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Ending epidemics   

Dr Jonathan Quick, Dr Kieran Walsh

This article is based on a podcast that was recorded by the BMJ. In this article, Dr Kieran Walsh, Clinical Director at BMJ, interviews Dr Jonathan Quick, family physician, health management specialist, and author of The End of Epidemics: The Looming Threat to Humanity and How to Stop It.  

 

Interviewer: In 1997, in Hong Kong, a three-year-old child, Lam Hoika died from a new type of flu, H5N1. At the time, Keiji Fukuda was an epidemiologist at the World Health Organisation. On hearing the news that a brand-new virus had killed a child, he thought, “This is how it begins.”

This story comes from a new book, ‘The End of Epidemics: The Looming Threat to Humanity and How to Stop It’, by Dr Jonathan Quick, and we are delighted to have Jonathan answer questions on pandemic infections. Jonathan is a global health expert and family doctor, with experience in more than 70 countries, including some of the most prone to pandemics.

So, Jonathan, could you tell us, what exactly is a pandemic?

Jonathan Quick: Well, if we start with the concept of epidemics: epidemics are an unusual increase in a disease, usually an infectious disease, but can be applied elsewhere. A pandemic is an epidemic that is affecting large areas, crossing borders, and typically kills thousands, if not eventually millions of people.

The human impact can be astounding. The 1918 Spanish flu pandemic that we talk about killed 50-100 million. Something like that today could kill 200-400 million people and rival the effects of a nuclear confrontation. The economic impact could be something like the Great Recession, putting millions out of work. So, something that big is low likelihood, but still possible, and that’s a pandemic.

Interviewer: Why, in recent years, are we getting so many infectious disease pandemics?

Jonathan Quick: Well, we’ve had, basically, an exponential increase, and three out of four new pandemics come from an animal to a human species jump. That was true of AIDS. It’s true of Ebola, and of Zika.

The factors are basically

Population growth. We’re four times the population we were 100 years ago.

Urbanisation. That crowding factor perpetuates things like flu, but also the Ebola outbreak in 2014 which was so horrific. What made that horrific was that it was our first real experience with urban Ebola. The 2014 Ebola outbreak was an example of the effects of urbanisation. That was the first urban Ebola outbreak, and it was devastating.

Travel. We’re 50 times as mobile. Ten million people every day in the air, and there isn’t any place in the world, virtually, that’s less than 24-36 hours by a combination of canoe, car and plane.

Climate change. That makes us more vulnerable. The food demand. Pigs and chickens are pandemic incubators, in a sense, for the flu particularly. Deforestation puts us closer.

Conflict.

So, all of the risk factors for major disease pandemics are on the increase.

Interviewer: Okay. You mentioned cities, or urban environments. What is it about urban environments that can contribute to the spread?

Jonathan Quick: Well, part of it is the crowding, just that we’re living closer together. Typically, cities will have parts that are really poor, with poorer sanitation, and that’s a factor. The Zika, yellow fever, dengue mosquito is more of an urban dweller, so that’s a factor.

Finally, that’s where major health institutions are, and without really careful planning hospitals quickly become not just treatment centres but transmission centres for outbreaks, when everybody is coming to the hospital. That’s what happened with Ebola in West Africa, clearly, and it happens sometimes in flu outbreaks. So, it’s all of those factors that make cities a particular risk.

Interviewer: Okay, great. Thank you. How can we prevent all these pandemics, if that’s not too simple a question?

Jonathan Quick: We can’t prevent local disease outbreaks. That’s going to happen. The bugs will always be with us but, to a very large extent, the difference between local outbreaks and catastrophic epidemics, regional epidemics and pandemics is human action, or inaction.

So, the key thing is investing in building strong public health systems that can do the prevention – immunisation, mosquito control – and whatever they can to detect early. The late detection of outbreaks increases the death rate, gives the epidemic a head-start on us. Finally, a rapid response. So, those three things – prevention, detection, response – are critical.

Only one out of three countries worldwide has the basic systems to do those three functions. So, number one, we have to build strong public health systems.

Number two, to prevent pandemics we need to invest in innovation for prevention. The flu vaccine, for example, was first used 80 years ago and, in many ways, we’re applying the same sort of trial-and-error approach to flu vaccine.  Whereas a universal vaccine offers real potential to cover most, or all, of the flus. But we’ve been late off the mark. That’s finally taking off. And, investing in early warning systems.

