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Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
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2

Global Coordination, Partnerships, and Financing

As the pandemic has unfolded over the past year and a half, the critical nature of a coordinated global effort has become ever clearer in the race to end the human and economic toll of coronavirus disease 2019 (COVID-19). Despite challenges, several areas have been explored and efforts attempted because of the political will and global momentum that can enable new findings and understanding to inform future pandemic planning. This chapter highlights the panel discussions centering on the localized, bottom-up governance structures that simultaneously support a globalized infectious disease response, augmented by local distributive and manufacturing capacities across regions and various financing and operational solutions to optimize vaccine supply. Additionally, funding and surveillance of One Health is highlighted, proposing various upstream and more proximal approaches to mitigate outbreaks and focus on equity.

GLOBAL END-TO-END GOVERNANCE AND FINANCING

Bridging local and global governance, Michael Ryan, executive director of the Health Emergencies Program at the World Health Organization (WHO), emphasized the importance of a unified global health security system that is first supported by strong local preparedness and response. He warned against taking sides on the “local versus global” debate and investing solely in global solutions predicted to “trickle out into local action.” Instead, he encouraged a system that includes a strong global plan supported by empowered local communities, strong public health systems, and good governance. Amadou Sall, director of Institut Pasteur Senegal,

Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
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echoed the same message of a balance between global and national or local action. Sall noted that strong global organizations can monitor and pace national and local actions.

Michael Kremer, Nobel Laureate and university professor in economics at the University of Chicago, added that this global plan needs to be agreed upon before a pandemic to optimize the balance between localized and centralized actions and avoid hoarding scarce resources. Ciro Ugarte, director of Health Emergencies at the Pan American Health Organization (PAHO), agreed with Ryan that pre-pandemic plans are necessary in order to secure resources located in regional hubs and redistribute them to other regions or nations. Ugarte shared the example of a humanitarian warehouse in Panama; due to pre-pandemic agreements between Panama and other South American countries, it did not hoard its vaccines and other medical supplies but instead was able to share with neighboring countries. Youngmee Jee, director of Institut Pasteur in South Korea, also agreed that pre-pandemic commitments are necessary but noted difficulties in ensuring that parties abide by them.

To achieve strong local preparedness, Ryan noted that the needs for special attention given to vulnerable communities because “the weakest point in your system is the critical point of failure.” The next influenza pandemic, he added, will most likely originate from a human–animal spillover, and the local, immediate response to that small-scale event will be critical. Thus, Sall continued, investments in bottom-up preparedness are necessary to build a strong local response, eventually contributing to a national and global response. He added that further research is needed into communication and community engagement strategies because they are key when bridging national and international measures to local actions and behavior change.1 As part of a strong local preparedness plan, Celia Mercedes Alpuche Aranda, director of the Research Center for Infectious Diseases at the National Institute of Public Health in Mexico, added that increasing local and regional manufacturing capacity will lead to a more equitable vaccine access and distribution plan.

In addition to bottom-up governance, Ryan also noted the need for an emphasis on an end-to-end financing system that bridges local investments to national and global finance solutions. Investments may take different forms. For example, if a wealthy country purchases resources, he said, it can incentivize short-term production of more such resources or mean that other countries do not have enough. This balance between supply and demand varies: the ability to increase supply is limited in the short term but greater in the long term. High-income countries should be investing in long-term solutions to ensure pandemic preparedness, Kremer said. This

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1 For more on research translation and communication, see Chapter 5.

Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
×

could include improving forms of surveillance. For instance, Ryan suggested that local farmers should be incentivized to report animal outbreaks within a community-based participatory surveillance system, rather than being punished for reporting by having their animals killed. However, very low-income parts of the world will not be able to make those investments without the international support of high-income countries. Sall agreed that financially reinforcing the health system at a local level is key to containing a future outbreak at its source.

