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Introduction

Microbial threats, including endemic and emerging infectious diseases and antimicrobial resistance (AMR), can cause not only substantial health consequences but also enormous disruption to economic activity worldwide. While scientific advances have undoubtedly strengthened our ability to respond to and mitigate the mortality of infectious disease threats, events over the past two decades have illustrated our continued vulnerability to economic consequences from these threats. For example, during the 2014–2016 Ebola virus disease outbreak in West Africa, the countries of Guinea, Liberia, and Sierra Leone suffered a cumulative economic loss of at least 10 percent of gross domestic product (UNDG Western and Central Africa, 2015). The severe acute respiratory syndrome (SARS) outbreak in 2002–2004 led to an estimated economic impact of $18 billion in East Asia (Fan, 2003) and cost the world economy $40 billion (Lee and McKibbin, 2004). To get a better understanding of the potential direct economic costs of future major infectious disease events, the National Academy of Medicine’s Commission on a Global Health Risk Framework calculated the average expected economic losses from infectious disease crises to cost $60 billion per year in the 21st century (GHRF Commission, 2016). Furthermore, an influential report on AMR in 2016 estimated that the economic cost of lost global production from resistant bacteria could amount to $100 trillion by 2050 if not adequately addressed (Review on Antimicrobial Resistance, 2016). As the world becomes more integrated, the global costs of infectious diseases are expected to rise.

Infectious disease outbreaks can disrupt the economy through various channels. The most obvious may be the direct and indirect effects of mor-

tality and morbidity, which drive the cost of health care and influence the availability of labor and income forgone (Fonkwo, 2008). Another channel that can disrupt the economy is from behavioral effects including social responses of individuals, organizations, and governments influenced by the fear of contagion (Bali et al., 2016). With information, news, and rumors instantly traversing the globe in an increasingly hyperconnected world, fear can become explosively contagious—and it is fear of the pathogen, not the pathogen itself, that often drives behavioral change which then affects the economy (Burns et al., 2006). Specifically, fear of infection may lead government officials to close borders and schools, investors to lose confidence, and individuals to change consumption and social patterns such as avoiding public transportation, movie theaters, restaurants, and other public gatherings. Such was the case in Hong Kong during the SARS epidemic, when mortality from the disease was relatively low at around 900 deaths, yet air traffic fell by nearly 80 percent and retail sales by 50 percent (Lee and McKibbin, 2004; Siu and Wong, 2004).

While there is increasing awareness of these consequences, a deep understanding of the economic dimensions of microbial threats remains incomplete, leaving the world vulnerable to significant economic impacts (Drake et al., 2012; GHRF Commission, 2016). It is still unclear how the aforementioned channels interact with one another to produce cascading effects, disrupt livelihoods, and drive up costs for the afflicted country, neighboring countries, and the world. Furthermore, the practice of modeling the costs as well as risks of microbial threats in the short, medium, and long terms is in its infancy. Other modeling challenges include consensus on the information and assumptions to incorporate, where to find the data, how to deal with uncertainty, and how to analyze, use, and communicate the results to the relevant stakeholders for action (Knight et al., 2016). These issues are further complicated by the fact that the economic impact of various types of microbial threats—endemic infectious diseases, emerging infectious diseases, and AMR—have often been calculated using different methodologies and presented and communicated differently, such as through cumulative cost versus average expected annual loss.

Additionally, the estimates of microbial threat risks are rarely factored into country-level macroeconomic assessments (Sands et al., 2016). As a result, governments underestimate the risk of infectious disease outbreaks, implementing economic policies that largely underinvest in preparedness (World Bank, 2017). On the public health side, strategies and interventions to tackle these risks are often naïve to economic issues. As many sectors have the potential to be affected by these threats, international and country-level coordination and multisectoral partnerships are imperative to preserve global economic stability (GHRF Commission, 2016).

