Risk of Infectious Disease Outbreaks: Analysis

The recent Ebola crisis will not be the last serious epidemic the world faces; indeed, public health outbreaks are likely to become ever more complex and challenging. Despite progress in some aspects of public health over the past two decades, endemic infectious diseases remain a major problem, and new or resurging infections, the spread of drug resistance and the rise in non-communicable diseases all pose enormous challenges to often fragile health systems.¹

Infectious diseases, which are among the leading causes of death worldwide, do not confine themselves to national borders. Their capacity to spread rapidly across geographies – jeopardizing social and economic security as well as challenging human health and well-being – is amplified by ever-growing globalization, increased trade and travel, the rise in urbanization, and changes in the environment, behaviour and society. Some threats, such as influenza, are known. Others are not. Unknown just a few decades ago, HIV/AIDS has killed more than 30 million people from all socio-economic backgrounds. What might be the next HIV/AIDS, and are we sufficiently prepared for its arrival?

At the same time, new opportunities to predict, prevent, detect and treat diseases are emerging from a better understanding of the social determinants of health and from trends including new technologies in real-time diagnosis, data analysis (including in the field of genomics), biomedical research, the internet and mobile data and communications, often developed outside the traditional health sector. More innovative ideas, partnerships, and ways of working and financing will be critical for containing the dynamic threat of outbreaks in the 21^st century.

Causes for Concern

By 2050, the world’s population will have risen to 9.7 billion.² Cities will become increasingly dense and shanty towns – with inadequate housing and a lack of basic services such as water, sewerage and waste management – will swell. A combination of high population density, poverty, changes in social structures, and a lack of public health infrastructure will create progressively more favourable conditions for communicable diseases.

Meanwhile the increasing transnational flow of commodities, people and animals coupled with increased spatial density will magnify the transmission of these diseases, both between people and across the human-animal barrier.³ Most large cities have airports through which millions of passengers travel: over 2 billion global passengers travelled annually by air in the first decade of the 21^st century, compared with just 68.5 million in the 1950s.⁴ Continued growth in the movement of people and commodities between urban centres intensifies the risk of infectious transmissions across geographies and diminishes the ability to respond to, and effectively prepare for, a global disease outbreak.

A recent study led by the University of Cambridge identified 20 known infectious diseases that have re-emerged or spread geographically, including dengue, chikungunya, typhoid, West Nile, artemisinin-resistant malaria and the plague.⁵ Other known threats – such as influenza (i.e. H1N1 Swine Flu), MERS-Cov, and Ebola – continue to raise fears, especially when they take hold in densely populated areas and when treatment and prevention measures are not necessarily available. Even when known infectious diseases can be mitigated by existing treatments or vaccines, we face the risk of emerging resistant strains, mutating viruses, or a pandemic that is so large it renders response supplies inadequate.

Advances in research and the discovery of diagnostics, drugs and vaccines have saved millions of lives, but these gains remain very fragile and are under threat from the growing resistance of microorganisms to the most effective known medicines. The number of deaths in the European Union and the United States as a direct result of antibiotic-resistant bacteria is increasing every year, and the burden in low- and middle-income countries is much higher.⁶ The emergence and spread of strains of HIV, tuberculosis and malaria that have evolved resistance to current medicines are of particular concern, as they could overturn much of the progress made against these diseases in recent years. An independent review, funded by the Wellcome Trust and the UK government, estimates that by 2050, if no action is taken, these drug-resistant strains could cost an additional 10 million lives each year and around US$100 trillion in lost output; approximately the equivalent of losing the UK economy from global output every year.⁷

Infectious diseases that are not currently on the radar are also a cause for concern. The greatest potential threats among unknown pathogens are those that spread easily – through the air, for instance – and to which humans have little or no immunity. The 2002–2003 SARS pandemic provides one recent case study: ultimately governments, businesses and people came together to overcome the outbreak, although not before it had caused nearly 8,000 infections and 800 deaths across 29 countries.⁸ The death toll would have been much higher had the virus been more easily spread: infectious disease experts believe that if SARS had been more contagious, it could have become one of the worst pandemics since the 1918 influenza outbreak that killed 50 million people.⁹

