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Author: Dr. Ronald St. John

Throughout history there have been outbreaks of infectious diseases. The well-known plague epidemic (Black Death) was a devastating global epidemic of bubonic plague that struck Europe and Asia in the mid-1300s, wiping out an estimated one-third of the population. Disease outbreaks, when large in scope, have been referred to as epidemics. More recently, epidemics that have involved or might involve the global population have been labelled as pandemics.

When does an epidemic become a pandemic? There is no single accepted definition of the term pandemic (ref: Journal of Infectious Diseases, Vol. 200:7, 1 October 2009). Some considerations for labelling an outbreak as a pandemic include outbreaks of diseases:

• that extend over large geographic areas, e.g., influenza, HIV/AIDS
• that have high attack rates and explosiveness, e.g., common-source acquisition and highly contagious diseases with short incubation periods
• that affect populations with minimal population immunity
• that involve a new or novel version of an infectious agent – the term pandemic has been used most commonly to describe diseases that are new, or at least associated with novel variants of existing organisms, e.g., influenza.
• that are highly contagious. Many, if not most, infectious diseases considered to be pandemic by public health officials are contagious from person to person
• that have severe health consequences. The term pandemic has been applied to severe or fatal diseases

For purposes of this paper, a pandemic is an epidemic occurring worldwide, or over a very wide area, crossing international boundaries and usually affecting a large number of people.(1)

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Why are pandemics inevitable?

The worst kinds of pathogens — ones with the highest mortality rates and limited countermeasures — are increasing due to population increases, population density, more global travel, and changing migratory and environmental patterns that result in encroachment upon animal and other populations.

• Population density – The world’s population is around 7,500,000,000 people.(2) Excluding Antarctica and considering only the Earth’s land area, population density is 55 people per km₂ (over 142 per sq. mile). Around 55 percent of the world’s population is thought to be living in an urban area or city, with that figure set to rise to 68 percent over the coming decades, according to the “Population Division” report.(3)
• Rapid Population Movement — The International Air Transport Association (IATA) expects 7.2 billion passengers to travel in 2035, a near doubling of the 3.8 billion air travelers in 2016.(4)
• War/Insurgency – Syria and polio; Yemen and cholera
• Emergence of New/novel pathogen – mutation of known pathogen or exposure to novel pathogen, e.g., by human encroachment on deforested land
• Cultural resistance – risks of transmission and poor disease outcomes may be amplified by unfavourable behaviours, with reluctance to adopt prevention and risk mitigation strategies.
• Fear and resistance to intrusion of outsiders
• Government cover-up; concern for economic impacts
• The intensity and spread of infectious disease outbreaks are highly influenced by the social determinants of health. Poor housing, poverty, and lack of access to health care decrease resiliency to cope with communicable diseases, leading to more transmission and/or more morbidity and mortality.

Challenge

Until some of the basic conditions that favour the expansion of an epidemic to a pandemic are addressed, future pandemics are inevitable. Early detection and coupled with efficient and effective management of a rapid response to contain a disease outbreak at the local level will hopefully minimize the health impact on the global population.

However, much more attention is warranted. Many pandemics are zoonoses — diseases that can be transmitted to humans from animals. Influenza, tuberculosis, bubonic plague, and AIDS (Acquired Immune Deficiency Syndrome) are examples. In fact, today the most promising work on the spread of infectious diseases is being carried out by physicians specializing in epidemiology, veterinary and environmental medicine, working jointly as an inter-disciplinary approach called “One Health.” As wildlife habitats are destroyed to make room for human settlements, and as local climates change with global warming, there are new opportunities for zoonoses to spread. One Health researcher seek to identify these situations quickly, as they emerge worldwide.

In previous times, some virulent diseases had a self-limiting effect; infected people might die quickly -—before they had time to spread their pathogens widely. However, the ease of air travel now makes it possible for infected persons to spread a disease to other continents even before showing symptoms themselves. Thus, the risk of pandemics remains high, despite the spread of advanced medical technology.

Estimates about the probability of a virulent global pandemic are only guesses, but even the most ominous predictions cannot be dismissed. Bill Gates, who is allocating large funds to solving global health problems, sees pandemics as the greatest immediate threat to humanity. He warns that an influenza epidemic alone may kill over 30 million people in six months.(5) Another researcher, David Mannheim, predicts an even more dire possibility. Noting that it is more difficult than ever before to contain an epidemic through local quarantines, he argues that “the evolving nature of the risk means natural pandemics may pose a realistic threat to human civilization.(6).

