From Ebola outbreak in West Africa to the most recently, the rapid spread of Zika has shown that even with all advances in modern medicine we are still not completely safe from pandemics. These epidemic of infectious diseases can spread quickly through human populations across a large region several continents, or even worldwide. Since the first reported case in December 2013 in Guinea, the Ebola outbreak quickly spread to bordering Liberia and Sierra Leone ravaging West Africa. In addition to these naturally occurring threats, terrorists and other potential adversaries have a growing palette of biological tools to engineer new biological threats.
Bill and Melinda Gates have also warned in their report “Goalkeepers” report , disease – both infectious and chronic – is the biggest public health threat the world faces in the next decade. “you can be pretty hopeful there’ll be big progress” on chronic disease, we are still unprepared to deal with the infectious variety.
The major threats are today’s major pandemics of AIDS, TB, and Malaria; future outbreaks with the potential to become pandemics; and rising risk from infectious diseases associated with climate change. Meanwhile, climate change and mass migration are compounding the complexity of the task. Without additional action, climate change is poised to put nearly a billion people newly at risk of mosquito-borne viruses. Drug-resistant infections are on the rise.
Pandemics put millions of lives are at risk and their economic consequences can run into billions. The 1918 pandemic killed approximately 50 million people around the globe, making it one of the deadliest events in human history. Last Ebola outbreak cost more than 11,000 human lives and more than $32 billion in economic ripple effects while Zika has cost the economies of Latin America and the Caribbean an estimated $18 billion.
The increase in frequency and diversity of reported disease outbreaks—such as dengue and Zika—probably will continue through 2018, including the potential for a severe global health emergency that could lead to major economic and societal disruptions, strain governmental and international resources, and increase calls on the United States for support, said annual world threat report by intelligence agencies. A novel strain of a virulent microbe that is easily transmissible between humans continues to be a major threat, with pathogens such as H5N1 and H7N9 influenza and Middle East Respiratory Syndrome Coronavirus having pandemic potential if they were to acquire efficient human-to-human transmissibility.
Pandemics also affect militaries. Warfighters must also operate in regions where diseases like chikungunya and dengue are endemic, and even seemingly mild challenges like seasonal influenza affect force readiness. The threat of infectious agents on U.S. and global national security can be mitigated if the Department of Defense (DoD) has the capability to rapidly deploy and impart near immediate immunity to military personnel and civilian populations for known and newly emerging pathogens.
Eliminating pandemic outbreaks and mitigating the impact of a potential high threat biological agent release are national security priorities. As the bipartisan Blue Ribbon Study Panel on Biodefense highlighted, U.S. levels of readiness and global coordination are woefully inadequate.
The U.S. military supports U.S. Government responses to public health emergencies such as Ebola, which can cause regional destabilization and spread through global travel, says DARPA. DARPA has issued a new broad agency announcement (“BAA”) seeking proposals to support the creation of an integrated “capability platform” for the delivery of medical countermeasures to prevent a pandemic threat within sixty days of targeting a known or newly emerging pathogen.
Risk of pandemics
The Global Challenges Foundation had released report that found pandemic as one of the 12 global risks that threaten human civilization. “There are grounds for suspecting that such a high impact epidemic will have a greater probability than usually assumed. All the features of an extremely devastating disease already exist in nature: essentially incurable (Ebola), nearly always fatal (rabies), extremely infectious (common cold), and long incubation periods (HIV). If a pathogen were to emerge that somehow combined these features (and influenza has demonstrated antigenic shift, the ability to combine features from different viruses), its death toll would be extreme”, says global challenges report.
The last 30 years have seen a steady increase in the frequency and diversity of disease outbreaks. With unprecedented mobility of people, products, and food, the myriad of disease-causing microorganisms are also increasingly mobile. No nation is immune to this growing global threat that can be posed by an isolated outbreak of an infectious disease in a seemingly remote part of the world, says World bank. Most of these outbreaks are caused by pathogens of animal origin that are transmitted to people, such as Ebola and avian flu.
Scientists estimate that between 1940 and 2004, 335 new infectious diseases appeared in humans. This number includes pathogens that likely entered our species for the first time, such as HIV, and newly evolved strains of familiar organisms, such as multidrug-resistant tuberculosis. The majority of these diseases—about 60 percent—were caused by zoonotic pathogens, meaning they were transmitted to humans from animals. And of those, about 70 percent were from animals that typically live in the wild.
These include HIV and AIDS, influenzas (including pandemic H1N1, H5N1 and H7N9), Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome-Coronavirus (MERS-CoV), Ebola, Marburg, and Nipah. Several of these have spread extensively in human populations to cause a global epidemic (also known as a pandemic).
Ran Balicer, director of the infectious diseases track in the public health department of Ben Gurion University in Israel, thinks that the most likely candidate for another pandemic is a strain of influenza. “It is always on the horizon, and is a devastating scenario,” he said. “It has a good possibility of manifesting in our lifetime; there have been three major pandemics, and a mild one three years ago – which doesn’t reduce the possibility of a pandemic happening.” If antibiotic resistance develops, humanity could see the resurgence of bacteria-based pandemics.