Diversifying Manufacturing of Medical Products

Sall underscored the importance of improving local distributive and manufacturing capacities, saying that rather than trying to distribute vaccines from a few centralized sources, widespread access can be better achieved through distributed manufacturing capacities. First, Sall and Kanta Subbarao, director of the WHO Collaborating Centre for Reference and Research on Influenza, noted that a decentralized manufacturing system would lower the risk for vaccine shortages and promote more equitable distribution. For instance, Africa produces only 1 percent of its vaccine needs but consumes 25 percent of vaccines globally. This imbalance leads to challenges in access, Jee added. Second, Sall noted that strengthened local manufacturing and distributive capacities of medical countermeasures could improve surveillance and diagnostic capabilities, which are important in the beginning of a potential pandemic. Third, he stated that local manufacturing capacity could improve equity because profits from vaccine manufacturing will not be highly centralized but can be distributed among multiple stakeholders. Finally, Ryan noted that a more localized manufacturing system would be better adapted to the regional sociopolitical and cultural nuances. Jee agreed that local vaccine, therapeutic, and personal protective equipment (PPE) manufacturing capacity needs to be increased and suggested that this can be achieved through greater financial investments in the Developing Countries Vaccine Manufactures Network (DCVMN). She noted that only 1 DCVMN member out of 43 is from Africa; most are located in Asia. Only 15 members are able to produce WHO prequalified vaccines, she said. Jee also called for a greater investment and diversification of DCVMN to include more African members and more members that are able to produce vaccines.

In addition to increased investments, Gian Luca Burci, adjunct professor of international law at the Graduate Institute of International and Development Studies in Geneva, suggested the Club Approach, in which like-minded countries collaborate in a multilateral space and are in turn catalysts for neighboring countries to join the club. Keiji Fukuda, director and clinical professor at The University of Hong Kong School of Public

Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
×

Health, agreed that practical political solutions are helpful and emphasized that “it is easy to dissipate energy by talking about things that will take place way in the future, but we need to concentrate on current solutions.”

ADVANCED MARKET COMMITMENTS

Incentivizing manufacturing capacity has been traditionally achieved through granting patents to inventors and research institutions, said Kremer. However, these patents also allow for monopolies and thereby reduce access to vaccines. To achieve a balance between incentivizing research and development (R&D) and promoting vaccine access, Kremer presented the idea of advanced market commitments (AMCs) against diseases common in low- and middle-income countries (LMICs), such as malaria. In this legal agreement, a government would cover the costs of vaccine R&D before a pandemic occurs. In exchange, the manufacturing company will commit to sell its vaccine at a predetermined and lower price, he explained. Burci agreed that if governments invest billions of dollars in private pharmaceutical companies, they need to receive something in return, such as “terms of the condition for tech[nology] transfer and licensing.”

Kremer discussed the advantages of AMCs, saying that first, governments have significant financial value to invest, much more so than private companies do, especially during the early stages of a pandemic. He posited that this would require a significant investment from governments. An AMC would provide the framework that allows clinical trials to run in parallel to manufacture capacity buildup, leading to financial and time benefits for governments. In addition, he stated that AMCs could also prevent hoarding and export bans because countries will already have the vaccine R&D capacity. Kremer said that politicians have strong incentives to prioritize their domestic populations, so they ban exports or hoard vaccines, providing some help to their own country but devastating the global response. In addition to ethical incentives that politicians should consider when executing export bans during a pandemic, financial incentives are needed, which AMCs could provide, Kremer explained. Finally, Kremer added that AMCs promote equity, as the price of the eventual vaccine would be fixed and the queue could be significantly decreased for LMICs, which tend to receive vaccines later than high-income countries. Rodrigo Salvado, deputy director of development policy and finance at the Bill & Melinda Gates Foundation, agreed that wealthy countries should be incentivized to take more risk in financing vaccine manufacture because LMICs cannot afford to do so.

