The state of emergency, in force since early in the COVID pandemic, will soon be lifted. But are we now better prepared for the next one?
When the COVID 19 pandemic began, there were no vaccines, and scant scientific knowledge about the virus. The world was unprepared. Different results from different countries depended at least in part on who made health policy decisions and why. When politicians made uninformed, politically motivated public health decisions, the results tended to be underwhelming.
In spite of speedy vaccine development, political meddling derailed competent health policy responses, causing thousands of avoidable U.S. COVID deaths. Myths, lies, and obfuscations poisoned the public’s response, even politicizing mask wearing and vaccination.
Future pandemic responses demand a globally coherent approach based on the costly lessons learned from the COVID-19 pandemic, the subsequent monkeypox outbreak, and the resurgence of polio. Missing is a consistent approach for selecting optimal response strategies for major emerging and re-emerging diseases, especially for outbreaks with the potential to become public health emergencies of international concern.
A new report in the Lancet by Michael G Baker, David Durrheim, Li Yang Hsu, and Nick Wilson suggests three high-level strategic choices for managing any infectious disease with pandemic potential:
“Elimination,” includes interventions to reduce transmissions to zero within a defined geographical area, modeled on the eradication of measles, polio and smallpox; “suppression” minimizes the disease burden on society (as with tuberculosis, HIV/AIDS); and “mitigation,” to prevent overwhelming the healthcare system (e.g., by pandemic influenza). Having no clear public health policy, whatever the excuse, is irresponsible.
Eliminating a disease is preferable to merely containing it. The goal is to reduce disease transmission to zero over a defined geographical area and time period. Such elimination strategies are widely used for a range of diseases, including polio, measles, rubella, and some parasite-caused diseases.
COVID-19 has shown that an elimination strategy can also be highly effective against a pandemic disease, short of a smallpox-style global eradication.
A public response strategy should be identified for all newly detected, emerging, and re-emerging infectious diseases. Elimination is the best default option for any infectious disease. Implemented early, an elimination strategy delays the spread of new infectious diseases, and provides time to develop such effective interventions as vaccines and antimicrobials.
If applied swiftly in a coordinated way, such a strategy could successfully eliminate the disease from individual jurisdictions and contribute to its global eradication. Even if ultimately unsuccessful, elimination still provides a strong unifying goal for organizing interventions. An elimination strategy shared by neighboring countries improves the chance of success.
As the COVID-19 response demonstrated in New Zealand, Australia, and Singapore, using a strict elimination strategy to delay widespread transmission of SARS-CoV-2 for 18 months or longer allowed time for the development and distribution of effective vaccines. These countries had relatively low cumulative COVID-19 mortality, less pressure on health services, and better economic outcomes than most other high-income countries.
Strict elimination lockdowns—relatively short, intense, stay-at-home orders designed to help end the spread of an infectious disease outbreak, were used very successfully by these jurisdictions as part of their elimination strategy. On the other hand, lockdowns used as part of a mitigation or suppression strategy, as done by China, proved to have a completely different meaning, purpose, and outcome. Such lockdowns typically need to be extended or repeated, since a still broadly circulating infectious agent will cause a resurgence as controls are eased.
Even with a pandemic disease threat less severe than COVID-19, such as monkeypox, much of the world appears to have instinctively adopted an elimination strategy without articulating this as a common goal. Global eradication of monkeypox is not feasible at present as there are yet unknown animal reservoirs for this infection in Africa. Still, a strategy of eliminating this disease could support capacity building in low-income and middle-income countries.
The World Health Organization is the obvious agency to coordinate global infectious disease strategies. It is already leading explicit regional elimination and global eradication programs for multiple diseases, including polio. Yet the WHO did not provide similar strategic leadership during the COVID-19 pandemic, despite the conspicuous success of the elimination strategies of some countries.
Possibly the greatest lesson from the COVID-19 pandemic is the need for a competent, coherent and consistent global strategy for managing new emerging infectious diseases. The WHO, as part of its Public Health Emergency of International Concern assessment process, should also select the optimal response strategy: elimination, suppression, or mitigation. This would strengthen the WHO’s role in a more proactive, coordinated, and effective approach to global pandemic management. The response strategy could change over time as new information and interventions became available.
(Paul Kando is a co-founder of the Midcoast Green Collaborative, which promotes environmental protection and economic development via energy conservation. For more information, go to midcoastgreencollaborative.org.)