multiple simultaneous epidemics around the world, with many cases and many deaths. Outbreaks of various diseases happen all the time, and they may even carry a high death toll, but what causes a disease to become a pandemic is how quickly it spreads to large groups via chains of transmission. In the case of flu, this is from person to person. With the ease of global transportation and urbanization, epidemics such as the flu virus can travel rapidly around the world.
The WHO has recommended that countries develop national preparedness plans, specifically to lay out a strategies for handling a flu pandemic. Over the years, more than 140 countries have created national plans for flu pandemics, but according to the WHO, many of these plans will work for outbreaks of other highly transmissable diseases as well. The WHO also has urged countries to adopt its suggested framework for pandemic preparedness.
Pandemic preparedness plans sometimes take years to draft and are supposed to be detailed and comprehensive. This is because the most effective plans take what the WHO calls a “multisectoral” approach, meaning the plan involves “many levels of government, and people with various specialties including policy development, legislative review and drafting, animal health, public health, patient care, laboratory diagnosis, laboratory test development, communication expertise, and disaster management,” according to its 2005 “Checklist.”
History is replete with pandemics that struck fast, hard, and without warning. This historically has left governments and communities ill prepared to handle the catastrophic effects of these pandemics. Many of the worst events killed millions, sickened and left vulnerable millions more, ravaged economies, and shook social and political structures. Some even may have altered the course of history.
One of the first reported pandemics struck the Mesopotamian city of Seleucia (in modern-day Iraq) in 165 CE and spread to Rome. At one point the scourge, which scholars believe may have been either smallpox (an acute contagious viral disease, with fever and pustules usually leaving permanent scars) or measles (an infectious viral disease causing fever and a red rash on the skin), killed an estimated 2,000 Romans per day and even claimed the lives of Roman emperor Marcus Aurelius Antoninus (121–180) and co-regent Lucius Verus (130–169).
The next deadliest pandemic struck the Byzantine Empire in 541 and was likely the first recorded case of the bubonic plague, a bacterial disease transmitted by Page 498 | Top of Articlethe bite of infected fleas (or, in its pneumonic from, person to person), characterized by fever, delirium, and the formation of buboes (swollen, inflamed lymph nodes in the armpit or groin). Known as the plague of Justinian, the event quickly killed roughly 25 million and sickened Emperor Justinian (483–565), although he survived. In the capital city of Constantinople, as many as 5,000 people were dying per day. The plague of Justinian lasted just one year, and by its end about 40 percent of the city's population and roughly one-fourth of the eastern Mediterranean population were dead.
Yet this was nothing compared to the bubonic plague that devastated Europe and Asia from 1339 to 1351. At the time the plague hit, the global population has been estimated to be about 450 million. By its end, about 75 million people, including half the population in Europe, had died. Scientists and scholars believe the disease, also known as the Black Death, originated in China and was carried via infected fleas on shipboard rats along the Silk Road (a network of trade routes that linked the regions of the ancient world in commerce) to Sicily where it quickly spread.
Ensuing centuries would bring more waves of disease. Smallpox from 1775 to 1782 devastated North and Central America; tuberculosis (an infectious bacterial disease characterized by the growth of nodules in the tissues, especially the lungs) ravaged Europe and North America from 1800 to 1922; and seven cholera (an infectious and often fatal bacterial disease of the small intestine) pandemics since 1817 have killed millions globally.
That said, nothing prepared the world for what would become known as the deadliest pandemic in history. In its first 25 weeks, the Spanish flu that began in 1918 killed on average 1 million people per week worldwide and about 40 million by the time it ended abruptly in 1919. The flu spread quickly, exacerbated by close living quarters among troops fighting in World War I (1914–1918).
The disease came on quickly, with people feeling perfectly fine in the morning only to die by nightfall. Those who did not die from the flu itself often succumbed to complications caused by bacteria, such as pneumonia. Furthermore, whereas most flu strains are deadly primarily for the very old and the very young, this flu killed healthy adults mostly between the ages of 20 to 50 years old.
Flu viruses are so common there is a new pandemic at least once per generation. Since the 1918 pandemic there have been three major flu pandemics including the 2009–2010 H1N1 pandemic. Also known as the “swine flu” because of the strain's resemblance to a virus that afflicts pigs, this flu was particularly virulent. Before it subsided, between 43 million and 89 million people had H1N1 between April 2009 and April 2010, according to the U.S. Centers for Disease Control and Prevention (CDC). There were an estimated 8,870 to 18,300 H1N1-related deaths, reports the CDC.