Kremer discussed several successful implementations of AMCs. For instance, a group of donors in collaboration with the Bill & Melinda Gates Foundation financed the R&D of a vaccine for pneumococcal strains

Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
×

present in LMICs. The AMC led to an estimated 700,000 saved lives and coverage levels comparable to that of wealthy countries (Gavi, 2020). AMCs were also used during COVID-19 in Operation Warp Speed, the United Kingdom’s vaccine task force, and several other governments and international organizations, he added. AMCs helped contribute to a vaccine manufacturing capacity 3–4 times larger and a vaccine R&D process that responded to needs at an unprecedented speed. Jee also emphasized the importance of partnerships between government and private vaccine manufacturers and noted that South Korea was not able to form such agreements as fast as it should have due to lack of flexibility in emergency fund usage. Mark Jit, professor of vaccine epidemiology at the London School of Hygiene & Tropical Medicine (LSHTM), also commented that AMCs should have been used for vaccine distribution as well as manufacture. Finally, Kremer concluded that AMCs could be implemented during future influenza pandemics. He emphasized that even a moderate risk for such a pandemic financially justifies significant government investments in vaccine AMCs.

APPROACHES TO OPTIMIZE AVAILABLE VACCINES

In response to a question about where influenza pandemic financing should be targeted to have the most value, Kremer suggested vaccine dose-stretching strategies, such as partial doses and different methods of delivery. He discussed the benefits in terms of finance, mortality, and vaccine availability. He emphasized that his team believes that dose-stretching could be a very wise financial investment, if it proves to be effective and ethical, because it could mitigate global vaccine shortages. The first step would be to conduct small-scale research studies that include a variety of strains, doses, and vaccines to better understand the effects on vaccine efficacy.

For example, a potential drop in vaccine efficacy from 95 to 70 percent might be a reasonable trade-off, he said, if, as they found, one-quarter of deaths are diverted as a result of using smaller doses (Więecek et al., 2021). Kremer emphasized the importance of research studies that determine the exact drop in efficacy with lower dosages. He also noted that in Belgium, Pfizer has promising evidence from phase two clinical trials that partial doses of mRNA COVID-19 vaccines are effective (Tuite et al., 2021). However, research needs to be expanded to multiple vaccines and different dosing levels. Kremer highlighted Brazil as a successful example of dose-stretching. In line with WHO recommendations, one-fifth doses of the yellow fever vaccine helped accelerate vaccination by close to a multiple of five (Casey et al., 2019) during a global shortage, he said.

Kremer suggested that partial doses could be effective for influenza vaccines as well. The first step would be small-scale studies with several hun-

Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
×

dred participants, gathering data on immune response related to multiple doses, vaccines, and strains. Ideally, these trials should be in countries or universities where compiling effectiveness data is easy and efficient. Kremer also suggested researching different delivery methods because alternatives to the standard intramuscular shot could be effective for dose-stretching. For instance, intradermal microinjections require half the standard dose (La Montagne and Fauci, 2004).

If dose-stretching strategies prove effective and ethical, sall-scale studies of different doses, strains, and vaccines could prove to be a very wise financial investment, he concluded. Kremer also referenced Ryan’s comment on how difficult it is to have sustained investments, noting that partial vaccine dosages would be able to mitigate shortages using minimal resources.

GLOBAL QUALITY STANDARDS FOR SURVEILLANCE AND RISK ASSESSMENT

Malik Peiris, chair of virology at The University of Hong Kong, asked what upcoming issues or viruses are of the highest priority in terms of spillover to humans. In response, James Wood, head of the Department of Veterinary Medicine at the University of Cambridge, highlighted the need for improved surveillance of existing viruses, especially in LMICs and tropical regions, where only a small percentage of spillovers are reported and tracked due to lack of necessary resources. This can be seen in the fact that small outbreaks are detected less frequently than expected, explained Wood. He described Ebola as an example of a disease that is well known, yet infections are recorded only when a large outbreak occurs in an area with higher-than-normal surveillance compared to the rest of the world (Glennon et al., 2019). Wood stated that more focus should be placed on improving surveillance of current diseases rather than worrying about unknown ones. Richard Webby, director of the Collaborating Centre for Studies on the Ecology of Influenza in Animals at WHO, also agreed that existing viruses, particularly influenza, are the greatest threat for a pandemic. Influenza’s ability to mutate within the host is of particular concern, he said, because that can cause significant yearly outbreaks. Wenqing Zhang, head of the WHO Global Influenza Program, agreed that an influenza pandemic is one of the greatest worries because, despite lower cases, the virus still remains within populations.

