Governance and infrastructure

Epidemics represent shared risks that cross borders and all of society. Health systems, routine care, trust in governments, travel, trade, business—all are disrupted during an epidemic. With such broad risks, the preparation and response must be nationally owned and led, internationally supported and undertaken with a whole-of-society approach. Some initiatives have started to build frameworks for this to happen in a coordinated way. For example, the WHO’s Pandemic Influenza Preparedness Framework brings together nation states, industry, other stakeholders and the WHO to implement a global approach to pandemic preparedness and response29.

A focus must be building coordinated regional and country expertise, resources and capacity through national and regional public health institutions30. This brings its own challenges—governance of institutions, leadership, collaborations and interventions have to be impeccable or misconduct can thrive31. Unwelcome in itself, misuse of funding, resources or people within efforts intended to support an epidemic response will also undermine trust in the organizations that respond to an outbreak and, in turn, prolong the outbreak.

Key governance components include drafting policies in advance and being willing to implement those policies for data collection and sharing during epidemics. They must be flexible enough to enable affected communities and nations to retain ownership of the response, while drawing on international expertise to find the best possible response. Governance should also include processes for vaccine and therapeutic approvals during outbreaks. However, it is clear that the centre of gravity for leadership, governance and implementation must be where the need is greatest if these are to truly deliver.

In 1971, Julian Tudor Hart proposed the inverse care law: “The availability of good medical care tends to vary inversely with the need for it in the population served.”32. An analogue of the inverse care law can be applied to public health and epidemiology. Expertise in these fields has traditionally gravitated towards centres of excellence in Europe and the United States. Of course, high-income countries are not immune to the disruption associated with epidemics, especially in an era of misinformation and growing mistrust in authorities and public health initiatives. However, the centre of gravity must shift so that globally representative distributed networks of collaborating centres can jointly ensure coverage in the regions that urgently need these skills on the ground33. International collaborations remain important; however, strengthening epidemiology, public health and laboratory capacity in low- and middle-income countries is essential34. Collaborative interventions should not be limited to when there is a major outbreak, but be integrated into regular interactions.

Capacity, resources, expertise and governance can be supported by the increasing role for regional and national centres of disease control. The US Centers for Disease Control (CDC) lends its expertise all around the world in addition to protecting the US population. In 2004, the European CDC started, followed by the China CDC in 2015 and by the Africa CDC in 2017. Although more can be done to improve data sharing and access to laboratories, the networks and connections between these centres have strengthened all of their work, as well as having a positive effect on public health systems in low- and middle-income countries.

Engagement and communication

During the pan-European wave of cholera in the 1830s, there were riots across the continent: doctors, nurses and pharmacists were murdered, hospitals and medical equipment destroyed27. Similar reports today usually come from communities that have not had positive prior interactions with public health initiatives, and thus the encounter with national or international teams who arrive only in response to a ‘new’ disease means that trust can never be assumed and has to be earned on both sides. Engagement needs to start before an outbreak—ensuring that patients, their families and their communities are at the centre of all public health is essential for the successful prevention and response to epidemics. There is no public health without the support of the community.

For example, the early detection of disease events will be improved if more national and regional public health institutions establish community event-based surveillance systems. Communities are the first to know when something unusual happens35—therefore training and mobilizing community volunteers to report such occurrences is a cost-effective way to rapidly detect diseases and contain them at the source. This will also help to sustain engagement between communities and the organizations that respond to outbreaks. Furthermore, improved information flow between the community and the public health system should provide a better understanding of local social networks to complement other means of tracking chains of transmission between individuals and places. This can be the community themselves, or it might be veterinarians who see clusters of sick animals, or nurses and doctors who care for patients in primary care—or it may be teams that are often forgotten in public health initiatives, such as those working in critical care facilities; it is striking how the first cases of Nipah, SARS, MERS and influenza A subtype H5N1 were all first identified by clinical teams in critical care facilities.

An inclusive, whole-of-society approach is challenging, and the challenges may be magnified in a conflict or post-conflict zone. Wars and conflicts not only increase the risk of epidemics as people move to escape violence and health services become harder to maintain36, but also make public health responses vulnerable to interruption, thus making them less effective. Then, miscommunication, mistrust, disease and violence can fuel each other in a vicious cycle. Engaging local communities remains the highest priority, even in unstable contexts such as North Kivu and Ituri provinces of the Democratic Republic of the Congo (DRC)37, where an Ebola epidemic started in August 2018. It seems inevitable that responding to epidemics in politically unstable environments will become more common, and skilled negotiators and peacekeepers will have to be better integrated in response teams. Equally essential, therefore, will be an improved understanding of these challenging operational contexts among affected communities and external responders alike.