Among the recent global pandemics is HIV/AIDS. This retrovirus (a family of enveloped viruses that replicate in a host cell through the process of reverse transcription) is transmitted through bodily fluids and breaks down the body's immune system. Scientists think the virus first infected people in Africa sometime before 1937 but was not identified until the early 1980s. The disease initially spread slowly, but an epidemic among homosexual men in Western countries at the end of the 1970s eventually caught the attention of scientists and public health professionals. There is no cure for HIV/AIDS, although antiretroviral drugs seem to temper the disease, allowing those infected to live longer.
HIV/AIDS is an ongoing pandemic. The virus has infected more than 75 million people, killed more than 39 million, and remains a major global health concern. According to the WHO, there were approximately 35 million people living with HIV at the end of 2013, with 2.1 million people becoming newly infected with the virus that year. Sub-Saharan Africa accounts for almost 70 percent of the global total of new HIV infections.
Impacts and Issues
There are myriad diseases that could cause a pandemic. For example, one that scientists and public health officials are watching is the coronavirus, which causes severe acute respiratory syndrome (SARS, a severe form of pneumonia). This disease first appeared in China in 2002 and quickly caused 8,096 cases and 774 deaths. It spread to 26 countries before that wave fizzled out in 2003 because infection control procedures prevented further spread.
One of the most difficult viruses to contain is the influenza virus because of its ability to spread and mutate quickly, rendering vaccines developed to fight it ineffective. Outbreaks of flu occur annually, but occasionally a strain emerges that causes a worldwide pandemic, such as the Spanish flu of 1918. But even a typical flu year can cause seasonal outbreaks that sicken as many as 5 million and kill 500,000. Furthermore, the virus is endemic in several species, including humans, birds, and pigs.
The concern in the 21st century has been several avian influenza A viruses that have emerged, including H5N1 virus, first detected in 1997, and the H7N9 and Page 500 | Top of ArticleH10N8 viruses, first reported in 2013. Any of these could hold potential for pandemic, but that is what frustrates scientists, public health officials, and the public: these diseases are unpredictable, with the only certainty being not if there will be a pandemic, but when.
This is particularly worrisome because pandemics share some common characteristics and challenges, including a rapid spread with a global reach among populations with little or no immunity to the disease. Because of this, health systems can become overwhelmed quickly. Most nations are not likely to have the staff, facilities, equipment, and hospital beds needed to cope with the sheer number of sick people coming through the doors. Putting plans in place to accommodate for such events is called surge capacity, which requires preparing to have enough staff, hospital beds, ventilators, medications, vaccines, coffins, morgue space, and so forth, in place if a pandemic occurs. For diseases where a vaccine is available and antivirals necessary, the supply is likely to be much smaller than the demand. In addition, if past pandemics are any indication, these viruses tend to spread globally in two or three waves of illness. Moreover, pandemics disrupt the economy and the regular function of society. From travel bans to event cancellations to school and business closings, pandemics can cause major financial and functional damage in a community.
Successful implementation of a comprehensive plan for addressing a pandemic can save many lives, although the unpredictability and rapid spread of pandemics will still exact a global toll. According to the WHO in its 2005 “Checklist for Influenza Pandemic Preparedness Planning,” “even in one of the more conservative scenarios, it has been calculated that the world will face up to 233 million outpatient visits, 5.2 million hospital admissions, and 7.4 million deaths globally, within a very short period.”
The international community had long recognized the need for coordination between countries in order to contain disease. Following cholera epidemics in Europe in the early 19th century, an 1851 conference in Paris produced the International Sanitary Regulations. These were revised and renamed the International Health Regulations (IHR) in 1969. By 1995, it had become clear that the IHR needed revision again, both to account for emerging infectious diseases and to better increase communication and coordination between countries in response to diseases. The revised version of IHR was completed in 2005 and went into force in 2007. The IHR is an international law that binds the WHO and its 194 member countries to uphold certain obligations when it comes to the prevention, control, and response to public health risks that may spread between countries. In addition to having a preparedness plan in place, member states also are obligated to notify the WHO, which the IHR establishes as the lead agency during an international public health crisis, of incidents that may affect public health. Other regulations govern international travel, including health measures for travelers and sanitary procedures at points of entry into a country.