Risk assessment beyond simple gene sequencing is needed, Webby and Subbarao advised. They explained that a clear laboratory characterization of each virus will allow for a better understanding of what specifically helps certain viruses jump from one host to another, helping track active or likely hot spots. However, this research is much more complicated and resource intensive, Wood cautioned. Therefore, risk assessment is neces-

Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
×

sary regarding which viruses are more likely to spill over, to target the research. Wood noted that authorities cannot predict what virus will cause the next pandemic with certainty, but prioritizations and risk assessments are possible. Coronaviruses, influenza viruses, and paramyxoviruses are likely candidates for the next outbreak due to their ecology, cross-species transmission, and history. Therefore, work is needed on pan-coronavirus and universal influenza vaccines, he added. Subbarao also noted the robust system for assessing risk for zoonotic influenza viruses by WHO and the U.S. Centers for Disease Control and Prevention, but the international ranking system should be implemented beyond influenza. Aranda agreed and added that countries and regions of WHO need to implement the results of these risk assessment studies. Additionally, Subbarao continued, the current risk assessment system would allow for creating a team of experts ready to respond to pandemics. For example, Peter Daszak, president of EcoHealth Alliance, has been working on identifying likely hot spots for outbreaks based on highest risk for spillovers. This pre-event surveillance allows public health officials to create interventions that reduce risk and effect of spillovers even before epidemics or pandemics.

All surveillance data and risk assessments need to be standardized so that data across countries can be correctly compared, Aranda added. She called for minimal standards for obtaining and collecting information and quality assurance for laboratory surveillance, both of which should be determined before a pandemic to increase trust in the resulting data. For instance, she noted that case fatality rates can be compared between countries, given standardized parameters.

A MORE UNIFIED ONE HEALTH SYSTEM

To be able to accurately report the full scope of potential spillovers, Webby explained that even zoonotic low-pathogenic strains need to be uniformly reported. For example, an international reporting mechanism exists for highly pathogenic strains of influenza, such as H5H7, despite the information not always being fully accurate or complete. However, it is not mandatory to report strains such as H9N2, which may cause just as many zoonotic infections but are not pathogenic to humans. Zhang agreed that these strains need to be notifiable diseases within the Food and Agriculture Organization of the United Nations and the World Organisation for Animal Health (OIE), not just human surveillance systems. Most data on low-pathogenic influenza strains come from small-scale academic studies, such as for swine influenza. Conducting surveillance, especially on low-pathogenic strains, is different for each influenza virus, Webby added.

Wood explained that many diseases that are pathogenic to humans are not pathogenic to farmed or wild animals, leading to a mismatch of report-

Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
×

ing mandates. Notifiable diseases within the OIE “are almost invariably those that are significant infections in animals” only. Webby gave an example, explaining that influenza is a threat to human health but is often not the priority of swine surveillance systems, which are often concerned with respiratory distress syndrome. This is a problem because the next pandemic, according to Wood, may likely be caused by antimicrobial resistance, but because of the inadequate surveillance of diseases that are not pathogenic in animals but are in humans, it may go unnoticed until it is too late. The lack of surveillance of such outbreaks means that specific genes might transfer between bacteria and cause antimicrobial resistance that scientists are unprepared for. To address the divergence between animal and human health, a more unified and integrated One Health system that focuses on common goals is needed, both Wood and Zhang stated.

Biosecurity should be at the forefront of One Health interventions aimed at farming, with variations in interventions depending on the size and style of farming, Wood noted. Biosecurity measures such as isolating infected animals are very effective and can be helpful even in asymptomatic infections. In addition to decreasing spread within animals, farming biosecurity interventions help prevent spillovers to humans. Wood also highlighted that international trade of live wildlife and farming of wild animals both pose an immense threat to human health and should be prevented. For instance, severe acute respiratory syndrome (SARS) emerged in 2003 from the live trade of farmed palm civets. To mitigate the risk posed by live wild markets, Peiris added, Hong Kong successfully implemented several generic interventions. Using rest days for live poultry markets and ensuring that they are closed and cleaned in the evening helped break avian influenza amplification, and separating the market chains of wild and domestic ducks reduced the risk of producing viruses like H5N1 or H7N9. Peiris noted that these are created via an overlap of viruses from wild and domestic birds.