References for this article can be seen at the Footnotes 3 page on this website (link will open in a new page).

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Rapporteur: Laura H. Kahn, MD, MPH, MPP; Research Scholar, Princeton University

One Health is the concept that human, animal, environmental/ecosystem, and atmospheric health are linked. It is a relatively new term but an ancient concept intuitively understood by indigenous peoples around the world. The One Health concept provides a useful framework for analyzing and addressing complex, interdisciplinary problems such as foodborne and waterborne illnesses, antimicrobial resistance, food security, and even climate change.

We live in a microbial world. We need to learn how to live better in it. We need to learn how to sustainably co-exist with the microbes living in us, on us, and around us.

For example, over 7 billion humans and almost 30 billion domesticated animals produce trillions of kilograms of fecal matter that contain billions of microbes. Each year, the massive amounts of fecal matter produced could fill an estimated 1.6 million Olympic-sized swimming pools. According to the World Bank(1), over 2 billion people don’t have access to basic sanitation systems, and almost 9 million of them practice open defecation. Open defecation, as the name suggests, means squatting and defecating out in the open. Many developing countries lack basic sanitation systems for human fecal matter, much less for animal fecal matter which makes up 80 percent of the total fecal matter produced.

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Fecal matter adversely affects human, animal, and environmental/ecosystem health by contaminating soils, crops, and waterways and causing foodborne and waterborne illnesses. Diarrheal illnesses are the second leading cause of death in children under 5 years, causing 525,000 deaths each year.(2) These diseases could be prevented with adequate sanitation, hygiene, and clean water. In other words—basic public health measures.

Unfortunately, countries that lack these basic provisions often use antibiotics as a substitute by making them readily available over-the-counter to anyone who can pay for them. Even worse, many people don’t have access to healthcare and rely on antibiotics for any sniffle or belly ache they might have. All of this indiscriminate use contributes to the worsening crisis of antimicrobial resistance.

Antibiotics are the foundation of modern medicine and have saved countless lives. Without safe and effective antibiotics, many of the medical treatments that we take for granted such as elective surgeries and cancer chemotherapies become too dangerous to do because the risk for infection becomes too great. But many bacteria are acquiring antibiotic resistance genes making them impervious to the effects of antibiotics, thus threatening the practice of modern medicine.

Many antibiotics are derived from soil microbes, and for many years, scientists believed that soil microbes used antibiotics as a form of chemical warfare against each other. But recent research of the planet’s soils suggests something far more profound.

Most soil microbes cannot be cultured in laboratories for a variety of reasons, so nobody really understands what exists in the soil. Some scientists came up with a clever strategy to extract DNA directly from the soil without knowing from which microbes the DNA originated from. Nevertheless, the findings were stunning. Scientists found antibiotic resistance genes everywhere—in the Arctic, in the Antarctic, and in other places that have never received human antibiotic exposure. Not only were antibiotic resistance genes everywhere, but they also appeared to be ancient. Microbes seem to use minute amounts of antibiotics as a form of communication with each other and not as a form of chemical warfare. Scientists coined the term, “the global resistome,” to describe the global, environmental nature of antimicrobial resistance.

Our widespread use of antibiotics in humans, animals, and agriculture as well as the massive amounts of fecal material contaminating the environment appears to be changing the “global resistome” and the micro-ecology of the planet in ways we don’t fully understand. We’re making it difficult for the soil microbes to communicate with each other, so they are sharing resistance genes with each other much faster than we can develop new antibiotics.

We need to start working with Nature rather than against it. We are losing the battle, and many people are dying from antibiotic resistant infections as a result.

So how might we work with Nature?

The natural foes against bacteria are tiny viruses called bacteriophages (aka “phages”). Bacteriophages were discovered in the early 20th century by Frederick Twort, a British bacteriologist, and by Felix d’ Herelle, a French physician.(3)

Antibiotics are relatively easy to use, akin to the shotgun approach to medicine – you don’t need to know exactly what bug you are treating to treat the infection. Unfortunately, since antibiotics usually have a broad spectrum of action, good bacteria are often killed off along with the bad bacteria. This feature has had negative unintended consequences.

