What will outbreak preparedness and response look like in the future?
What innovations and technologies have been developed for outbreak preparedness and response?Data Collection, Analysis & ModellingTraditionally, outbreak surveillance has involved a healthcare worker notifying a new cluster of conditions or an unexpected presentation. Increasingly, internet access and social media use have allowed digital surveillance, called Digital Disease Detection (DDD). Existing in many forms, DDD includes; ProMed Mail and HealthMap which summarise formal and informal outbreak reports. Through them, outbreaks of Zika and Ebola were reported globally well before WHO’s official notification. Detecting outbreaks through examining the frequency of internet searches of ‘flu symptoms led to the creation (and subsequent failure due to inaccuracy) of Google flu trends. Mobile phone use has enabled population movement tracking after natural disasters and predicted related outbreaks1. Importantly, there has been recognition of the need for an ethical framework to safeguard and share individual and collective data in DDD2.
Community-based surveillance reporting by mobile phone, Somaliland
© Abdifatah Hussein Beledi/SRCSGreat progress has been made in outbreak data collection using tablets and mobile phones. SORMAS and Open Data Kit, amongst many other platforms, were used to collect data on monkeypox and Lassa fever in Nigeria in 2017-2018. Data collection using technology rather than paper allows rapid and accurate collection of case and contact information, allowing centralised tracking of an outbreak and rapid allocation of resources and responders to where they are most needed. In order to plan future resources, mathematical modelling is increasingly being used. During the Ebola outbreak in West Africa, mathematical modelling was used to assess the contribution of various risk factors to the spread of Ebola, subsequently informing the prioritising of higher impact interventions, such as safe burial, rather than border restrictions or eating bush meat. During the Zika outbreak in Brazil, modelling aided understanding of the effect of rising herd immunity on the epidemic’s trajectory, resulting in improved resource forecasting and planning of clinical trials.Microbiology
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Disease Outbreaks in Low and Middle Income Countries
Figure 1: Portable real-time device for DNA and RNA sequencing similar to that used during the West Africa Ebola outbreak. © Shirin Ashraf/CVRThe availability of rapid diagnostic tests (RDTs) for an outbreak allows quick identification and isolation of infectious patients and contact tracing to commence, reducing the size of an outbreak. Ebola RDTs, which require no electricity and use saliva or fingerprick blood, were developed and tested in West Africa during the 2014 Ebola outbreak. The high sensitivity of the fingerprick test allowed patients to be triaged and admitted to an isolation centre or sent for alternative treatment. Future outbreak responses will include similar speedy development of sensitive and specific RDTs.Clinical Trials & Research During OutbreaksWhere no effective treatment exists for a disease, the trial of novel therapeutics during an outbreak is now considered under an ethical framework developed by WHO, called Monitored Emergency use of Un-Registered Interventions (MEURI). Currently, two antivirals and three monoclonal-antibody cocktails are approved for use in Ebola in DRC. Trial designs during emergency response have also been carefully critiqued and novel randomization strategies developed4.Excellent basic clinical care during outbreaks remains essential for reducing mortality. This can be difficult to deliver in the case of viral haemorrhagic fevers but well-designed isolation centres, near-patient monitoring devices and portable, rapid biochemistry analysers have revolutionised clinical care (Figure 2).
Figure 2: Health worker cares for Ebola patient in the CUBE (biosecure emergency care unit), Beni, Democratic Republic of Congo. © Jennifer Lazuta/ALIMAInnovation in personal protective equipment (PPE) proliferated during the West Africa Ebola outbreak and rapid removal PPE suits have been developed, as well as improved fabrics and simulation mannequins.Vaccine development is an essential area for some outbreaks. The Coalition for Epidemic Preparedness and Innovations (CEPI) is funding the development of Middle East respiratory disease, Lassa fever and Nipah virus vaccines. An Ebola vaccine available at the end of the 2014 outbreak, using a novel trial design of ring vaccination5, was highly effective. This enabled vaccine deployment to the DRC Ebola outbreak in 2018.The FutureInnovation in outbreak response arises in multiple areas with exciting developments in Digital Disease Detection; rapid pathogen sequencing and RDT development; real-time modelling of the trajectory and response; improved isolation and treatment centres; near patient monitoring devices; novel PPE designs; treatment trials; and rapid vaccine development and testing. Research teams are an important element of outbreak response to direct the response most effectively, and ensure innovations are tested, publicly reported and peer-critiqued. Affected countries and global response teams should strive to provide evidenced-based outbreak response, with trials of innovative tools aiming to improve outbreak preparedness and response.
Disease Outbreaks in Low and Middle Income Countries
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