The third thing is to hold our leaders accountable.  Get clear commitments for investing in building health systems and innovation, and keeping their commitments to do that. We’ve seen over and over again the cycle of fear and panic, where lots of promises are made by local, national and international leaders. And then we look three, four, five, ten years later, and they’re not keeping their promises and we’re not moving.

So, those three things: the health systems, the innovation and holding the leaders accountable.

Interviewer: Specifically, you mentioned, I think, a universal vaccine. Can you tell us more about that? What exactly is that?

Jonathan Quick: Not everyone really appreciates what an incredibly vicious potential enemy the flu virus is. That’s what killed 50-100 million people 100 years ago, and it could do it again today.

Flu travels in packs. It’s not one virus. There’re usually two, or three, or four viruses. It’s got lousy self-correction mechanisms, so it’s continually mutating, exchanging genes among pigs and waterfowl and humans.

So, with the seasonal vaccine, we keep trying to keep up with this. The idea of a universal flu vaccine is to get the parts of the flu virus that are the most stable, that don’t change. It won’t be one-and-done like some of the childhood vaccines, or one, or two, or three. What it would be is a vaccine that would last multiple seasons and cover a wide range of influenza viruses.

Interviewer: Okay, and are there any downsides to this type of vaccine?

Jonathan Quick: None if we develop it in a proper way, with the proper safety tests, and are sure that it works to create flu immunity. Also, we have to be sure that it’s not inadvertently stimulating unintended immune responses, which are sometimes associated with flu.

So, yes, there are potential adverse effects that we need to take into consideration in the development. I have great confidence that, with a well-developed universal flu vaccine, any potential downsides will be far, far outweighed by the major impact on saving lives.

Interviewer: Okay. Thank you. You mentioned leaders and leadership. How can we put leaders and leadership in place to prevent pandemics?

Jonathan Quick: Well, the first thing is to take initiative on our part, on the part of the public health community, and the medical community, to understand, number one, what’s at stake. Number two, to take pride in the fact that scientists and public health people know what we should be doing. What we need is the public support and the support of the business community.

In each country the particular network of stakeholders is going to vary.  But in most countries today there are medical organisations that are attuned to the local political scene. Politics – political engagement – is not a positive or negative value in itself. It’s a way of getting public decisions – decisions by government, local, national, international, and by private industry. Decisions to invest and to do the things that are needed.

So, first of all, our own knowledge, and next of all, really engaging with those groups in the country that are involved in making the decisions about public allocations and public investments.

Then, participating in groups like Global Citizen. Global Citizen is an international network of people in scores of countries, largely young people, but people who are engaged in wanting a fairer and safer world.  Among other things, when the G20 – the largest economies – come together, the Global Citizen group is there, and basically saying, “When you were in Japan two years ago, here’s what you promised to do to protect the world from pandemics. Here’s what you’ve done.  Here’s what you haven’t done.” That’s the accountability part of it.

Interviewer: Okay. Thank you. What place does the One Health movement have in preventing pandemics?

Jonathan Quick: One Health is a concept that says humans and animals are all part of the overall global ecology. We really need to pay attention to that interaction, and to recognise that, indeed, three out of four epidemics come from animals. Bats are at the top of the list for being the hosts of potential pandemic viruses.

We need to be involved with the animal folks in several different ways. Within countries, the agriculture departments play an important role in food safety, and so that’s a critical factor. Bush meat is a source of Ebola. So, there’re several interactions, and we always make more progress in this area when we work with the veterinarians, and we work with the departments of agriculture, as well as the departments of health. Again, this is both local and national.

Interviewer: What about disease surveillance and reporting? What role does that play?

Jonathan Quick: We’re in an interesting evolution now because the difficulty that we had 10 or 15 years ago was that the local disease surveillance tended to be bureaucratic – a slow process that goes up the line with a series of reports. Back then, we weren’t harvesting the information that was coming through social media.

What’s happening now is that a number of different groups – HealthMap and other groups – are harvesting information and outbreak reporting through crowdsourcing. In essence, this is participatory surveillance where smartphones become a source of reporting. That sort of direct reporting is an important way of gathering information.

In the field of hurricanes and various tropical storm deaths, we’ve been able to reduce mortality – deaths from weather-related events – by 95% in the last 50 years by good early-warning systems. So, frontline surveillance that is really tied through so-called ‘big data’, through information systems that really see patterns, has great potential to save lives.