The SARS crisis demonstrates the socially destabilizing potential of unfamiliar new diseases. As affected areas came to a standstill, in cities such as Beijing, Singapore and Toronto people stayed home, public places emptied and health workers were shunned.¹⁰ Next time an unfamiliar disease causes panic, there is no guarantee that it will occur in a geography where effective solutions can be initiated as quickly as in this instance. Furthermore, the risk posed by the immediate effects of outbreaks must not minimize the long-lasting effects on society as a whole. The recent Ebola crisis in West Africa points to the intensified nature of the risk and its heightened complexity in places where health systems are vulnerable and lack diagnostic or response measures. Over the course of the crisis, more than 11,000 people died and more than 16,000 children were orphaned.¹¹ Basic health services such as prenatal consultations, routine vaccinations, antiretroviral therapies and treatment of endemic diseases in the region were sharply reduced. As stigma rose, schools closed while growing distrust and fear shifted community interactions. The hours of schooling lost, the reconfiguration of families, and decreased food security and employment, to name only a few of the epidemic’s effects, will impact the affected region well beyond the halt of the outbreak.¹²

Economic Risks

Beyond direct effects on health, infectious diseases impose significant economic costs. Adding to the direct costs borne by sufferers and their households, infectious diseases – particularly those that are relatively fast-spreading or poorly understood by the general population – have an additional economic impact through a response called “aversion behaviour”. This was demonstrated when Singapore came to an economic standstill over SARS, as well as in responses to Ebola in 2014 and HIV/AIDS in the early 1980s.

Aversion behaviour includes actions taken by individuals to avoid any exposure to the illness, as well as actions taken by investors as they anticipate those individual decisions.¹³ Even individuals who have no direct contact with the disease will take a range of actions to avoid any risk of contracting the disease. As shown by the recent Ebola outbreak, these reactions can be rational or they can dramatically overestimate risk, leading to a wide variety of factors that can negatively impact the economy, from stress to labour and supply scarcity, financial market instability, and price increases.

The economic impact of aversion behaviour may be significantly greater than the direct economic impact from sickness and death. In the Ebola crisis, the loss of life in Guinea, Liberia, and Sierra Leone was accompanied by the closure of businesses, dramatic reductions in travel and tourism, and trade slowing to a trickle. At the beginning of 2014, expected economic growth for the year was 5.9% in Liberia, 11.3% in Sierra Leone and 4.5% in Guinea. By the end of the year, actual growth was only 2.2% in Liberia and 4.0% in Sierra Leone, while in Guinea the economy shrank.¹⁴ In Liberia, more than 70% of households reported having insufficient money to buy food.¹⁵ The adverse impacts were not restricted to countries that experienced cases of Ebola: Burkina Faso, Côte d’Ivoire and the Gambia all experienced adverse impacts on GDP.¹⁶ For 2015, the World Bank estimated a potential loss in GDP of more than US$1.6 billion in the three most affected countries, and more than US$500 million across the rest of the continent.

Any fears about an inability to contain a major epidemic will have economic effects outside the affected areas because of the increasingly interconnected nature of the global economy. The economic impact of the Ebola epidemic could have been much worse: at its height, the most pessimistic epidemiological projections of how the disease could spread, combined with economic modelling, suggested a potential impact of tens of billions of dollars in West Africa alone.¹⁷ During the SARS outbreak in 2003, estimates of the potential impact ranged from US$30 billion to US$100 billion. In the case of SARS, too, the actual impact was likely lower because the epidemic was contained – but the economic damage was still significant.¹⁸

Challenges in Containing the Risks

To know where to channel resources most effectively, stakeholders face the challenges of preparing for and responding to known threats and anticipating the source of new ones. The lack of adequate, resilient public health surveillance systems, infrastructure to effectively deploy resources and a health workforce to provide accessible, quality care where needed leaves us vulnerable to regional and global spread. Many emerging infections and antibiotic-resistant strains of common diseases originate in one location and then disseminate to new places at often alarming speeds: societies are only as strong as the most fragile health system (see Initiative 1).