Billions of microbes live in us and on us. They are as important for our health and well-being as any human organ. In his book, Missing Microbes, Dr. Martin Blaser, a physician and microbiologist,(4) argues that antibiotics have had a deleterious impact on public health by contributing to the obesity epidemic, the food allergy epidemic, and possibly even some cancers, among other maladies.

Bacteriophages, by contrast, are highly specific. They only attack the bacteria to which they are targeted against. This specificity requires better diagnostic capabilities than are currently available for widespread clinical use. Also, the technology for identifying, isolating, and developing phages as antibacterials has not changed since the early 20th century. Much more research and development needs to be done with them.

Nevertheless, there have been some important breakthrough cures of multi-drug resistant infections using bacteriophage therapy.(5) Dr. Steffanie Strathdee has written and spoken about her experience saving her husband’s life with bacteriophages in her book, the Perfect Predator(6) and her TEDx talk.(7) Phages are now being sought after by people with cystic fibrosis and antibiotic resistant infections.(8)

Microbes are contributing to climate change. Microbes in manure create methane and nitrous oxide, greenhouse gasses more potent than carbon dioxide. In addition, cattle, buffalo, goats, and sheep digest their feed in their rumens, their digestive tracts, in which bacteria decompose and ferment feedstuff, producing methane as a by-product. Globally, livestock produce about 14.5 percent of anthropogenic greenhouse gas emissions.(9)

Agriculture is the foundation of civilization. It is in the unique position of contributing to climate change and being threatened by it. Without agriculture and the food security it provides, civil society breaks down. For the past 10,000 years, during the geological Holocene era, the planet’s climate has been remarkably stable and mild, with the exception of the Little Ice Age, during the 17th, 18th, and 19th centuries, during which the planet’s climate cooled, resulting in crop failures, famines, and wars.(10) According to Philipp Blom, author of Nature’s Mutiny, witch trials and murders increased after severe weather and crop losses. Somebody had to be blamed for the divine punishment of famine; usually it was poor, elderly women. Now, in contrast to the Little Ice Age, the planet’s climate is warming and deviating above the Holocene baseline, threatening agriculture and food security through heat, drought, and severe storms. The impact of climate change on agriculture is thought to have contributed to the conflict in the Middle East and mass migration.(11) In essence, climate change means change from the Holocene baseline. Humanity’s goal must be to keep the planet’s climate as close to the Holocene baseline as possible to ensure the continuation of agriculture, food security, and civilization.

Sustaining civilization requires recognizing the interconnectedness between global human and animal health, agriculture, the environment, and climate. One Health provides an important framework to identify and address these interconnections. We live in a microbial world. Our health relies on microbes, but they can also make us, our environment, and atmosphere sick. To save civilization, we must embrace a One Health approach to address the global challenges of the 21st century and beyond.

References for this article can be seen at the Footnotes 3 page on this website (link will open in a new page).

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Rapporteur: Ronald St. John

Basic Premise:

There will be pandemics at some time in the future.

Small outbreaks of infectious diseases occur daily throughout the world. Depending on the transmission potential for specific or unknown pathogens, a small cluster of infected people can rapidly become an epidemic at a local, district/provincial or national level. In the absence of a comprehensive and internationally accepted definition of what constitutes a pandemic, for purposes of this paper, a pandemic is an epidemic that is occurring worldwide, or over a very wide area, crossing international boundaries and usually affecting a large number of people with a high degree of morbidity and mortality. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3127276/

Why are pandemics inevitable?

The worst kinds of pathogens – ones with the highest mortality rates and limited countermeasures – are increasing globally due to population increases, population density, more global travel, and changing migratory and environmental patterns that result in encroachment upon animal and other ecological systems. Social determinants such as poor housing, poverty, and lack of access to clinical and preventive health care can favour the transmission of communicable diseases and result in more morbidity and mortality, which can be pre-conditions to a global pandemic.

