Outbreaks are here to stay

JIMMY WHITWORTH: As I mentioned in week one, outbreaks continue to happen. They can occur anywhere and at any time. Very often, they spill over into human populations from animals, both wildlife and livestock.

Outbreaks are being reported more frequently than in the past. Certainly, there is better surveillance than there used to be in the past, which might account for this. But it is also possible that outbreaks are actually occurring more frequently than in the past. Certainly, the drivers of outbreaks are not decreasing.

These factors include human population increase with urbanisation, crowding and poverty. This increases pressures on sanitation, refuse, and water supplies. Also, there are changes in agricultural practise, with more cultivation occurring in previously forested areas or in forest margins where many wild animals live. Climate change affects agriculture as well as the distribution of insect vectors. Climate change also causes population movement, both of humans and of animals. With increasing air travel, we are ever more connected, and with over two million people crossing an international border every day, and increasing international trade, it is inconceivable that any one country can isolate itself from the rest of the world.

Breakdown of public health systems, which may lead to decreases in vaccination coverage, can lead to outbreaks of infectious diseases that were previously controlled, and this can be magnified by crises and conflict. To illustrate the scale of the problem caused by infectious diseases, let me tell you that WHO monitors at any one time around 30 outbreaks just in Africa alone. While a lot of progress has been made in recent years in the control of epidemics, there’s still a long way to go, as the ultimate aim is to achieve health systems around the world that have detection and prevention of outbreaks as a core part of service provision.

Only when we achieve that, will we be able to prevent outbreaks at the early stages, or indeed, prevent them occurring altogether. Until we reach that stage, the prevention of outbreaks will remain a never-ending emergency function.

The use of electronic tools for surveillance and data collection have increased greatly in recent years, and in some cases, have also included information on animals, as well as humans. In this way, we’re able to detect outbreaks in early stages when they are easier to control. This also helps us to be able to predict and prevent outbreaks from occurring in the future. Mathematical modelling is being increasingly used in real-time to monitor and inform the response to an outbreak, and also to predict what may be happening in the future.

Molecular sequencing of the pathogen is also being increasingly done, and this is reaching a stage where it can be performed close to the patient and in real-time so that it can inform the outbreak response. Allied to this is the need for improved diagnostic tests that are rapid, accurate, and can be performed close to the point of care. We need more of these tests, particularly those that don’t require an electricity supply and can be used by people with minimal training. Having the affected community engaged and positively involved is essential for the detection and the control of outbreaks.

This has been neglected for too long, but the incorporation of anthropologists, social scientists and community experts in the response team is increasingly being recognised, and this needs to be promoted further.

Research needs to be more embedded within every response. This is starting to happen with increasing standardisation of reporting and data collection, and with an increased emphasis on the sharing of information. An ethical framework has been developed for testing experimental therapeutic drugs within outbreaks, and a pipeline for vaccine development has also been established for major pathogens. It is increasingly recognised that research and development needs to be done not just during outbreaks, but also between outbreaks, so that we are prepared for the next one.

The weakest part of preparedness and response to outbreaks is the local-national component, especially in countries that are prone to outbreaks. They’re very often fragile and ravaged by repeated crises. Creating a trained workforce able to respond to outbreaks is a critical need. Many countries have now established field epidemiology and laboratory training programmes, and these can be supported by networks such as TEPHINET, which supports over 70 courses in more than 100 countries worldwide. This network focuses on standardised training and programme improvement, and has been accrediting courses since 2016. Increasingly, this incorporates veterinary training, so embracing One Health principles.

There are also regional networks and courses, such as AFENET in sub-Saharan Africa, and European CDC’s EPIET & EUPHEM programmes, which cover field epidemiology and microbiology respectively.

The national trained workforce can be supplemented as needed by a global workforce reserve. This is organised and coordinated by WHO’s Global Outbreak Alert and Response Network, GOARN. This includes organisations such as the UK Public Health Rapid Support Team with its triple mandate of responding to outbreaks when invited by national governments, conducting operational research on outbreaks and strengthening capacity in low- and middle-income countries to develop their own response mechanisms. This is increasingly being supplemented by regional efforts, such as the new Africa CDC’s emergency response team, which is able to provide surge capacity, either at regional or at continental level.

Trained workforces need to be able to operate within effective health systems that are able to operate within the full “Prepare, Detect, Respond and Learn” cycle. Too often, health services are weak, particularly the public health preventative services, which are often ill-coordinated. WHO and the Global Health Security Agenda have promoted Joint External Evaluations to assess a country’s level of preparedness and ability to be able to respond to outbreaks. Many countries have now requested a Joint External Evaluation, which includes a national self-assessment followed by a visit from external experts and the production of a publicly available report, which identifies the most urgent needs for improvement of a country’s health system.

But in many countries, it remains to be seen if the funding can be found to improve the health system to provide the level of health security that is required.

As so often, the key to this is political will and commitment, and the strategic leadership to develop effective public health systems that are able to detect and respond to outbreaks, and so to provide better global, public health.