Developing preparedness imagination
I have recently finished reading the book “Disease X” by Kate Kelland, the chief scientific writer for the Coalition for Emergency Preparedness Innovations – CEPI. As I have worked in the development and commercialization of vaccines for neglected diseases such as malaria, and other diseases prevalent in economically disadvantages areas, I experienced how disconnected the real needs can be, from the material means necessary to respond to them.
Governments worldwide have been preparing to respond to novel diseases, but as we experienced with COVID19, nobody seemed to be really prepared. Globally, countries had very different means at their disposal to respond to the viral spread. And they were at very different “preparedness imagination” stages, leading up to the COVID19 pandemic.
“Disease X – The 100 Days Mission to End Pandemics” tells the story of how COVID19 took over, through the lense of preparedness and points to the lessons learned, including the learning that there will be a “next one”. In the book, the author outlines “must haves” for a collective prepared mindset and some of the material global initiatives necessary to support preparedness.
“Disease X” is a good read, that threads around political issues. Even though the book tells a story that I have just lived through, the author succeeded in keeping (my) interest throughout. In addition, I found the book very informative, because it shares views of people (namely, the CEPI Director Richard Hatchett and others in his network) that were alert at all stages of the pandemic, something that the general public could not really see in most of their government representatives.
The message in the book is simple and important too: we have to prepare for “the next one”.
Preparedness requires that bespoken funds are available, which has not been the case globally.
A “Pandemic Fund” has now been established at the World Bank. Countries and Institutions have committed 1.6 Billion USD, as of June 2023. For clarity: this is very nice, but really not enough.
Furthering the global preparedness plans, the Fifth meeting of the Intergovernmental Negotiating Body (INB) for a WHO instrument on pandemic prevention, preparedness and response took place in early June 2023. A report will be published.
In reading more broadly to write this blog, it is reassuring to confirm that, as illustrated by the above initiatives, learnings from the COVID19 pandemic are being compiled in preparedness plans locally and globally, at the various relevant institutions. As for the CEPI, they are already actively working on a response plant to deliver a vaccine within 100 days of the acknowledgment of a new infectious agent of concern (#100daymission)
Why “100 days”, why a vaccine?
While the pharmaceutical intervention of the #100daymission is focusing on developing vaccines, the mission includes several non-pharmaceutical interventions, equally important in the response plan.
Given the COVID19 experience, it seems possible to reduce the “record” of just under 350 days to developing and deploying the COVID19 new vaccines to about 100 days. Speeding up because we all understood that the faster safe and effective measures of protection can be put in place, the more lives will be spared in a deadly pandemic. Vaccines are one of the most effective means humans have, to defend themselves from infections.
Important measures that need to be developed and that are being considered in the various national and international preparedness plans include, for example, establishing a global surveillance and readiness infrastructure and establishing the response plans to any detected threat. Global surveillance is an essential step. We saw its importance during the COVID19 pandemic, in providing data about the evolution of the pandemic and about the emergence of “varieties of concern”. A global surveillance network is being reinforced. Any detected “varieties of concern” need to be fully sequenced and tracked, which also necessitates the pre-existence of the adequate global infrastructure that supports these activities.
The book argues for the need of the right mindset (see insert) for enabling preparedness.
“Disease X” 8 “need be” of preparedness:
- Be scared
- Prepare to move fast
- Prepare to take risks
- Prepare to share
- Prepare to listen
- Prepare to fail
- Prepare to spend money
- Prepare for the next one.
Technology is an important basis for the preparedness plans. Access to technology is very granular worldwide, so pandemic preparedness plans need to include how the relevant technologies can be implemented globally.
The CEPI outlines their #100daymission plan on their website, from which I’ll highlight the following two aspects, relevant in the context of broad access to the needed infrastructure:
- The preparation of “prototype vaccines” for representative pathogens across multiple virus families of greatest pandemic potential and building relevant platform experience to be leveraged for rapid adaptation in an outbreak.
- The need for optimizing manufacturing processes for rapid initial production and subsequent scaling and the development and maintenance of a network of ready manufacturing facilities with reserved capacity for the multiple platforms that could be activated within days.