Preparedness and response measures must therefore address three key areas: behaviour; diagnostic, drug and vaccine research and development (R&D); and regulatory and financial environments.

Behaviour

The multifactorial nature of broader global health issues poses an enormous challenge to all stakeholders – governments, non-governmental organizations (NGOs), industry and citizens. Changing demographics, climate change, urbanization, travel, political instability, war and terrorism are only a few of the factors challenging our preparedness for and response to endemic and emerging infections and the spread of non-communicable diseases.

There is an urgent need for society to value and invest more in evidence-informed public health strategies. Despite major advances in the global economy over the past 50 years, millions of people worldwide still cannot access basic needs, such as improved tap water and toilets.

Even with political interventions to provide the necessary infrastructure, halting the spread of infectious diseases will require addressing individual and collective human behaviours. Proper prevention and responsible, fact-based crisis communication, including educational campaigns and behaviour change strategies to facilitate the long-term adoption of health-maintaining behaviours, need to be carefully designed, field-tested and implemented (see Box 3.3.1).

Understanding the social and cultural contexts that may contribute to epidemics, such as burial practices or misconceptions about how a disease is transmitted, is also critical. To increase trust in evidence-based medical interventions, it is essential to gain insight into cultural sensitivities and work in partnership with local communities.

Diagnostic, Drug and Vaccine Research and Development

It can take 20–30 years to develop a new drug or vaccine, and the costs and risks are high. R&D efforts are not coordinated to achieve their greatest impact: the current model prioritizes the development of profitable products that can generate maximum sales, usually through volume rather than benefits, instead of focusing on unmet public health priorities. There is a lack of mechanisms that incentivize and stimulate the development of novel diagnostics, drugs, and vaccines and compliance with treatments.¹⁹

The recent Ebola outbreak arguably illustrates the human cost of the current development model in the face of potential public health threats. Recent tests on an Ebola vaccine in Guinea seem to show that it provides remarkable and immediate protection; however, the same vaccine had been tested on monkeys a decade ago, but subsequently languished in scientific limbo (see Box 3.3.2).²⁰ Had resources been devoted to following through earlier, the development of a vaccine could have been accelerated, potentially saving many of the 11,000 casualties.

Regulatory and Financial Environments

Despite the progress that has been made in the last two decades, more needs to be done to create enabling regulatory environments. Development of the aforementioned Ebola vaccine, for example, could conceivably have been accelerated more quickly as the epidemic took hold, but a number of barriers hindered the ability to expedite clinical trials. Mobile data is another area where regulations on privacy need to be balanced with public health imperatives, as it has increasing potential to track the spread of epidemics (see Initiative 3).

The sluggishness of progress towards a regulatory environment specifically targeted to epidemic crisis situations is a matter of growing international concern. This work needs to be coordinated by an empowered and properly funded global health body: the World Health Organization (WHO). A collaborative framework exists – the International Health Regulations, originally created in 1969 to contain cholera, smallpox, yellow fever and the plague, and since expanded to cover more diseases – but it does not provide adequate reassurance that countries are putting in place what is needed to prepare for, and respond to, emerging crises.

Countries need to be empowered to allow a timely and robust response so they can request and expect speedy international assistance when needed. Incentives and financing mechanisms need to be generated to encourage investments in public health, and countries need to be held accountable. Platforms such as the Global Health Security Agenda and the WHO’s Global Influenza Surveillance and Response System have had some success and aim to complement current regulations and mitigate threats, but they fall short of constituting a comprehensive, robust global system with the flexibility to defend against both known and unknown biological threats.

