Abstract
The current (10th) Ebola outbreak in the Democratic Republic of Congo (DRC) has once again exposed the limits and the challenges of global outbreak preparedness. Since it was declared in August 2018, there have been more than 3,000 confirmed cases and more than 2,000 deaths. 1 Over the years, the global health community has invested significant resources in preparedness, and yet this outbreak comes on the heels of the unprecedented Ebola outbreak in West Africa in 2014-2016. That outbreak was the largest ever recorded, with 28,000 suspected cases and 11,000 deaths. Not only did it cost already-weak economies billions of dollars, but 7% to 8% of the health workforce was lost in some of these countries. 2 The United States, the UK, and Germany directly spent more than US$3.5 billion on the outbreak response, 3 but the total costs have been estimated at up to US$50 billion. 4
Pandemic threats from influenza and emerging infections are very real. The longer an outbreak lasts, the more opportunity the microbe has to evolve into dangerous strains. 5 These mutations or evolutions could help the virus to break down human defenses by increasing infectivity or by acquiring antimicrobial resistance. 6 And the growing menace of antimicrobial resistance is further complicating our response capacities to numerous transboundary diseases, including influenza, carbapenem-resistant Enterobacteriaceae (CRE), malaria, gonorrhea, HIV/AIDS, XDR typhoid, and tuberculosis.
Many governments take this pandemic threat seriously. For example, the US government has spent nearly a billion dollars to strengthen global epidemic preparedness and response through a collaborative program called the Global Health Security Agenda (GHSA). 7 The GHSA is a multisector collaboration of 64 countries and organizations that aims to strengthen countries' capacities to prevent, detect, and respond to infectious disease threats. It is acting as a complement to an earlier international agreement, the International Health Regulations (IHR 2005), which were aimed at preparedness.
Germany has committed 500 million euros (US$599 million) for work on antibiotic resistance. 8 Other countries and international agencies have also lined up resources to improve pandemic preparedness. 7 Apart from these resources for global preparedness, countries are investing to improve their local capacities to detect and respond to disease. Unfortunately, we are still far below the required financial investment of an estimated US$4.5 billion per year for preparedness. 9 But are current investments, no matter how large, making the world better prepared? Are we going in the right direction? Will the next pandemic be managed well?
Measuring preparedness is complex. The World Health Organization (WHO) is leading a collaborative effort to assess countries' preparedness for pandemics using Joint External Evaluations (JEEs). 10 This process covered all 11 areas of the GHSA, so the GHSA assessment tool was considered redundant and the JEE has been universally adopted. These evaluations are guided by the JEE tool. The evaluations are voluntary, use a multisectoral approach, and emphasize transparency, information sharing, and public release of the resulting reports. The second edition of the tool includes 49 indicators in 19 technical areas.
In a study that analyzed the results of the first 55 JEE assessments, the median score on 43 of the 48 indicators in the first edition tool was less than 4 on a scale of 5. (This score reflects that a country has not shown demonstrated expertise in that area. 11 ) “Prevent Epidemics” by Resolve to Save Lives has developed a “ready score,” which gives a numerical value to country readiness based on JEE evaluations. More than 80% are not ready for a major pandemic, including the 3 African countries that faced the brunt of the last Ebola outbreak. 12
Even for the few countries that are passing these evaluations (with full scores of 5 on the JEE), we are just assessing compliance with the IHR/GHSA requirements of preparedness and not actually assessing readiness. There is a huge difference between these 2 terms. A country could be 100% compliant but not ready. This is akin to counting the number of guns in an army but not checking that they could actually fire a bullet.
So, why, with all this attention and resources, are we still not ready for a pandemic? The main reason is that the 48 indicators in the JEE tool exposed an overwhelming number of critical gaps, and, in practice, this translates into huge financial costs for countries to implement their roadmaps. Despite the expenditures, the timing and coordination of resources for ameliorating these gaps in preparedness for the member countries becomes complicated and has not occurred. This is the reason that we have not seen a lot of funded country roadmaps or plans, even after full costing exercises.
While all of the technical areas that the JEE covers are very important, there is a need to focus on the most critical areas first. The GHSA partnership also felt the need to prioritize and have created a more focused approach. Under GHSA 2024, the action packages have been reduced from 11 to 8 (by deferring reporting, linking public health with law and multisectoral rapid response, and medical countermeasures and personnel deployment). 13 In contrast, the second edition of the JEE has not reduced the technical areas and has increased the indicators to 49.
There is still a need to further reduce the GHSA action packages and the JEE technical areas to the most critical areas. A phased approach should be adopted, with a focus on no more than 3 or 4 action packages at a time. In initial reviews, modified indicators of surveillance (including antimicrobial resistance), laboratory systems, and work force development focused on disease surveillance, and outbreak detection and response could be the first one to be evaluated. Once these critical areas are covered, then other technical areas or action packages could follow.
It will help the external reviewers and local experts to have an in-depth evaluation of these areas and help create more focused roadmaps. Costs will not be as high, and local decisions makers could then own the process and champion it with their own governments.
The JEE tool has been further revised with more clarity and changes to some indicators. 10 Although some indicators do now include some component of readiness, this could be strengthened to ensure that countries do not become complacent once they have set up the required indicator.
Exercises are also essential but rarely done. In a recent survey report of WHO member states on preparedness for an influenza pandemic, only 40% had conducted an exercise in the past 5 years. 14 Bringing new capacities into tabletop exercises to assure they work will enhance readiness. Continuously testing the minimum readiness indicators in tabletop exercises and performances in managing actual outbreaks should also be required. This could be added as a component of JEE evaluations so it will be a process and not just a one-time snapshot. Even with a prioritized list of limited (or circumscribed) indicators, these countries will need significantly more resources to get prepared.
This world is a big mixing pot of humans, animals, and their infectious organisms. With more than 4 billion airline passengers each year and US$19.48 trillion worth of goods crossing borders, the globe is in an era of heightened risk for infectious disease outbreaks and pandemics. Today, an outbreak in a remote area in Africa or Asia could reach anywhere else on the globe within 24 hours. Any weak link in the chain of preparedness could be detrimental to global preparedness. It is important that locally supported readiness processes are in place to make preparedness more sustainable. Financial investments need to be prioritized for those measurable indicators that are relevant, critical, and have the greatest impact. But first it is necessary to revise the technical areas of the JEE into tiers to build a foundation of preparedness.
History shows us repeatedly that outbreak response costs more than outbreak readiness. We should not wait until our weak defenses are broken by a major pandemic. We need to think of public health strategies in military terms. We have many very clever and dangerous foes. Danger to a nation's security does not come in the form of invading armies alone. Think bacteria, parasites, viruses, and fungi!