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1 Introduction I n 1918, an influenza pandemic of unparalleled scope and severity swept across the globe. By the time it subsided, the pandemic had infected around 500 million people, roughly one-third of the worldâs population at the time, and resulted in at least 50 million deaths worldwide (Barry, 2005). One century later, outbreaks and pandemics of influenza and other infectious diseases have caused widespread human suffering and deaths, and continue to pose major threats to public health, health security, and societal and economic stability at the local, national, and global levels. The past several decades alone have seen more than 30 large-scale recurring and emerging infectious disease threats that have caused events ranging from fairly localized outbreaks to pandemics (Mukherjee, 2017). This trend is expected to rise, as the result of many factors such as increased humanâÂ nimal contact, climate change, land use changes, global popula- a tion growth, and increased global interconnectedness (Jones et al., 2008). Advancements in science and technology related to diagnostic capaci- ties, vaccines, and antivirals have provided more effective tools for preventÂ ing and responding to infectious disease threats. Given the host of challenges associated with the timely development and deployment of strain-specific influenza vaccines, international efforts for developing a universal influ- enza vaccine have generated some optimism. The movement toward a One Health approach to pandemic preparedness, which encompasses human, animal, plant, and environmental sectors, is also promising, as many infec- tious disease threats of significance originate among animals and cross-over 1
2 LESSONS LEARNED FROM A CENTURY OF OUTBREAKS to humans (Morse et al., 2012). While many advances have been made, critical challenges remain in developing, evaluating, and deploying medi- cal countermeasures and other interventions to adequately counter major outbreaks (GHRF Commission, 2016). On the international front, global health experts have established global governance frameworks, financing mechanisms, and legal instru- ments to support the global community to respond to infectious disease outbreaks and epidemics. However, the failures in response to the 2014 Ebola outbreak in West Africa suggest that current global governance structures and operational synergies within and among various coun- tries, institutions, and international bodies may be unable to respond adequately to catastrophic infectious disease crises (GHRF Commission, 2016). Progress has also been made in strengthening preparedness from local to national levels, but health systems in many countries and commu- nities still lack day-to-day health delivery functions and have little capacity to surge during an infectious disease outbreak or pandemic. No other pandemics in the past century have approached the magni- tude of the 1918 influenza pandemic. If a pandemic of comparable scale and impact to the 1918 pandemic were to occur today, modeling estimates suggest that the impact could be similarly devastatingâkilling between 50 and 80 million people worldwide, with expected annual global losses from pandemic risk of around $500 billion per year (Murray et al., 2006; Fan et al., 2018). However, there are opportunities to mitigate these grim s Âcenarios. Collective action at local, national, and global levels could strengthen preparedness for infectious disease outbreaks and pandemics by leveraging and intensifying the scientific and political momentum that has gathered over recent decades. WORKSHOP OBJECTIVES In November 2018, an ad hoc planning committee under the auspices of the Forum on Microbial Threats at the National Academies of Sciences, Engineering, and Medicine planned two sister workshops held in Washing- ton, DC, to examine the lessons from influenza pandemics and other major outbreaks, understand the extent to which the lessons have been learned, and discuss how they could be applied further to ensure that countries are sufficiently ready for future pandemics.1 The first was a public, half-day 1 The planning committeeâs role was limited to planning the workshop, and the 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.
