A Century of InfluenzaIs the World Prepared for the Next Pandemic?
Over the last century, four international public health crises challenged global health-systems and severely damaged communities. Influenza pandemics, or influenza epidemics that spread throughout the world, all stemmed from changing subtypes of the influenza A virus. Although its unassuming popular name—the "flu"—sometimes minimizes public perception of the threat, influenza is a complex, constantly changing threat, and globalization has created both benefits and new challenges for global health-systems in combating it. Despite all we know about the virus' structure, transmissibility, and epidemiology, there is still much to be discovered in order to combat its potential for causing death and global disruption.
Leading up to the centennial of the 1918 "Great Influenza," which caused up to 100 million deaths worldwide, public health officials reviewed and commissioned historical analyses. These studies focused on the following: [End Page 163]
• Reconstructing the pathogen's epidemiological characteristics as well as the temporal and geographic spread of the pandemic, including its social and health consequences
• Understanding the impact and effectiveness of non-pharmaceutical interventions and other population-based control strategies in various US cities
• Identifying parameters and other assumptions for pandemic influenza models, which were subsequently used to assess prevention and control strategies
This research, along with studies of other 20th-century pandemics, informed global, federal, state, and local preparation for a possible avian influenza pandemic in the 2000s. It was also used to guide the response to the 2009 H1N1 pandemic, which was far different in character from the 1918 pandemic and the expected avian influenza pandemic. Today, this research continues to guide pandemic planning at both the national and global levels.
In order to apply findings from research and to gain further insight into possible responses to a global pandemic in the 21st century, we conducted a simulation exercise of a hypothetical, but realistic, pandemic influenza today. Approximately thirty Georgetown medical, graduate, and undergraduate students played the roles of global, national, and local officials as well as medical advisors responding to a pandemic. The exercise included two phases, each of which ended with a presentation by the student participants to a panel of "decision-makers" from public health and other sectors. The simulation highlighted several areas that were key to the simulation, that would likely also arise in the case of an influenza pandemic today: identifying epidemiological characteristics of the novel pandemic strain, coordinating globally in accord with the International Health Regulations, implementing a Public Health Emergency of International Concern, applying non-pharmaceutical interventions, assessing availability and distribution of medical countermeasures, maintaining standards of care in a crisis, and communicating risk information locally.
Global Health Challenges
The first phase of the simulation focused on global issues following the emergence of a new subtype of influenza in Vietnam. Several unusual influenza cases were identified in rural Vietnam with a high fatality rate. It was initially unclear if the influenza cases were part of the normal influenza season or whether they were due to a novel strain with pandemic potential. Different subtypes of influenza are characterized by proteins on the surface of the virus.1 A novel influenza subtype arises when the proteins on the surface of the virus combine in new ways. It is important to distinguish whether the influenza cases in Vietnam were due to a novel subtype that could cause a pandemic because often large groups of the population tend to be immunologically naive to novel subtypes, meaning that people do not have immunity because they have never been previously infected by the novel subtype. If the novel subtype is easily spread from human to human, the result could be a pandemic, in which the pathogen can rapidly spread throughout the world. Furthermore, if the novel subtype is highly virulent, meaning that the virus causes severe disease and high rates of death, the result can be catastrophic. Currently, there are several subtypes of avian influenza that could potentially result in the next influenza pandemic.2 Fortunately, these viruses are currently not easily transmissible between humans. Yet, if they mutate and become more transmissible, we would face a catastrophic pandemic, especially considering [End Page 164] the highly connected nature of today's global society, where air travel could easily spread pandemic influenza around the world in days. Thus, Vietnam needed to know if they had a pandemic influenza strain on their hands, but struggled with the laboratory capacity to clearly identify if this was the case.
The situation escalated as an American working in Vietnam became ill and was evacuated to the US, where he then died. This became an issue of international concern and required coordination of information between multiple countries. Expectations for international communication in pandemic situations are governed by the International Health Regulations (IHR). WHO member states are obligated to report any potential disease threat. They are also obligated to develop and maintain minimum public health capacities to detect, assess, report, and respond to public health events.3 In the United States, for instance, this process starts with a local lab or health department and works through state health departments, the CDC, the Department of Health and Human Services, and eventually the WHO. The expectations established by the IHR, the global laboratory and epidemiology networks, and modern information technologies have made this process far more efficient than it was a few decades ago.4 The complications for information sharing stem from the need to decide what to share, with whom, and when. At the global level, many countries have not yet developed the required surveillance capacities and may even be reluctant to report an outbreak for fear of trade or travel restrictions. Indeed, Vietnam was hesitant to share information and viral samples owing to consideration of negative social and economic impacts. However, they cooperated as the situation escalated, and the strain was identified as a pandemic influenza strain through sharing of viral samples.