”Be prepared to spend money”
“Disease X” describes how in the very early days of the COVID19 pandemic, when a novel “flu-like” disease in Wuhan was reported, the CEPI reached out to its existing network of scientists, to find the applied technological strategies with the goal to develop a vaccine – even when technologies had not yet been proven.
Investing (i.e., spending money) always includes a component of risk. In situations such as the onset of a new communicable infection, not investing, or not investing enough may carry an even bigger risk. Recently, economic models were used to compare the cost of the COVID19 pandemic globally, to the total estimated in investments needed for global preparedness, this later representing about one tenth of the estimated cost of the pandemic . If “the next one” doesn’t come, has the money been wasted? Of course not! First, because the next one will come, and second because in preparing for it, some of the existing unacceptable inequalities in the ability to surveil infections and deploy first measures would have hopefully been reduced.
The technology that faster delivered an effective vaccine against SARS-CoV2 was, as we all know, one of those “untested technologies”, the mRNA technology. Its supply chain is a challenge, given the requirement for transport and maintenance at very low temperatures. Be that as it may, the limitations in the global distribution of these vaccines had more to do with politics than with logistics.
Equitable, broad access to vaccine manufacturing is also one of the aspects that needs to change in a global preparedness plan. It cannot be accepted that a very few countries control and have responsibility for global vaccine manufacturing, not only because it is ethically wrong, it also weakens the preparedness plan. As an example of how relevant for pandemic response a global functioning manufacturing network is, Kelland refers (p121) to the decision, in March 2021, by the government of India to stop export of SARS-CoV2 vaccines, as long as the population of India needed them for its protection. The Serum Institute of India (SII), the biggest global supplier of vaccines, was the biggest supplier of vaccines for COVAX, the vaccines pillar of the Access to COVID-19 Tools (ACT) Accelerator, co-led by CEPI, GAVI, WHO, UNICEF. This decision by the government of India (driven by the need to vaccinate a very large number of people in need of vaccination in India) lead to a global slowdown in sharing vaccines across the world.
Reliance on one or on very few vaccine suppliers was recognized as a weak link in the global strategy and lack of access to money was the factor that led to this vulnerability. At the time of having to order millions of vaccine doses “at risk”, because none of the ongoing trials had yet delivered results, COVAX limited finances drove the teams to deciding to order a maximum of doses of a less expensive vaccine from a sole huge manufacturer, the SII.
Thus, two lessons learned:
- the need for a broader manufacturing base and
- the need for ensuring that appropriate financing is available to the institutions charged with managing vaccine supply for the least developed populations.
The role that climate change has on the higher instances of novel or re-emerging infectious agents should be emphasized. The One Health concept provides another argument for the importance of preparedness. “One Health is a holistic approach to understanding health and is based on collaboration between different professions. The underlying basis for One Health is an understanding that the health of humans and animals and the conservation of our environment are connected.”
“New pathogenic viruses are being discovered all the time, and changes in human activities result in the re-emergence of known viruses, or the emergence of new or previously unrecognized diseases. Most of the viruses of concern are either arboviruses – transmitted by arthropods, in which they also multiply – or are derived from zoonotic infections, entering the human population from direct or indirect contact with wild animals.”.Ed Rybicky
Recalling the lack of action at the initial stages of COVID19, I can’t but make parallels with what we are experiencing regarding the climate crisis. Expansion of human activity is one of the factors making more infection agents “jump” from animals to people. Overcrowded and in close quarters, humans may transmit the viruses back to animals, thus supporting the reservoirs of virus and their re-emergence.
“These epidemics are now part of modern life”. CEPI wants to “embed the gained knowledge in preparedness so we can act on next epidemic before it spirals out of control.”
Fear as a tool is blunt and hard to control, so while people need to be concerned to act fast, they should not panic nor despair.
It seems to me that to be prepared, one needs to be brave, not scared. Brave to understand that whatever the choice, there is a cost to it, brave to continue to argue one’s rational point, even when everybody is saying that it is irrational and brave to do all the other things on Kelland’s list.
Preventing pandemics is possible through preparedness – and deployment.