Today, a pathogen like influenza has the potential to travel around the world within hours and could kill tens of millions of people, disrupt economies, and destabilize national security. Modelers predict the emergence of an airborne virus of this sort sometime in the next 10 to 15 years. The number and diversity of disease outbreaks has increased significantly since 1980.
Factors that impact severity and probability
Christophe Fraser, a professor of epidemiology at the medical research council center for outbreak analysis at Imperial College, London, described four factors that are crucial in determining how severe an epidemic will be: how easily the disease is transmitted; how feasible it is to develop a vaccine and a treatment; how long before symptoms are visible the patient is infectious; and the severity of the disease – what proportion of people who contract it die.
The” Lancet Global Health: Beyond Ebola: lessons to mitigate future pandemics” says, Increasing anthropogenic environmental changes, coupled with a globalised network of travel and trade, allow zoonotic pathogens to spill over into human beings with increasing frequency, and leave us supremely vulnerable to their international spread.
The impact depends on factors including how mobility of goods and people, as well as population density, will affect pandemic transmission, how fast medical research can proceed in an emergency and whether humans can develop novel and effective anti-pandemic solutions.
Pandemics are one of the risks where there is a possibility for a very large number of direct casualties, depending on the severity of the pathogen. Mass casualties could destabilize the world political and economic systems. If the pathogen is transmissible to farm animals, this could affect the world food supply.
Hence the risk of a civilisation collapse would come from the ripple effect of the fatalities and the policy responses. These would include political and agricultural disruption as well as economic dislocation and damage to the world’s trade network (including the food trade).
The World Bank Group released a report in April 2015 showing that the Ebola epidemic continues to cripple the economies of the three hardest-hit countries—with a projected $2.2 billion in lost GDP for 2015. Estimated economic losses for 2015 across sub-Saharan Africa range from at least $500 million to as high as $6 billion if the epidemic were to spread further through the region. Recent economic work estimates that the annual global cost of moderately severe to severe pandemics is roughly $US 570 billion, or 0.7% of global income.
Ebola isn’t our first wake-up call that pandemics are costly. From 1997-2009, six major outbreaks of highly fatal zoonoses—animal-borne diseases that can be transmitted to humans, such as Ebola, SARS, avian and H1N1 flu—caused an estimated $80 billion in economic losses. The human and social costs are incalculable.
Extinction risk is only possible if the aftermath of the epidemic fragments and diminishes human society to the extent that recovery becomes impossible before humanity succumbs to other risks (such as climate change or further pandemics).
While progress has been made since the recent Zika and Ebola crises, a report by the International Working Group on Financing Preparedness, established by the World Bank, finds that most countries are still not adequately prepared for a pandemic. Many countries chronically underinvest in critical public health functions like disease surveillance, diagnostic laboratories, and emergency operations centers, which enable the early identification, response, and containment of outbreaks.
This is especially short-sighted given the low cost of preparedness relative to the devastating impact of a pandemic. In low- and middle-income countries that have calculated the cost of financing preparedness the investment required is up to $1 per person per year.
The inadequacies of the health-care systems in the three most-affected countries help to explain how the Ebola outbreak got this far. Spain spends over $3,000 per person at purchasing-power parity on health care; for Sierra Leone, the figure is just under $300. The United States has 245 doctors per 100,000 people; Guinea has ten.
What would mitigation strategies to deal with future pandemic risks?
The” Lancet Global Health: Beyond Ebola: lessons to mitigate future pandemics” says, “Pandemics are no longer simply the domain of public health and clinical medicine, but are a social issue, a development issue, and a global security issue.Mitigation of future pandemic threats such as Ebola is more cost-effective than the current approach of responding to outbreaks after they have begun to spread rapidly in the human population.
Analyses of emerging disease trends during the past six decades have shown that Ebola fits the dominant pattern. This pattern involves zoonotic spillover from wildlife or livestock driven by changes in land use, crop choices, migration patterns, animal husbandry, trade, transport, and travel.
Global mitigation of future pandemic risk must focus on the largescale behaviors that lead to zoonotic spillovers. This approach means engaging with the sectors that drive disease emergence, including industries involved in land-use change, resource extraction, livestock production, travel, and trade, among others.
The improvements to surveillance and sensing technologies (including indirect detection via web queries or social media) open the possibility of smarter interventions (such as microquarantines) and faster understanding of the pathogen’s transmissibility. Various countermeasures are available in terms of detection, virus analysis, treatment, and quarantining. Future research, technological and political developments may open up new methods of fighting the pathogen.
The efficiency of global reaction to a new pandemic will be strongly determined by the speed of research on the pathogen during the pandemic. The acceleration of vaccine development for Ebola as part of an outbreak control strategy could also have a crucial role to mitigate future outbreaks.