Social sciences

Social scientists have long applied their skills and knowledge in epidemic responses, although their roles have become more visible in recent years38. By focusing on communities, social science humanizes the epidemic response39, helps to increase understanding of context and may uncover associations between the context or local practices and the risk of transmission. The Social Science in Humanitarian Action Platform40 has successfully produced rapid reports and briefings on regions in which an epidemic has been identified, and the Global Research Collaboration for Infectious Disease Preparedness includes a social science research funders’ forum to ‘propel research in this area’41, acknowledging that its integration in the preparation and response to outbreaks is often missing or added as an afterthought to solve a problem that could have been forseen. There is still much to learn about how epidemic responders and social scientists can make the most of each other’s expertise42 and how data from social science can fit into the wider information architecture of epidemic response.

As an example, behavioural surveillance43 will be critical in twenty-first century responses to disease outbreaks44. Just as behavioural surveillance to improve the understanding of HIV was crucial in identifying high-risk groups for HIV infection, so human behaviours will continue to be important as we respond to future infectious diseases. For instance, the Ebola virus outbreak in West Africa probably began before December 2013, but it took several months before hospital transmission and traditional burial practices were found to be the leading causes of its rapid spread.

Emerging technologies

The increasing prevalence of mobile phones, wireless internet connectivity and social media activity raises the possibility of using these tools to gather data for epidemiological studies, diagnostics45, population mobility during an Ebola epidemic46 or influenza incidence in real time47. Future developments in predictive technology, machine learning and artificial intelligence will bring more opportunities to move towards ‘precision public health’ (Box 2).

The use of data from people is becoming strictly controlled, however, and it will be a challenge to persuade countries to invest in a new surveillance system, for example, before its general effectiveness has been demonstrated at a country level48. Even then, technology-based solutions should be integrated with community-based programmes and other existing epidemic preparedness and response systems because surveillance is more effective when standardized among different countries, districts and communities. To this end, suites of guidance and open-access standardized tools are being developed for reporting cases of disease, as well as consent forms, standard operating procedures and training materials49, properly validated diagnostic assays and access to quality-assurance panels in public50 and veterinary51 health. The rising trend of engaging citizens in data gathering is also welcome—the use of mosquito-recognition apps enables the collection of data far beyond the capacity of routine mosquito surveillance52. This way, citizens feed information into the public health system and the feedback loop offers a fast and direct way to provide citizens with details of potential actions that they can take.

As well as potentially supporting diagnosis and surveillance53, the fast-developing field of genomic epidemiology54 can yield information to track the evolution of a virus such as Ebola during an epidemic55,56. There will be times when it can detect outbreaks better than traditional epidemiology, illustrating the need to have these tools available in the same toolbox. During the large Lassa fever outbreak in Nigeria in 2018, real-time genomic sequencing provided clear evidence that the rapid increase was not due to a single Lassa virus variant, nor attributable to sustained human-to-human transmission. Rather, the outbreak was characterized by vast viral diversity defined by geography, with major rivers acting as barriers to migration of the rodent reservoir57. These findings were crucial in containing the outbreak.

Developing and sustaining the capacity to conduct real-time sequencing with adequate bioinformatics analyses at regional and national levels will be challenging in low- and middle-income countries. Moreover, investments in relatively high-tech capacity (such as real-time sequencing) are competing with other, arguably more fundamental needs, such as equipment and training in primary laboratories. Political engagement must be nurtured between epidemics: it is not enough to offer technological and laboratory support during a crisis, even with the promise of building capacity, if the political will is not there. However, with proper preparation, and accessible and trusted data sharing and governance mechanisms, laboratories with limited resources may be able to leap-frog into the twenty-first century58,59.