The Future of Collaboration

From logistics to communications, from financial services to pharmaceuticals, the private sector has capabilities and expertise that can be truly beneficial in a public health outbreak. To leverage them most effectively, however, requires common ground and trust-based cooperating mechanisms at local and global levels with the public and non-government sectors that have been established in advance of an emergency (see Initiative 2).

There is a long history of public-private cooperation in response to infectious diseases. The Medicine for Malaria Venture (MMV) and the Global Alliance for Vaccine Initiative (GAVI), for instance, are long-standing examples of cross-sector partnership that came out of a projected public health disaster that was the result of escalating antimalarial drug resistance in the late 1990s and the need for greater equitable access to vaccines.

Despite these and similar advances, new collaborative approaches are needed as the danger of outbreaks grows. Such approaches could explore:

• Ways to harness the data being generated by businesses in a range of sectors to strengthen predictive models and improve early detection and monitoring of epidemics;
• Ways to drive forward the research agenda by pairing private vaccine, drug and diagnostic researchers with public health experts and policy-makers;
• Ways to improve regulatory frameworks and policies across nations;
• Ways to provide stable and flexible long-term financing to deliver the necessary interventions;
• Ways to optimize in-country operators in source regions who can provide on-the-ground capabilities for building stronger health systems and early-stage logistical support in a crisis, and who can undertake emergency response measures; and
• Ways to promote responsible media engagement as part of crisis management communications, with the identification of trusted sources of information and the dissemination of messages targeted to the right audience, using the most appropriate local or global information channels.

New predictive models, financing mechanisms and leadership for the preparedness and response of future outbreaks and antimicrobial threats are key to reducing the risks we face in the short, medium and long term.

The Ebola response was financed by contributions from a range of non-governmental organizations, notably Médecins Sans Frontières, philanthropy (the Bill & Melinda Gates Foundation, the Paul G. Allen Family Foundation, the Skoll Foundation, and the Wellcome Trust), governments, social sector organizations, private sector companies and individuals. However, new models are needed if future response is to be faster, more stable, flexible and long term. To enable such models, the private and public sectors must jointly develop new financing options, such as draw-down facilities, insurance programmes and bonds.

The World Bank Group, in collaboration with the WHO and private sector players, including Swiss Re and Munich Re, is developing an insurance product that will provide early financing to affected countries to respond to future epidemics (see Box 3.3.3). Such initiatives and incentives could be linked with the willingness of governments to invest sustainably and in a verifiable way in critical public health infrastructure.

Conclusion

The Ebola crisis has put the spotlight on the importance of reducing the vulnerability of societies to infectious disease threats. As public health becomes ever more complex and our interdependency grows, it is clear that new equitable approaches, technologies and innovative community and business models, and response strategies and financing mechanisms will increasingly be needed to contain known and unknown threats that endanger social and economic stability worldwide. There must also be better mechanisms in place to manage risks through international cooperation, involving both the public and private sectors beyond the traditional healthcare industry.

Three Initiatives to Mitigate the Risk and Impact of Global Disease Outbreaks

1. Building Resilient Health Systems

As highlighted most recently by the Ebola crisis, a single and localized outbreak can put national and even international health systems at risk if they are unprepared to react quickly. The world will remain vulnerable to public health emergencies until every state has comprehensive primary care services, an adequate number of healthcare workers, available medicines, robust health information systems, infrastructure, public financing and a strong government to deliver equitable and high-quality services to all its citizens.