The challenge then fell on the World Health Organization to assess the situation and decide whether they should declare a Public Health Emergency of International Concern (PHEIC). A PHEIC is defined by the World Health Organization as an extraordinary event that is determined to constitute a public health risk to other states through the international spread of disease and to potentially require a coordinated international response.5 The World Health Organization did declare a PHEIC because the situation met the WHO's criteria of (1) being serious, sudden, unusual, or unexpected; (2) carrying implications for public health beyond the affected state's national border, and (3) requiring immediate international attention.
Domestic Health Challenges
The second phase shifted the participants' focus to issues that any country would face during a pandemic. Set approximately two months later, the pandemic virus has spread globally and remains a PHEIC. A surge in cases has been reported on both coasts of the US, while a vaccine has yet to become available. Vaccine development for influenza viruses is a slow process—the highest speed at which a vaccine could be produced for a novel influenza virus is about six months.6 Efforts are underway to develop a universal influenza vaccine that could protect humans against all types of influenza. However, there are many challenges in creating such a vaccine, and more research is needed before it could be made readily available.7 In the absence of a universal influenza [End Page 165] vaccine, behavioral interventions are needed to prevent the spread of pandemic influenza. These types of interventions are called nonpharmaceutical interventions (NPIs). Both analyses of past pandemics8 and mathematical modeling studies9 indicate that NPIs can mitigate the spread of a virus and, especially if layered, can reduce mortality during an influenza pandemic. These interventions include quarantine of susceptible individuals and "social distancing" policies such as restrictions on public transportation and cancellation of group events. NPIs, however, carry economic and social burdens and must be used judiciously. For instance, since children are at high risk for transmission and can spread disease to members of their households, school closures can be effective only if they are started early and maintained for a long period. School closures, however, remain controversial due to their high costs (especially for parents who have to stay home from work to care for their children) and potential for social disruption.10 Discussions during the simulation centered around local decisions regarding school closings, quarantine, and other NPIs. School closures were not implemented owing to their high cost. However, other interventions, like isolation of infected individuals in the same hospital and checking for influenza infection at airports to prevent further spread, were implemented.
Another challenge for US-based decision-makers was the distribution of medical countermeasures for influenza. Antiviral medications currently on the market would likely be effective in treating victims of a 21st-century influenza pandemic. Antivirals can prevent transmission to others such as family members and health care personnel. However, since these medications are costly, are in limited supply, and have significant side effects, they must be used strategically. During a pandemic, the increased demand for medications would result in supply chain issues for antivirals and other medications, personal protective equipment, and many other supplies. Since the US Strategic National Stockpile only has limited amounts of these and other resources, the federal government is bound to face challenging decisions about when and in what quantities they should be released to the states. The states, in turn, will require plans to distribute them efficiently and fairly. The simulation decision-makers did decide to distribute antiviral medications from the US Strategic National Stockpile. They distributed some of the antivirals to the states most affected but maintained some of the stockpile in case the pandemic situation worsened. States distributed antivirals to areas most affected and set up antiviral pickup locations within communities to keep infected individuals from needing to go to a hospital and risking further spread of the virus.
However, as the virus continued to spread, hospitals did become overcrowded. The heightened demand for health care services—from the infected and the "worried well" who seek information or diagnosis—increased the burden on the health care system. Therefore, a triage system that prioritizes high-risk patients is needed, even though it is ethically challenging. The Centers for Disease Control and Prevention (CDC) has developed a set of tools to inject as much objectivity as possible into the triage process.11 The Pandemic Influenza Triage Algorithm, for instance, asks a series of questions about the patient's immediate state, co-morbidities, and infectiousness and classifies the patient into one of five levels based on the likelihood that health care would improve outcomes. Local hospitals implemented this triage system in order to maintain standards of care. However, this did not solve the problem entirely. Since hospitals must maintain regular operations [End Page 166] and treatment of critical conditions other than influenza, such as dialysis, chemotherapy, and childbirth, it is necessary to divert low-risk patients from seeking care at the hospital and reserve ambulatory settings for high-risk patients. Thus, alternative care facilities located outside traditional hospital settings were recommended for such patients to serve as overflow treatment sites, isolation sites for infectious patients, alternatives to home care, rapid screening centers, etc.12 This diverted low-risk patients to alternative care facilities to allow hospitals to focus only on high-risk patients and decrease patient-to-patient interaction, thereby limiting disease transmission within the hospital.