INTRODUCTION 3 pre-workshop event held on November 26, 2018, titled A Century After the 1918 Influenza PandemicâWhy Are We Still Concerned Today? This event was co-hosted with the National Academy of Medicine to mark the 100th anniversary of the 1918 influenza pandemic. It provided a platform to highlight the benefits and progress of driving science, public health, global governance, and cross-sectoral alliances for pandemic influenza pre- paredness. The event opened with a keynote address and featured a session of presentations, followed by a panel discussion with the general audience. Building on the pre-workshop event, the Forum on Microbial Threats then held a 1.5-day public workshop on November 27 and November 28, 2018, titled Readiness for Microbial Threats 2030: Exploring Lessons Learned Since the 1918 Influenza Pandemic. Keiji Fukuda, director and clinical professor, School of Public Health, The University of Hong Kong, chaired this workshop. The participants in this workshop examined the lessons from major outbreaks and explored the extent to which they have both been learned and applied in different settings. The workshop also focused on key gaps in pandemic preparedness and explored immediate and short-term actions that exhibited potential for the greatest impact on global health security by 2030. Workshop speakers and discussants contributed perspectives from government, academic, private, and nonprofit sectors. This workshop opened with a keynote address and a plenary presentation, followed by three sessions of presentations and discussions. Additionally, panelists, forum members, and attendees were given the opportunity to assemble into small groups and asked to consider potential priority actions and strategies for systematizing and integrating outbreak and pandemic preparedness so that it is a routine activity from the local to global levels. Specifically, participants discussed the following topics during the 1.5- day workshop2: â¢ Recent progress achieved in monitoring global health security and pandemic preparedness at national and global levels, including advances in developing national action plans that stem from the Joint External Evaluation, building strong public health capacities that incorporate a One Health approach, and developing risk analysis and assessment tools to guide resource allocation; â¢ Critical challenges and opportunities in developing and evaluating medical countermeasures, including seasonal vaccines, a universal influenza vaccine, and novel diagnostics and therapeutics, as well as strategies to secure their adequate supply and distribution; 2 The full Statement of Task is available in Appendix B.
4 LESSONS LEARNED FROM A CENTURY OF OUTBREAKS â¢ Various methods and tools, such as effective surveillance systems and sequencing technologies, to shorten the time between onset and detection, lab confirmation, and public communication of major disease outbreaks; â¢ Strategies to protect supply chains and build surge capacity for essential services and infrastructure, such as emergency operations centers; and â¢ Effective mechanisms for stimulating meaningful coordination and communication among various stakeholders, including multilateral organizations, national governments, private sectors, and civil societies. Finally, to provide a contextual foundation to support the workshop discussions, the Forum on Microbial Threats commissioned a paper that reviews the literature on the observations and lessons that were made previ- ously after major outbreaks in the past century and provides reflections on what needs to be accomplished to make progress in epidemic and pandemic preparedness moving forward (see Appendix A). This paper was distributed to the public audience during the workshop. 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 needs and future directions, focusing instead on information presented, questions raised, and improvements suggested by individual workshop participants. Chapters 2 and 3 are dedicated to the half-day pre-workshop event. Chapter 2 includes highlights from the pre-workshop welcome remarks and the keynote presentation, in which the speaker provided a historical overview of the 1918 influenza pandemic and considered whether the world is ready to respond to the next influenza pandemic. Chapter 3 provides an overview of the pre-workshop panel discussion, in which participants addressed progress in global efforts to prepare for the next influenza pandemic across the realms of virus biology, universal influenza vaccine development, global governance structures, and the One Health approach. The chapters thereafter focus on presentations and discussions from the 1.5-day workshop. Chapter 4 features the workshopâs keynote presentation, which described the impact of outbreaks and pandemics on people, communities, and economies. The chapter also outlines a plenary presentation, which provided an overview of evolving and recurring challenges over a century of pandemics and emerging infectious diseases.
INTRODUCTION 5 Chapters 5 through 7 cover lessons learned from major outbreaks and the lessons that still need to be applied from the local to global levels. Specifically, Chapter 5 highlights local- and national-level experiences with pandemic preparedness and examines whether adequate national capacities are in place. Chapter 6 offers private-sector and institutional perspectives on lessons learned in vaccine preparedness and examines the spectrum of challenges in vaccine development, manufacturing, and deployment during the 2009 H1N1 pandemic. Chapter 7 explores global perspectives on and lessons learned about equity and fairness related to preparedness, with a focus on the discussions of virus and benefit sharing that arose out of the 2006 H5N1 outbreak and led to the development of the Pandemic Influenza Preparedness Framework. Finally, the two remaining chapters highlight potential actions for overcoming impediments and achieving greater outbreak and pandemic preparedness moving forward. Chapter 8 summarizes a workshop session that focused on ending the cycle of panic and neglect that often occurs in pandemic preparedness, developing a business case for sustained political and financial support, and systematizing outbreak and pandemic preparedness at local, national, and global levels. Chapter 9 features global health expertsâ visionary statements on potential immediate and short-term actions in outbreak preparedness that may have the greatest impact on global health security by 2030, and participantsâ reflections on some top priorities and actions raised throughout the workshop.