Ebola’s propensity for nosocomial spread could be curtailed by pre outbreak vaccination of critical care workers in Ebola virus hotspots. Likewise, targeted training in infection control, and efforts to maintain surge capacity between outbreaks, will be crucial for rapid response to the first cases in a future emergence event.
Philips and the U.S. Department of Defense Develop Breakthrough Technology Using AI to Identify Infection More Than 48 Hours Before Observable Symptoms
Royal Philips , a global leader in health technology, the Defense Threat Reduction Agency (DTRA), and Defense Innovation Unit (DIU) of the U.S. Department of Defense (DoD) announced in oct 2019, highlights from an 18-month project in predictive health monitoring aimed at developing an early warning algorithm to detect infection before an individual shows signs or symptoms.
The project, Rapid Analysis of Threat Exposure (RATE), is the first large-scale empirical exploration of prediction of pre-symptomatic infection in humans and is part of efforts to improve readiness, as well as being broadly applicable in healthcare settings. As envisioned by DTRA, an early warning system that facilitates faster diagnosis and treatment of infection can reduce individual downtime and aid in quickly containing the spread of a communicable disease by isolating exposed individuals sooner.
The prototype revealed that using artificial intelligence (AI) to look at certain combinations of vital signs and other biomarkers could strongly predict the likelihood of infection up to 48 hours in advance of clinical suspicion, including observable symptoms. In addition, it found that the combinations of significant vital signs and biomarkers varied based on time before clinical suspicion of a hospital acquired infection (HAI). Future research is currently being planned to leverage this information as an algorithm to be integrated into a wearable device, allowing a soldier’s health to be non-invasively monitored and delivering earlier alerts to potential infection. The technology could further be applied in a civilian capacity by helping to monitor hospital patients for infection prior to clinical symptoms.
“The unique capability that Philips has produced enables the chemical and biological defense medical paradigm to shift from a reactionary focused one to a predictive one. This provides our commanders with insight into their troops’ future readiness levels and can influence mission planning and overall military effectiveness,” said Edward Argenta, Science and Technology Manager for the Joint Science & Technology Office at DTRA.
Traditional approaches to diagnosing infections rely on recognition of overt signs, which can mean implementing medical countermeasures after active duty personnel have already been compromised and potentially exposed others. Characterizing pre-symptomatic sentinels indicative of infection using AI mechanisms can help reduce time to diagnosis and treatment, but as with any AI, this process requires a large reliable dataset.
Unlike other narrow attempts to predict human infection, the RATE approach uses large-scale data machine learning and trade-space analyses across 165 different biomarkers from a rich Philips dataset of over 41,000 cases of HAIs. The dataset was extracted from a large data repository of more than seven million hospital patient encounters. The pared down cases were used as a surrogate dataset for infection in otherwise healthy military personnel and analyzed to develop a predictive algorithm of disease. The performance of the algorithm to predict infection 48 hours before clinical suspicion can be characterized technically as area-under-the-curve of 0.853. For comparison, this performance lies in between blood-based breast and prostate cancer screening tests and an enzyme immunoassay based first-tier Lyme disease test.
“At Philips, we understand that large, reliable datasets are the lifeblood of AI-based healthcare applications and we have been at the forefront of creating them for the development of machine learning in collaboration with our clinical and academic partners for some time now,” said Dr. Joseph Frassica, chief medical officer and head of research for Philips North America. “By coupling large-scale data, with our experience in AI and remote patient monitoring with DTRA’s drive for innovation, we were able to develop a highly predictive early-warning algorithm based on non-invasively collected biomarkers. While the RATE data is derived from acute care settings, we believe that it is adaptable to active duty personnel. These results can be extended in future work to also apply to other healthcare settings, and to include scenarios where vital signs and biomarkers fluctuate as a function of factors such as physical exertion and heat stress.”
Need for Pandemic Emergency Facility
Fraser said that the current outbreak of Ebola has shown that the global systems that are supposed to spot outbreaks of diseases are not good enough, “and more importantly, the action that follows is not fast enough, not coordinated enough, to cut off an epidemic at source. Although existing multilateral agreements (eg, the International Health Regulations) allow for some coordination of national responses to outbreaks and bilateral interventions to build public health capacity in poor countries, more is needed.
The Ebola crisis and other similar crises point to the need for prevention, preparedness, early detection and timely support to help countries deal with infectious disease outbreaks. Financing for a pandemic emergency is essential—to ensure that the right amount of money is available at the right time, minimize the human and economic impacts, and spur better preparedness. The better prepared, the faster and less expensive our response. In a world of scarce resources and fast-moving, unpredictable crises, the traditional approach of mobilizing resources in the wake of an outbreak is slow, inefficient and fragmented.
The World Bank Group (WBG) is working with WHO and other partners, including the private sector, to develop and implement a new Pandemic Emergency Financing Facility (PEF). The PEF is a global financing facility that would channel funds swiftly to governments, multilateral agencies, NGOs and others to finance efforts to contain dangerous epidemic outbreaks before they turn into pandemics. Post-pandemic politics will also be important for preventing a civilisation collapse or enabling reconstruction.
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