WORKSHOP OBJECTIVES

To assess the current understanding of the interaction of infectious disease threats with economic activity and suggest potential new areas of research, an ad hoc planning committee under the auspices of the Forum on Microbial Threats at the National Academies of Sciences, Engineering, and Medicine planned a 1.5-day public workshop on understanding the economics of microbial threats.¹ This workshop built on prior work of the Forum on Microbial Threats (IOM, 2004, 2010a,b; NASEM, 2016, 2017) and aimed to help transform current knowledge into immediate action. The following topics were explored during the workshop²:

• Economic costs from infectious diseases that may place a disproportionate burden on low- and middle-income countries but affect regional and global stability
• Gaps in assessing economic costs of microbial threats through multiple channels of disruption, including dynamics of fear-based behavioral change
• Critical opportunities and challenges to model and develop metrics of risk, including identifying and using appropriate data, dealing with uncertainty, and building analytical tools to understand the potential economic consequences of infectious diseases
• Strategies to incorporate estimates of infectious disease risk to macroeconomic assessments of economic growth to ensure these risks are reflected in financial markets, business investment decisions, and flows of development assistance, and to link these assessments to incentives for action to minimize the threats
• Implications for upstream and downstream strategies, policies, and interventions that various sectors of government, multilateral institutions, and others may carry out in preventing and mitigating the economic costs
• Collaboration and coordination mechanisms among various stakeholders and across the sectors of public health, animal health, economics, travel, trade, commerce, and agriculture, among others

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¹ The planning committee’s role was limited to planning the workshop, and this Proceedings of a Workshop was prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, and are not necessarily endorsed or verified by the National Academies of Sciences, Engineering, and Medicine, and they should not be construed as reflecting any group consensus.

² The full Statement of Task is available in Appendix A.

The 1.5-day workshop was held on June 12 and 13, 2018, in Washington, DC, and was chaired by Peter Sands, executive director of The Global Fund to Fight AIDS, Tuberculosis and Malaria. Workshop speakers and participants contributed by sharing perspectives from government, academia, and private and nonprofit sectors. With multisectoral participation, the workshop aimed to build more mutual understanding and to bridge those in the economic world with those with public health and clinical experience. The workshop comprised 1 keynote address and 29 speaker presentations over 3 sessions. During the final session, speakers and discussants broke into three groups to identify potential knowledge gaps, research priorities, and strategies to advance the field in understanding the economics of microbial threats.

ORGANIZATION OF THE PROCEEDINGS OF THE WORKSHOP

In accordance with the policies of the National Academies, the workshop did not attempt to establish any conclusions or recommendations about addressing the economics of microbial threats, and instead focused on the information presented, questions raised, and improvements recommended by individual workshop participants. Chapter 2 includes highlights from the keynote presentation on how economic analysis can contribute to global health decision making. Chapters 3 through 5 examine the economics of different types of microbial threats, including endemic infectious diseases, emerging infectious disease outbreaks, and AMR. Specifically, Chapter 3 focuses on the economic cost of endemic infectious diseases. It presents specific examples from global efforts to combat polio, HIV/AIDS, and tuberculosis. Chapter 4 discusses the economics and modeling of emerging infectious diseases and biological risks. It presents the economic costs of past epidemics such as pandemic influenza, Ebola, and Zika, and models for potential future economic consequences. Chapter 5 focuses on cost issues pertaining to AMR. It discusses direct and indirect costs related to AMR, the cost-effectiveness of interventions to mitigate AMR, and the effect of AMR beyond the health sector.

Chapters 6 through 8 focus on the economic perspectives of investing in preparedness to counter microbial threats. Chapter 6 highlights the costs and benefits related to national preparedness initiatives and features perspectives on public health and veterinary services and the One Health approach to building national capacities. Chapter 7 reviews the challenges of accelerated research and development of medical products to address AMR. It reviews opportunities and barriers to incentivizing product discovery and development. Chapter 8 features opportunities to invest in sustainable solutions to microbial threats. It presents issues pertaining to

international collective action and economic bottlenecks in the supply chain of medical products across Africa.

The final two chapters provide potential strategies and final observations made by some participants of the workshop to move the field forward. Chapter 9 provides an overview of next steps suggested during the breakout groups’ discussions that took place during the final session of the workshop, as well as the subsequent discussion and general synthesis. Chapter 10 presents reflections on lessons learned and concluding remarks from the workshop.

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