Research and development

Vaccination is one of the most effective public health interventions and innovative strategies for research and development of vaccines, such as using ring vaccination as a trial design during Ebola epidemics since 201560,61,62, must be encouraged. At the start of the 2013–2015 epidemic in West Africa, vaccine candidates were already in development, based on a long history of preclinical research, although a lot of work was still required to get clinical trials underway in time to be useful63. In 2015, when Zika was first internationally recognized as a pathogen that could cause birth defects64, there was hardly any research and no vaccines in late-stage development. Two-and-a-half years later, results from three phase I clinical trials had been reported65, although challenges remained for further development. The lack of a profitable market for such products means that pharmaceutical companies lack the incentives to push this work between epidemics. Initiatives such as the Coalition for Epidemic Preparedness Innovations are attempting to positively disrupt financing models for vaccines against epidemic diseases66, and stockpiles of meningococcal vaccine, yellow fever vaccine and oral cholera vaccine are maintained by the International Coordinating Group to minimize potential delays due to limited manufacturing capacity67.

Similarly, if investigational treatments or vaccines are to be used as part of the response to an epidemic, ethical protocols68 for managing informed consent and introducing them in clinical settings must be planned in advance with at-risk communities (Box 3). Trial designs69 should be created as soon as the option becomes viable. The essential consideration is how the resulting data can add to previous trials and influence the approach to trials in future epidemics. For example, research during the 2013–2015 Ebola epidemic enabled progress on therapeutic agents70 that are now being trialled in the ongoing outbreak in DRC71. Scientific progress during and between epidemics must be matched by other workstreams, such as the preparation of supply chain logistics and communication with at-risk populations. Plans have to be made for a series of future outbreaks, enabling adaptive, multi-year, multi-country studies72. Similar plans are needed for continual preclinical research to ensure that future vaccine and therapeutic pipelines will be filled.

One Health

The term ‘One Health’73 is used to acknowledge that human, animal and ecosystem health are tightly interconnected and need to be studied in the context of each other (Fig. 1). Changes in the environment—whether natural or anthropogenic—affect interactions between pathogens, vectors and hosts in multiple and complex ways, making the emergence or decline of endemic, epidemic and zoonotic diseases difficult to predict, while epidemics of animal diseases can challenge a community’s access to food. The fact that pools of viruses, bacteria and parasites are maintained in wild and domesticated animals74 makes surveillance of potentially zoonotic diseases an intrinsic part of One Health epidemic planning. Many agencies and nations around the world now use prioritization tools such as those developed by the US CDC75 or the United Nations (UN) Food and Agriculture Organization (FAO)76 to identify and prioritize zoonotic diseases of concern. An early precedent was a joint consultation on emerging zoonotic diseases by the WHO, the FAO and the World Organisation for Animal Health in 200477. Understanding disease ecology in the zoonotic reservoir could potentially lead to ways to predict the risk of human disease, thus providing the basis for smart early-warning surveillance systems.

Fig. 1: An ecosystem of interactions. The tightly interconnected nature of human, animal and environmental health makes the emergence and decline of epidemics difficult to predict. One Health integrates multiple perspectives in a framework that emphasizes the need to consider any particular aspect in this broader context. Full size image

Individual countries with limited resources for epidemiological studies and epidemic preparation and response must decide their own priorities. However, infectious diseases do not respect borders. Similarly, the interdisciplinary nature of One Health means there are several different lenses through which different sectors assess risks and priorities. For One Health approaches to work, these multiple perspectives must be taken into account, whether human health or animal health, ecology or social sciences78.

Box 2 Precision public health Precision medicine refers to the use of genomic sequencing to retrace the specific course of a disease in individual patients, with the aim of being able to choose the best treatment option for each person. In public health, the analogous idea of precisely directing the right intervention to the right population is equally appealing. The potential of such an approach has been illustrated by the identification of two areas in the United States in 2016 that were at risk of Zika transmission89. Rather than the whole country, or even only Florida, being declared at risk, these two areas each measured less than 5 km2, and the response focused only on these specific neighbourhoods. By contrast, a campaign against yellow fever, also in 2016, defined risk ‘at the level of entire nations’. A broad interpretation of precision public health90 incorporates many different types of data to increase the power of epidemiology91. Such data would not only include genomic information, but also satellite imaging, mobile phone data, social media use data and so on. For example, a study published in 2019 combined epidemiological surveillance data, travel surveys, parasite genetics and anonymized mobile phone data to measure the spread of malaria parasites in southeast Bangladesh92. A retrospective analysis of mobile phone call data in Sierra Leone from 2015 showed how it might have been used to assess the impact of travel restrictions on mobility during the Ebola epidemic46. The principle of selecting the most relevant information from all available data seems within the scope of good epidemiological practice already. The challenge is recognizing and incorporating new types of data when they become available.