Much of the decision-makers' attention was focused on slowing the spread of influenza and effectively treating those infected. One thing that was overlooked was emergency risk communication (ERC) with the public. During a pandemic, the public receives information about the developing situation and recommended behavior changes through various channels. These include government statements, traditional media such as newspapers, television, and radio, online media such as blogs and social media, health care providers, as well as friends or family. The main challenge to ERC is the uncertain nature of the changing explanations and recommendations for the public as the scientific understanding of the pandemic evolves during an outbreak. When official communications are unclear or uncoordinated with local governments, health care providers, and the press, rumors as well as misperceptions may arise that would not subside easily. Social media can spread rumors but, on the other hand, can be an effective and efficient communication tool, as was shown by the CDC's success in using social media during the 2009 H1N1 pandemic to quickly address concerns of rumors, after which the public reported high satisfaction with the CDC.13 However, even after ten months into the pandemic, messages about virus transmission did not reach the less educated.14
One of the major challenges for ERC is the dissemination of pandemic information among, and the uptake and understanding of the information within, diverse populations. Health officials must be aware of the at-risk populations and groups with whom they come into contact and communicate. As in all emergency settings, distrust of institutions and misinformation can complicate the ERC process. Historical experience suggests that building trust and rapport prior to emergency situations, especially through community leaders, can be critical to the population's uptake of recommended behaviors. In addition, these recommended behaviors must be realistic and applicable for the population and, most important, should emphasize self-efficacy.15 The simulation highlighted that ERC does not take place in a vacuum and that conflicting priorities in the context of an emergency hamper effective communication. Communication with the public is difficult to prioritize ahead of information sharing globally and within the national public health system. Maintaining economic stability or strengthening the health system can be valued ahead of ERC, especially if the country has a weak health system prior to a pandemic. In the simulation, overlooking ERC had multiple negative effects. Those in Vietnam placed ERC as a non-priority because the pandemic harmed the country's tourism and agriculture [End Page 167] industries. By the time the government officials acknowledged the pandemic, mass panic had already occurred. Similarly, in the US, panic was widespread, as well as misperceptions like that Vietnamese communities in the US might be at higher risk of transmission. Neglecting ERC can result in the spread of misinformation and can prevent the public from adopting behavioral mitigation strategies. Strengthening communication prior to an emergency is vital to ensuring good emergency risk communication and a calm public when a pandemic does arise.
Beyond the specific issues discussed above, the simulation exercise identified a number of points for consideration as the world prepares for the next global pandemic. To begin with, the simulation illustrated the difficulty of developing a clear understanding of what is happening during a global pandemic owing to asymmetrical information, as well as differences in expertise, disciplinary perspectives, interests, and values. Furthermore, while the criteria for countries reporting to the WHO and for declaring a PHEIC may be clearly stated in international law, the simulation demonstrated that making these decisions when the epidemiological facts and scientific understanding are still developing can be very challenging. For instance, in the first phase, Vietnam knew of some potential cases but did not have the laboratory capacity to characterize the pathogen and was thus reluctant to trigger trade and travel bans based on incomplete information. It was only after the US CDC identified a new viral subtype in its own worker that the world became fully aware of the pandemic threat. Yet, although the pandemic began with a few cases in rural Vietnam and ultimately required action by country health officials and hospital managers, a global response involving information sharing, scientific cooperation, good diplomatic relationships, and strong global institutions was essential.
The exercise showed that globalization has both advantages and disadvantages—it makes populations more vulnerable and enables faster and farther spread of viral pathogens via air travel, yet at the same time, it facilitates international cooperation to find solutions. The same can be said of advances in technology. For example, antiviral medications can be effective, but there are challenges in their production and distribution as well as in equitably dealing with shortages. Despite many new technologies, the simulation demonstrated that the "old-fashioned" concepts of isolation, quarantine, and social distancing can still be effective mitigation tools. Global-level scientific cooperation and guidance issued by the WHO helped both the US and other countries develop their own control strategies.
Thus, regarding the question posed by this paper's title—whether we are prepared for the next pandemic—our answer is neither a resounding "yes" nor a disheartening "no." Considering both the challenges and benefits of globalization, our literature review and simulation exercise show how it can often be difficult to understand the "big picture" through the barrage of information, to effectively share information among nations, and to coordinate responses. This work also illustrates the challenges of effective emergency risk communication, which is a vital, yet often overlooked, tool for public dissemination of information. Global health systems are constantly evolving their approach to combat pandemic influenza by evaluating the successes and failures of countless decisions that are made in the course of a pandemic response. Rather than confidently believing that the world is prepared [End Page 168] for the next pandemic, or pessimistically worrying that it is not, our analysis shows that it is better to identify specific gaps and to remedy them by building on existing health systems. [End Page 169]
Michael A. stoto, PhD, a professor of health systems administration and population health at Georgetown University, is a statistician, epidemiologist, and health services researcher. He also holds adjunct faculty appointments in the Department of Family Medicine, the Georgetown University Law Center, and the McCourt School of Public Policy. Dr. Stoto's research includes methodological topics in epidemiology and statistics, including systematic reviews/meta-analysis and other analytical methods for comparative effectiveness research, community health assessment, evaluation methods, and performance measurement. His substantive research interests include public health practice, especially with regard to emergency preparedness; drug and vaccine safety; infectious disease policy; and ethical issues in research and public health practice. Dr. Stoto is also an expert on population health and public health assessment and the associate director of the population health scholars program in the Georgetown University School of Medicine.