Addressing the aforementioned issues, an international mandate on surveillance would have multiple benefits, Wood commented. First, it would ensure that infections that are pathogenic to humans but not to animals are reported. Second, it would better allow tracking of antimicrobial resistance. Third, we would be able to track infections before they become problematic, especially in LMICs. Daszak described a significant return on investment if the world can stop outbreaks before they become a pandemic. Finally, according to Wood, this mandate would create practical on-ground capacity instead of theoretical box-checking, leading to a unified One Health framework and goals. Zhang and Burci also agreed that globally coordinating surveillance and governance is necessary.

This unified One Health network is vital to preventing diseases at their root, according to Wood and Subbarao. However, it is not an easy task to break the silos between animal and human surveillance. To produce a

Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
×

surveillance system that is more effective at preventing spread of disease, Wood emphasized, it is important to create a unified One Health system that focuses on not only cases that present in a medical clinic but also the sources of outbreaks. He noted that both animal and human surveillance should be under the umbrella of One Health, where partners can have joint and holistic surveillance objectives. Webby agreed, suggesting that perhaps the way to destroy the silos is to create a completely new One Health governance structure. Zhang added that in order to yield systematic and quality results from this unified One Health system, participants need to know not only how to conduct unified surveillance but also why they are doing so. This will lead to increased trust and confidence. Dennis Carroll, chair of the Global Virome Research Project, added that increasing the number of stakeholders, including private companies and the food industry, will allow for a more complete integration between animal and human health and for a bigger cross-section of different viewpoints that have the same objective.

Participants gave several examples of successful One Health interventions. One such example, which Wood also praised, is Hong Kong’s risk-based approaches to mitigate avian influenza spread. A second example of a biosecurity-focused intervention, Wood continued, is the cost-effective local solution to stop date palm sap from being contaminated with the Nipah virus in Bangladesh. However, intervention uptake was not high, because behavior change is very difficult to achieve, especially when no alternative source of livelihood was proposed to the farmers as a solution. Wood suggested that a more effective intervention would address long-term drivers of pandemics, such as biodiversity loss or poverty, rather than concentrating on “proximal causes.” Third, Carroll discussed Thailand’s strong One Health alliance, which successfully addressed issues of animal husbandry by bridging the silos between different ministries and the private sector. Thailand has been proactive in sharing information and methods with neighboring countries to build a regional approach that lowers the risk of virus spillovers and outbreaks.

REFORM OF ONE HEALTH FINANCE

To achieve a unified surveillance mandate that places animal and human threats under one umbrella, unified funding is also necessary, Webby and Peiris noted. For example, Wood stated that 60,000 people die of rabies annually, 99 percent of whom contract the disease through a dog bite. Wood explained that many countries invest heavily in post-exposure rabies treatment. However, he continued, many of these governments do not invest in vaccinating dogs, something that would require a significantly lower budget, because it may generally fall outside of the U.S. Department of Health and Human Services budget and into that of the U.S. Depart-

Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
×

ment of Agriculture. This lack of unity within a One Health system results in interventions that are not cost effective, Wood explained.

Carroll added that an increased number of stakeholders within One Health will lead to increased financial security and lower the effects of funding fatigue, which will likely happen once the momentum of the current pandemic is over. Salvado supported a diversification of One Health finance, stating that it will bridge the gap between Ministries of Health and Finance and help LMICs have greater access to vaccines. Salvado also emphasized that increased financing is not always the solution but rather diversification of investments into multilateral organizations. Jit agreed that further collaboration between the medical and financial sector is necessary. More specifically, he called for increased studies on the economic analysis of vaccination. Although health ministries focus primarily on lives saved, governments ultimately make decisions based on financial restrictions, he explained. For instance, when distributing vaccines, LMICs argued that they have struggling health sectors and wealthy countries argued that they have an older population that is more susceptible to COVID-19. Although COVID-19 Vaccines Global Access (COVAX) has come up with a good temporary solution of giving every country enough vaccines to cover the same percentage of the population, Jit emphasized that consensus is needed on “what is the metric that we are trying to optimize, [which is] not necessarily purely lives saved.”