During and in the aftermath of an outbreak, health systems become more vulnerable to new crises. For example, in November 2014 fewer than half of the health facilities in Liberia were seeing patients; the government estimates that from May to August 2014, skilled birth attendance was 27% below 2013 levels, measles immunization was down 50% and overall health services were operating at 40% lower capacity. Even in areas where essential health services have begun to resume, the loss of these services during the height of the epidemic continues to have an impact.²¹

During the United Nations Development Programme (UNDP)’s International Ebola Recovery Conference in July 2015, the international community pledged funds to build robust health systems to “get to zero and stay at zero” in the Ebola-affected countries. However, it took a global health threat and close to 11,000 deaths to create this momentum.

One challenge to strengthening health systems is that very few programmes address the entire system. No single innovation or player can allow an entire system to leapfrog in the way that, in the telecommunications industry for example, mobile phones made it unnecessary to establish expensive infrastructure for landlines.²² The WHO has identified six building blocks of health systems; most strengthening interventions address only one of these blocks. Some target health worker training; others focus on demand financing and insurance schemes; still others aim to improve service delivery and access to medicines and technologies. Although all these efforts lead to meaningful improvements, their impact remains limited because they do not address all dimensions of the health system in a synchronized and synergistic way.

It is critical to understand the most efficient way for all health stakeholders to collaborate. An extensive analysis of successful innovations in emerging economies has shown that well-thought-out ecosystems of partnerships can significantly improve the impact and financial sustainability of health initiatives.

Ogun State in Nigeria, for instance, is pioneering an ecosystem of partnerships that synchronizes all projects and programmes in primary service delivery, creating a model that will increase low-income individuals’ access to basic healthcare that can be replicated in other Nigerian states. 

The World Economic Forum supported the state’s Commissioner of Health in convening private and public sector stakeholders that together defined the priorities and mapped out partners that could contribute in a synergistic way. Projects include a state-subsidized insurance scheme, work on modernizing transport and logistics, upgraded equipment, improved sourcing of basic medical products, and a community-based primary care facility model with elements of public-private partnership. The intervention is coordinated by a project management unit funded and managed by African Health Markets for Equity in partnership with governments, foundations and private sector players from across industries.

The programme is the first of its kind in aiming to build the resilience of an entire health system. Although still in its early stages, it has already won Nigeria’s Excellence Award for 2015, which recognizes efforts in healthcare delivery.

2. Harmonizing Public-Private Networks: The Key for Early Detection and Response

Coordination and time are invaluable assets in an emergency, so mechanisms that bring together public and private players in high-risk geographies to address emerging epidemics are likely to pay dividends. Although response measures remain primarily international, harnessing the potential of national and local actors to optimize early detection and response on the ground is also critical.

Local actors or in-country operators (multinationals and small or medium-sized enterprises) have the greatest incentive to act swiftly in any outbreak or epidemic.²³ They are motivated not only by responsibility to their communities but also by a desire to protect their operations, maintain business continuity and reduce business risks. Embedded in their communities, and often operating in remote areas with little public infrastructure, they are likely to see emerging public health issues at an early stage. They also have the capacity to raise an alert in the event of an emerging threat.

The potential of private sector actors to contribute in an emergency was prominently witnessed in the Ebola crisis. Although several multinationals chose to shut down their operations and leave the area, many others – along with domestic businesses – maintained their presence and contributed meaningfully to the response through channels such as the Ebola Private Sector Mobilizing Group (EPSMG). In-country operators such as ArcelorMittal conducted initiatives on community awareness and screening programmes, and used their machinery and capacity to construct Ebola Treatment Centres. Alcoa educated its employees and their families on the transmission of Ebola and taught them how to protect themselves. Firestone built its own isolation and treatment centre in its facility after a case was detected and nearby hospitals were unable to accommodate the patient. Beyond funding and in-kind donations, local actors also played an important role in influencing decision-makers and mobilizing each other: the Sierra Leone EPSMG chapter successfully lobbied to keep national ports open, which enabled crucial supplies to be shipped in as well as minimized the loss of livelihoods through disruption to economic activity.