The first test of this law came during the 2009–2010 swine flu outbreaks. While this framework created mechanisms for good communication, information sharing, and a recommended chain of command, it broke down in some key areas, according to Dr. Harvey V. Fineberg, in his 2014 review of the process for the New England Journal of Medicine titled “Pandemic Preparedness and Response—Lessons from the H1N1 Influenza of 2009.”
Among the challenges, Fineberg found, was that different countries had plans at varying levels of completion. Some countries and even the WHO did not have the budget or resources to implement certain mandated portions of the law, and the law lacked financial penalties or punitive trade sanctions should member states violate any portion of the law. Efforts to address these shortcomings are ongoing.
Moreover, the WHO states that another problem with the law is that different countries have different legislations, policies, regulations, and requirements that support IHR implementation to varying degrees. To that end, the WHO has been working with member countries to push through legislation at the national level to help smooth this process.
When it comes to the creating the plans themselves, the countries have to at minimum establish a procedure and leadership protocol to address preparing for an emergency, surveillance, case investigation and treatment, preventing spread of the disease in the community, maintaining essential services, and researching, evaluating, and implementing testing and revision of the national plan. To implement these plans, the WHO recommends what is called a “Whole of Society” approach, which emphasizes the importance of involving everyone—not just the health sector—in helping to contain the spread of a pandemic.
For example, national governments need to lead the overall coordination for preparedness. It is the governments' responsiblity to enact or modify legislation and policies in support of pandemic preparedness while also ensuring that resources are properly allocated. Governments are also best equipped to coordinate efforts across agencies both in the public and private sector to mobilize a broad response to a pandemic should the need arise.
Meanwhile, the health sector's responsibilities include providing reliable information on the risk, severity, and progression of a pandemic; prioritizing and continuing health care during a pandemic; enacting steps to reduce the spread of the disease in the community and in health-care facilities; and protecting and supporting health-care workers during a pandemic.
Under this approach, even businesses, communities, individuals, families, and civil society organizations have roles to play in mitigating the effect of a pandemic. For example, if electrical or water services are disrupted during a pandemic, the service providers are supposed to have a contingency plan so that if nothing else, they can Page 501 | Top of Articleget power and water to medical facilities to ensure the facilities can continue to operate and provide care.
Furthermore, civil society organizations are expected to harness their various expertise and their close and direct relationship with the public to offer support as well as raise awareness and communicate accurate information to the public. For individuals and families, their primary responsibilities include making sure that they have access to accurate information, food, water, and medicines and are self-quarantining if necessary.
One of the major challenges outlined by Fineberg in the 2014 article analyzing the global response to the 2009 H1N1 epidemic was the failure of many member states to fulfill the requirements for pandemic preparedness mandated by the IHR. A WHO questionnaire distributed to member states in 2011 received only a 66 percent response rate, or 128 members of a total of 194. Of those who responded, only 58 percent had developed blueprints for achieving pandemic preparedness, and less than 10 percent reported having fully implemented the recommendations of the IHR.
Still, one of the biggest limitations in preparedness remains how little is known about pandemics. Fineberg notes that “the annals of influenza are filled with overly confident predictions based on insufficient evidence.” In reality, it is impossible to know which virus will emerge as the next pandemic, and how severe it will be, but more research can help mitigate the uncertainty.
Although information and even vaccine sharing between countries is improving, the traditional methods of vaccine production, particularly when it comes to the flu, cannot respond quickly enough to an emerging pandemic. The traditional model relies on growing vaccine viruses in eggs, which requires a large amount of eggs as well as time for the viruses to grow and replicate in the eggs. In 2013 the U.S. Food and Drug Administration approved a method of vaccine production that involves a “recombinant” vaccine virus (meaning that its genetic Page 502 | Top of Articlematerial comes from different sources) that can replicate in insect cells. The fact that this methodology is not reliant on the egg supply or the availability of the influenza virus means that production can ramp up far more quickly.
Fineberg's analysis of the 2009 H1N1 epidemic acknowledged the challenges of readiness, including insufficient resources, the need for international coordination, and the difficulty inherent in making quick and measured decisions when a pandemic arises. Beyond better research and vaccine production, pandemic preparedness requires the full commitment to pandemic preparedness on the part of government and health agencies, including the provision of adequate funding for research and preparedness initiatives, proper staffing of public health leadership and analysis positions, and better coordination and information sharing between countries. Fineberg also offered this warning: “Whenever the next influenza pandemic arises, many more lives may be at risk. By heeding the lessons from the 2009 H1N1 pandemic, the international community will be able to cope more successfully the next time.”
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Melanie R. Plenda