One example of multilateral collaboration between the public and private sector, Carroll continued, is a potential partnership between governments and private insurance companies. He highlighted Iran during the 2005–2006 avian influenza as an example. The government would have to provide proper “inspection and oversight of poultry production to adhere to OIE biosecurity standards” to lower the risk of avian influenza outbreaks. In return, insurance companies agreed to cover any possible financial losses. The results of this partnership, Carroll explained, were very positive; within a few months, the number of outbreaks in Iran plummeted, even with Armenia and Georgia and neighboring countries still aflame with avian influenza.

Webby gave an example of a successful funding mechanism that was able to combine animal and human health. The National Institute of Allergy and Infectious Diseases established the Centers of Excellence for Influenza Research and Surveillance Network within the United States and was able to finance multidisciplinary surveillance activities.

Zhang proposed a solution to the need for a unified One Health financial system. She explained that for a surveillance system to be sustainable in the long term, it should be owned by a country. She gave influenza as an example that shows how difficult it is to sustain surveillance research unless it is owned by a country as well as funded through One Health. Another

Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
×

solution, which Wood proposed, is to create unified funding mechanisms “that specifically reinforce the [One Health] alliances.” Carroll agreed, saying that the Food and Agriculture Organization of the United Nations, WHO, the Office of Health Economics, and other associations should take responsibility to actively unify One Health.

DISASTER RISK REDUCTION APPROACHES: ADDRESSING POVERTY AND PROTECTION OF BIODIVERSITY AND INDIGENOUS PEOPLE

In addition to direct medical and public health interventions, zoonotic spillovers can also be prevented through more upstream approaches to reduce the risk of eventual disaster, such as reducing poverty and protecting biodiversity and Indigenous people. Wood described one of the greatest risk factors for populations suffering from zoonotic diseases as poverty and livelihood restrictions that force people and animals to live closer together. Many of the likely hot spots for spillovers are in poor countries that lack the proper infrastructure and sufficient animal or human health care. One example of local poverty reduction, Wood explained, is accessible primary health care, which is a surveillance tool and an early detection mechanism that is widely underrated. Locally driven and locally owned poverty reduction mechanisms are vital to preventing pandemics, he stated. Poverty reduction, although not sufficient on its own, creates a sustainable and long-term solution to pandemic prevention and preparedness. In addition to benefiting low-income communities, it could benefit wealthy countries, Wood added.

Zhang agreed that poverty is the fundamental issue behind governance and prevention of spillovers. She recounted a visit to a village to investigate the avian influenza outbreak, where she witnessed poverty that increased the risk for outbreaks: lack of running water, poultry feces on the streets, and dead animals in the water. Carroll explained that the lack of sufficient poverty reduction mechanisms is not due to technical barriers but rather a need for “social reengineering” in terms of breaking down the silos between animal and human health. Reducing poverty also allows public health officials to prioritize prevention of outbreaks, Wood noted. He explained how a provider of medical surveillance in sub-Saharan Africa had to prioritize underfunded and existing outbreaks of HIV and tuberculosis versus a potential Ebola spillover.

Wood also explained that biodiversity loss and mass farming practices are underlying drivers of pandemics, noting that interventions should aim to mitigate these long-term risks rather than concentrating on immediate solutions to outbreaks. He emphasized that Indigenous people, many of whom still rely on wild meat, are an important part of biodiversity and that it is vital for public health officials to protect their way of life. More

Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
×

specifically, Wood said that he has great concerns about the international vision of protecting “30 percent of the world by 2030” model because, by removing Indigenous people from the Central Congo basin and other locations, conservationist groups will disrupt biodiversity and thus increase the risk for future pandemics. He warned against removing Indigenous people from national parks, which he said is an immoral and misguided effort to protect biodiversity. Instead, a greater focus should be placed on reducing harmful agricultural practices, he said. Furthermore, Wood recognized that the line between farmed and wild animals is not always clear and that perhaps it is not specific species that increase the risk for pandemics but rather the ways in which people handle those animals for mass consumption. For instance, beef and soy production in the Amazon has caused a great deal of biodiversity loss that places animals in close contact with disrupted environments, leading to a higher risk for future outbreaks. Carroll agreed, noting that in the latter part of the twentieth century, the number of poultry under production dramatically increased across Asia, but biosecurity measures have not increased to reduce interaction between wild and farmed birds.

DATA AND BENEFITS SHARING

To facilitate a more coordinated and robust global response during a pandemic, some of the participants believe certain information must be immediately shared. This highlights challenges of governance, data ownership, and surveillance. Aranda noted that the fast release of the full viral genome sequence was crucial during COVID-19 for quick vaccine development. She also added that sharing epidemiological data with common parameters was vital to comparing transmission parameters between countries. Subbarao and Joshua Sharfstein, vice dean for public health practice and community engagement at the Johns Hopkins Bloomberg School of Public Health, agreed that detailed epidemiological information should also be made readily available and that new virus isolates and treatment formulas, such as monoclonal antibodies, also need to be shared, especially with LMICs.

Aranda also pointed out the lack of data sharing during COVID-19 in regard to the sustainability of pandemic response. How can countries be more self-sufficient, and how do they initiate industrial transformation? For any of this sharing to occur efficiently, she emphasized that countries must coordinate in advance and create a culture of trust. While sharing the SARS-CoV-2 genome occurred, it was not uniform, Aranda noted. Burci agreed that greater uniformity is necessary, especially in relation to isolates. He added that predetermined regulations should define what information must be shared. Sharfstein highlighted that the lack of a standard on the contents or quality of information that must be shared about each vaccine before it is used, and many countries rely on the say-so of other countries

Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
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without being able to analyze the underlying data during a pandemic. Standardized and transparent vaccine research is vital so that governments, health professionals, and the public have trust in their efficacy, he said. The minimal way to achieve this transparency, Sharfstein noted, is an independent review of the research. He gave the Johns Hopkins map2 as an example of a successful and uniform epidemiological information sharing platform by a third party, and he emphasized the need for detailed epidemiological data sharing building on this, which would also include individuals’ treatments, the nature of their clinical course, and whether they have been vaccinated.

In response to a question about whether we can expect countries to transparently participate in uniform data sharing, speakers disagreed. Burci noted that countries are always tempted to use pandemic-related data as political leverage or power to negotiate benefits. This political power is in stark contrast to the “ethos of a scientist to collaborate and share.” In response to this tension, the Nagoya Protocol3 has “legitimized this almost transactional access” to isolates, Burci explained. Zhang countered with successful examples of data-sharing mechanisms. For instance, the Global Initiative for Sharing Avian Influenza Data (GISAID) was established in response to the hesitancy of some countries to share H5N1 genetic information because they were afraid that they would not receive any benefits and would need to purchase vaccines. But GISAID is still being implemented for sharing SARS-CoV-2 genetic sequence data. Zhang also warned that when reforming the Nagoya Protocol and antigen-benefit sharing legislation in the long term, special attention should be paid to the immediate needs of the public.

Wood cautioned, however, that data sharing is much harder for countries and institutions that are less privileged and have fewer resources. He suggested that this equity issue needs to be addressed when creating or altering a data-sharing mechanism for it to function well. Burci also added that such mechanisms were a reaction to “neocolonial imperialistic attitude, which has prompted the work on the biodiversity regime to begin with, to fight bio piracy.”

Fukuda asked if the data and benefit sharing should be bundled together or seen separately. Burci noted that most countries already consider genetic information part of the country’s resources and would like to see benefits in return for sharing. He emphasized that data sharing and benefits

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2 The COVID-19 Dashboard can be found at https://coronavirus.jhu.edu/map.html (accessed August 11, 2021).