• Population density – Around 55 percent of the world’s population is thought to be living in an urban area or city, with that figure set to rise to 68 percent over the coming decades, according to the “Population Division” report. Source: UN’s Department of Economic and Social Affairs. May 17, 2018.
• Rapid Population Movement – The International Air Transport Association (IATA) expects 7.2 billion passengers to travel in 2035, a near doubling of the 3.8 billion air travelers in 2016. https://www.iata.org/pressroom/pr/Pages/2016-10-18-02.aspx
• War/Insurgency – armed conflict interrupts health services, both clinical and preventive.
• Emergence of New/novel pathogen – there is on-going mutation of known pathogen or exposure to novel pathogen, e.g., by human encroachment on deforested land
• Cultural resistance – the risks of transmission and poor disease outcomes may be amplified by unfavourable behaviours by affected populations, with reluctance to adopt prevention and risk mitigation strategies (e.g., cultural resistance to vaccination or “western” medicine).
• Fear and resistance to intrusion of outsiders who arrive to stop an epidemic.
• Governments may wish to cover-up or minimize an incipient epidemic due to concern for economic impacts (e.g., a negative impact on tourism or foreign investment).

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Challenges

Stopping a pandemic requires early detection of an outbreak of an infectious disease before it reaches epidemic levels. To mitigate the transition from a localized outbreak to a large-scale epidemic to a world-wide pandemic, an efficient and effective response to contain the disease outbreak at the local level is required. To be able to respond quickly, early detection by an astute clinician or health care worker of a cluster of an unusual illness is essential. Some obstacles limiting early detection include lack of primary care capacities; lack of trained personnel; weak surveillance systems; no rapid communication linkage for remote areas; limited laboratory capacity for pathogen identification or referral of specimens to more sophisticated laboratory. Obstacles to effective containment once an emerging communicable diseases is detected include a lack of well-resourced, trained and coordinated emergency preparedness and rapid response infrastructure.

Addressing the Challenges

It is beyond the scope of this paper to address and propose solutions to the many challenges noted in the preceding paragraph. Efficient and effective management of an outbreak, epidemic or pandemic is essential to mitigate the effects as much as possible. There are four basic resources that must be organized and managed to respond to an emergency: people (technical skills), logistics (appropriate intervention tools), money (adequate financing) and time.

While there are many possible approaches for effective management of the four basic resources, the Incident Management System [IMS] is one recognized best practice for emergency management and successful resolution of the emergency. An IMS saves lives. The United States has one such system, which was initially developed by firefighters during the 1970s. After Hurricane Katrina revealed the government’s serious lack of preparedness, the current system was developed: the “National Incident Management System,” which is meant to respond to all types of disasters and emergencies, including wildfires, floods, riots, the spilling of hazardous materials, hurricanes, tornadoes, earthquakes, tsunamis, collisions of trains, planes, and other traffic, terrorist attacks, and of course health crises such as pandemics. Not all other countries have a similar nation-wide IMS, though these are necessary to allocate resources efficiently, manage information, and facilitate cooperation among the agencies that can respond to disasters.

IMS systems are flexible and scalable; they can be used for small, day-to-day incidents but expand whenever necessary, from local teams to those at the state and national levels. They cover five missions: Prevention, Protection, Mitigation, Response, and Recovery. They train and certify personnel and maintain inventories of technological and medical material.

The Incident Command System [ICS] is the basis of the IMS. The ICS provides command, control, and coordination of a response. It includes the principles to coordinate the efforts of individual agencies for the common goal of stabilizing the incident and protecting life, property, and the environment.ICS uses principles that have been proven to improve efficiency and effectiveness during health emergencies. Every incident has an Incident Commander. During a small crisis, he or she may handle the situation alone, but if it becomes more complex, the Incident Commander will appoint additional team members to roles that are already well-defined.

Much of the value of IMS comes from its capacity to expand an organization rapidly, while retaining clarity about the obligations of all the personnel. For example, because a disaster requires the collaboration of teams from multiple jurisdictions, specialties, and disciplines, everyone is taught a common set of terms and advised to speak in plain language and avoid acronyms.The command system is separate from the agency’s usual hierarchy, and the personnel are intentionally called by quite different titles from the usual staff. Every role is accountable to only one other person, and no one should have more than about five subordinates.For a detailed description of the IMS, please consult: http://www.who.int/health-cluster/about/structure/IMS_structure.pdf

IMS and WHO Member States

Given that the use of the IMS for responding to health emergencies is now standard policy within the World Health Organization (WHO), it is imperative that all Member States establish policies to support on-going emergency planning and preparation. Member states should consider adapting and using the IMS as an approach for responding to local emergencies to prevent them from becoming larger epidemics and pandemics. It is an accepted role for the WHO to provide technical assistance to Member States and WHO’s technical assistance should include the introduction and adaptation of the IMS in all member states.

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