Interviewer: Okay. There’s a lot of talk about building capacity. How do we effectively build capacity in the healthcare workforce to prevent pandemics?

Jonathan Quick: Well, making sure that the pandemic risks are an important part of health worker training. It’s not a question of just training frontline health workers or community health workers or midwifes or other frontline health workers. It’s not an either/or. It’s an ‘and/both’. So, training about identifying unusual disease occurrences and reporting them should be part of the curriculum of all these learners.

One example: Uganda is a country that’s had multiple Ebola outbreaks and other infectious disease outbreaks. The Ministry of Health has had a programme to train and accredit community drug sellers – medicine dispensers.  These folks have been given a module on early recognition of new outbreaks.

So, that sort of involvement at the front line is a key part of building the capacity of the workforce to early identify outbreaks and then, also, to be aware of the do’s and don’ts about responding to outbreaks.

Among other things, when you do have outbreaks of things like Ebola, it’s about rapidly organising to quickly separate and triage the folks who are potentially ill with Ebola from people who are seeking care for other conditions.  Outbreaks often cause as many deaths as they did in West Africa from disruption of primary care services (like immunisation and skilled birth attendance for safe deliveries).

So, what you want to be sure is that the frontline health workers are able to separate out, triage and manage the acute outbreak and keep routine services running in parallel, to the maximum extent possible.

Interviewer: Okay, thank you. The last question is about this concept of ‘Disease X’, related to priority infectious diseases. Tell us about ‘Disease X’. What’s it all about?

Jonathan Quick: Well, this is a term from the World Health Organisation research and development blueprint for infectious diseases – a priority list of diseases for which vaccines, medicines or diagnostics are needed. Creating this list is something that WHO has been doing since Ebola. In March of this year, when they did the annual review, they added what they called ‘Disease X’.

Now, this sounds like some sort of a Madison Avenue or Hollywood term, but actually, it’s not. The concept is, we need to be ready for a disease that we’ve never seen before, and understand that we’re going to have to think differently and be aware. This isn’t science fiction.

If you think about it, when AIDS hit, and was recognised in the early 1980s, that was the ‘Disease X’ of the 20th century. It was the first new pandemic human pathogen in modern times. We now know that it came out of south-east Cameroon in around the 1920s, slowly worked itself down into the Congo, and then really spread when guest workers who the colonial Belgians had brought from Haiti were sent back to Haiti. We spent a decade trying to just figure out the basics. So, that was the ‘Disease X’ of the 20th century.

SARS, a totally new pathogenic virus that came out of rural China in 2003 was carried by a doctor who’d cared for a patient. It was carried to the Metropole Hotel in Hong Kong, and from there spread within weeks to 27 countries. Fortunately, through good public health response, that outbreak – which in the end killed about 800 people and infected about 8,000, but could have gone really, really global in a big way, and stayed – that was stopped within six months. That was basically a ‘Disease X’.

You could argue that because the Zika virus – which has been around more than 70 years, and was most of that time an asymptomatic sort of nothing virus – underwent a major change in Micronesia when the virus started moving east 15 years ago, it was really, effectively and functionally a new virus when it landed in Brazil and got embedded, and all of a sudden broke out.

It had gotten into the mosquito community, and all of a sudden was in large parts of Brazil causing horrific agony to mothers because of the birth defects, which were new since that outbreak in Micronesia, and Guillain-Barré, the syndrome that comes with Zika.

So, we need to be alert to the fact that there are going to be new viruses we haven’t seen before.  We need to be ready to respond quickly, and we need to take some confidence that we actually have been successful against some of these ‘Disease Xs’ through good public health responses. That’s why it’s so important to have that on-the-ground preparedness, and invest in good health systems to be ready to prevent, detect and respond.

Interviewer: Okay. Thank you very much, Jonathan. We hope that this has been helpful, and we hope that you’ll be able to put what you’ve learnt into action to better recognise, report and refer affected patients.

If you want to find out more, click on the links to sign into BMJ Best Practice or BMJ Learning, and look at the content on pandemic infections and extremely dangerous pathogens.

BMJ Learning

https://learning.bmj.com/learning/home.html

BMJ Best Practice

https://bestpractice.bmj.com/


Competing interests

KW works for BMJ which produces a range of resources in pandemic infectious diseases.

JQ has no competing interests.

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