3 The Nagoya Protocol is an international legally binding agreement that establishes rules on collection, usage, and sharing of genetic resources. More specifically, it addresses the benefits associated with use of genetic resources. See more at https://www.cbd.int/abs (accessed August 11, 2021).

Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
×

sharing should be bundled in order to avoid “abusive behavior by western and northern industries.” However, further clarification and uniformity on data and benefits sharing is needed. For instance, Burci noted that according to a 2-year study funded by a Swiss organization at the Graduate Institute of International and Development Studies, different countries have various concepts of what “benefits” are, ranging from academic recognition, such as co-authorship in a paper or recognizing an institution, to financial return, capacity building, or commitment to sharing of vaccine reagents. Clarity and uniformity on the definition is needed in order to have a consistent conversation about the topic, Burci said.

Sharfstein, Subbarao, and Aranda agreed that data and benefits should be taken together, but Sharfstein cautioned against a transactional attitude toward sharing both, with a pathogen first and then a negotiation. Instead, he suggested that data sharing and benefits sharing should be parallel. Instead of concentrating on specific pathogens and negotiating based on that, a global network of data and benefits sharing should be seen as a continuously operating platform that increases overall efficiency and information exchange between countries. Sharfstein noted that he supports a global pandemic treaty that would allow the world to better prepare and understand agreements in advance.

Conversely, some speakers voiced concerns over data and benefit sharing mechanisms. With a focus on LMICs, Aranda noted the work to be done on equitable access to COVID-19 vaccines within a global pandemic treaty. While data and benefits sharing should be bundled, she continued, countries with internal H1N1 or COVID-19 vaccine production have preferential access when the global supply is limited. For example, Aranda and Subbarao stated, even if LMICs share information and are ready to buy products, they still need to wait longer for access.

Addressing the issues of equity within data-sharing mechanisms can be done in several ways. One solution, Subbarao added, is to create a mechanism that exempts certain diseases, such as influenza or zoonotic coronaviruses, from the restrictions of such agreements because “they’re caught up in something that was probably not the original intention.” The Nagoya Protocol is designed to protect genetic resources within a country and allows nations to withhold sharing of “resources” (plants, animals, bacteria, viruses, etc.) until they feel that a sufficient agreement has been met and that they will receive appropriate benefits (Cueni, 2021). Many argue that this should not be the case for pathogens related to epidemics and pandemics. Waiving intellectual property rights in pandemics, she explained, would allow for greater technology transfer and data sharing and alleviate vaccine nationalism and vaccine distribution inequities. Burci noted that certain cases create an urgency to have the discussion on waiving intellectual property rights to ensure awareness of agreement parameters on all sides.

Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
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Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
×
Page 6
Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
×
Page 7
Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
×
Page 8
Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
×
Page 9
Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
×
Page 10
Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
×
Page 11
Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
×
Page 12
Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
×
Page 13
Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
×
Page 14
Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
×
Page 15
Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
×
Page 16
Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
×
Page 17
Suggested Citation:"2 Global Coordination, Partnerships, and Financing." National Academy of Medicine. 2022. International Workshop on COVID-19 Lessons to Inform Pandemic Influenza Response: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26352.
×
Page 18
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While the world continues to respond to the COVID-19 pandemic, novel influenza viruses persist as a constant pandemic threat. The global response to COVID-19 has pushed the boundaries on what is possible for rapid pandemic response in several areas, including vaccine research, development, manufacturing, equitable distribution, allocation, and administration. If well understood and sufficiently adapted, these actions could be applied to future pandemic and seasonal influenza vaccine preparedness efforts. However, developing and delivering these more effective vaccines to meet the demand goes beyond simply technical challenges and includes issues across governance, financing, research, supply chain, and public engagement.

To address these challenges, the National Academies of Sciences, Engineering, and Medicine convened a virtual public workshop in May of 2021 to discuss the emerging evidence on unprecedented actions related to COVID-19 that could inform and advance pandemic and seasonal influenza vaccine preparedness efforts and subsequent response. This Proceedings of a Workshop provides a high-level summary of the presentations and discussions that occurred during the workshop.

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