Although these and many similar efforts deserve and have received recognition, a lack of coordination limited the ability of the private sector to apply its full set of capabilities, and their interactions were not aligned with public sector efforts on a day-to-day basis. Local companies did not always know how best to contribute to the response, and national governments and responding agencies were not always aware of potential opportunities to partner with the local private sector.

Building on the flexible partnership responses that complemented the channels of official assistance to Ebola-affected countries, the Forum has drawn up a wide set of recommendations for public-private cooperation models to manage any potential future outbreaks more effectively and reduce the risk of their occurrence. The study disaggregates private sector interventions into three categories – in-country operators, expert capability companies and greater private sector contributors – and makes specific recommendations for each category to enhance collaboration. At a high-level dialogue in Cape Town, senior leaders expressed a desire to home in on optimizing local actors in early detection and response plans.

With subsequent endorsement from partners including the United Nations, the African Development Bank and the Wellcome Trust, the Forum has launched a 12-month initiative to mobilize in-country business operators and facilitate dialogue with ministries of health for the local implementation of networks in national preparedness and response schemes. This entails the creation of country-wide playbooks and communication platforms between local actors across sectors to develop a rapid and efficient response in the event of an epidemic. Networks and their implementation roadmaps will be designed for specific high-risk geographies including Mali, Guinea, Liberia and Nigeria, with the vision of defining a broader coordination mechanism to expand regionally and apply globally.

3. Big Data and Infectious Diseases: Mapping the Outbreak

One key to determining how viruses spread is to understand how people move around and interact with one another on a daily basis. Big data allows the modelling of how a virus spreads, and the potential for it to be contained by various possible interventions.

The 2009 H1N1 Swine Flu pandemic response in Mexico is an early example of how mobile phone data can be used. As the outbreak began to spread, the Mexican government acted to limit the movement of people, advising them to stay away from public places such as airports, hospitals and universities. A digital research team in Telefónica, one of Mexico’s largest mobile network providers, saw an opportunity to test the effectiveness of the advice by analysing patterns of movement. Drawing from anonymized mobile phone call records of 1 million customers in one of Mexico’s most affected cities, the team found that call traffic was lower or stable in hospitals and universities but increasing at the airport, suggesting that people were ignoring government advice and trying to leave the area.

Next, the team created a model to simulate what would have happened if the government had not intervened. Analysing more than five months of encrypted call records, including the period of government interventions, the research team found that the intervention had resulted in between a 10% and 30% drop in movement, postponed the peak of the epidemic by nearly two days and reduced the number of infections by 10%.²⁴

A more recent intervention has been witnessed in the use of GPS technology in the roll-out of treatment-as-prevention to control the HIV pandemic in Sub-Saharan Africa to construct predictive prevalence maps for migrating populations.²⁵ Health workers can immediately report newly identified cases through solar radios or a new mobile application, facilitating social network analysis. The resulting communications and data collection system allows for faster identification of transmission chains, which in turn allows for faster isolation of potentially contaminated individuals and a more effective implementation of ring vaccination when necessary.

The Ebola crisis also saw innovative attempts to use technology to predict, detect and prevent new cases, such as the mHero platform – supported by a consortium of partners including UNICEF, UNAIDS and IntraHealth – to connect ministries of health with frontline workers using text messaging services and analyse the resulting data. However, the lack of interoperability of data information systems between responders in the crisis highlighted the need to review new fabric architecture, diagnostics and logistics. The mHero platform is under development to overcome these barriers.²⁶

Finding the fastest and most efficient channel to disseminate information is key to fighting an infectious disease outbreak, and access to data for real-time monitoring, multi-path surveys and detailed analysis is essential. The better the information, the more sure decision-makers can be of their strategy. Real-time sharing of data in a coordinated and collaborative manner can make responses more efficient. If ways can be found to reconcile the need for data with current regulatory environments and the legitimate right to data privacy, lessons from the Ebola crisis could potentially be applied in future emergency settings.

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