Normand LeBlanc is a rising senior in the School of Nursing and Health Sciences at Georgetown University.
Nellie Darling is a third-year medical student at the Georgetown University School of Medicine with a background in public health, infectious disease, and disaster management. She holds a BS in international health from Georgetown University, and an MS in crisis, emergency, and risk management from George Washington University. She most recently worked as an epidemiologist for the Department of Defense conducting biosurveillance on diseases such as Ebola, Zika, and MERS-coV, as well as designing and facilitating military epidemic response exercises.
Julia Gasior is an undergraduate student at Georgetown University studying health care management and policy with a focus on health systems, drug policy, and infectious disease control.
Mikaela Harmsen is an undergraduate student at Georgetown University pursuing a Bachelor's of science in healthcare administration and management.
Casey Zipfel is a PhD candidate in the Department of Biology at Georgetown University. Casey's research focuses on using empirical data and computational epidemiological models to understand the interaction between human behavior and infectious disease dynamics.
. This project was supported by the Georgetown University Global Health Initiative as part of the Great Influenza Centenary Project. The authors are grateful to the following Georgetown students who contributed to the literature review or participated in the exercise: Reilly Barry, Katheryn Bell, Caroline Bucca, Haley Byman, Gina Celata, Yadhu Dhital, Dani Feller, Emily Graul, Tony Jeong, Olivia Lal Alatan, Sophie Lockwood, Angela Lu, Luke Martin, Amy Meng, Andrew Meshnick, Sahaj Patel, Sheela Ranganathan, Rhea Rijhsinghani, Grant Rosensteel, Siona Sharma, Marina Tian, Robert Treval, and Valencia Waller.
2. W. D. Tanner, D. J. A. Toth, and A. V. Gundlapalli, "The Pandemic Potential of Avian Influenza A(H7N9) Virus: A Review," Epidemiology and Infection 143, no. 16 (2015): 3359–74, doi:10.1017/S0950268815001570.
3. Lawrence O. Gostin and Rebecca Katz, "The International Health Regulations: The Governing Framework for Global Health Security," Milbank Quarterly 94, no. 2 (2016): 264-313, doi:10.1111/1468-0009.12186.
4. Michael A Stoto, "Biosurveillance Capability Requirements for the Global Health Security Agenda: Lessons from the 2009 H1N1 Pandemic," Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 12, no. 5 (2014): 225–30, doi:10.1089/bsp.2014.0030.
5. "International Health Regulations and Emergency Committees," World Health Organization, 2016.
6. "Pandemic Influenza Vaccines," World Health Organization, 2019, https://www.who.int/immunization/newsroom/vaccine_PI/en/.
7. Sophie A. Valkenburg et al., "The Hurdles from Bench to Bedside in the Realization and Implementation of a Universal Influenza Vaccine," Frontiers in Immunology 9 (2018), doi:10.3389/fimmu.2018.01479.
8. H. Markel et al., "Nonpharmaceutical Interventions Implemented by US Cities during the 1918–1919 Influenza Pandemic," Jama 298, no. 6 (2007): 644–54.
10. Tamar Klaiman, John D. Kraemer, and Michael A. Stoto, "Variability in School Closure Decisions in Response to 2009 H1N1: A Qualitative Systems Improvement Analysis," BMC Public Health 11, no. 1 (2011): 73, doi:10.1186/1471-2458-11-73.
11. Centers for Disease Control and Prevention, "Pandemic Influenza Triage Tools," 2016, https://www.cdc.gov/cpr/healthcare/pan-fluapp/desktop/d.index.html.
13. Shari R. Veil, Tara Buehner, and Michael J. Palenchar, "A Work-in-Process Literature Review: Incorporating Social Media in Risk and Crisis Communication," Journal of Contingencies and Crisis Management 19, no. 2 (2011): 110–22, doi:10.1111/j.1468-5973.2011.00639.x.
14. Elena Savoia, Marcia A. Testa, and Kasisomayajula Viswanath, "Predictors of Knowledge of H1N1 Infection and Transmission in the US Population," BMC Public Health 12, 1 (2012): 1, doi:10.1186/1471-2458-12-328.
15. "Communicating Risk in Public Health Emergencies. A WHO Guideline for Emergency Risk-Communication (ERC) Policy and Practice," World Health Organization, 2018.