Saturday, September 12, 2020

Flying Blind In the Age Of Pandemics & Emerging Infectious Diseases


WHO IHR Infographic


Nearly 10 years, and more than 10,000 blog entries ago, in The Third Epidemiological Transition  I wrote about the work of anthropologist and researcher George Armelagos (May 22, 1936 - May 15, 2014) of Emory University who proposed 25 years ago that since the mid-1970s the world has entered into an age of newly emerging infectious diseases, re-emerging diseases and a rise in antimicrobial resistant pathogens.

Since publishing that blog we've seen a steady stream of new infectious disease threats emerge, including MERS-COV, avian H7N9, H5N6, H5N8, H5Nx, H10N8 (and others), new swine flu threats (EA H1N1), epidemics of vector borne illnesses like Zika and Chikungunya, several major Ebola outbreaks in Africa, and our second pandemic in just over a decade (COVID-19). 

To this short list we can also add re-emerging diseases, like Cholera, measles, Dengue, and scarlet fever - all of which have either blossomed or expanded their range - over the past decade, along with spread of antimicrobial resistant pathogens (e.g. NDM-1 Carbapenem resistance, MCR-1 Colistin Resistance, Acinetobacter baumannii, Carbapenem-resistant Enterobacteriaceae (CRE)) whose proliferation have led to stark warnings that the World Faces A `Post-Antibiotic Era’..

In order to improve surveillance and reporting, in 2005 – two years after the SARS epidemic, and during the early years of H5N1’s emergence – the World Health Organization produced the first major revision to the IHR (International Health Regulations) in 35 years, which was voted upon and approved to go into effect in 2007.
With expanded global travel and trade, along with a growing number of emerging disease threats, it was glaringly obvious the world needed a more cohesive, and cooperative approach to managing emerging infectious diseases.
The new 2005 IHR required – among other things – that countries develop mandated surveillance and testing systems, and that they report certain disease outbreaks and public health events to WHO in a timely manner.

The reality is that 15 years later many countries have still failed to implement these mandated systems, and that every couple of years the WHO has granted `extensions' to countries who have not complied.  Timely reporting of outbreaks, and sharing of viruses, by many countries has been haphazard at best since there are few penalties for ignoring the IHR (see Adding Accountability To The IHR).

From Indonesia’s refusal to share H5N1 virus samples to the Saudi’s chronic foot dragging on MERS, to China's slow rolling of releasing H7N9 information, we’ve seen many examples where the spirit – and at times the actual letter – of the 2005 IHR has been ignored by member nations.

But despite this chequered and often frustrating history of IHR compliance, I can't recall anytime in the past 15 years of blogging when the day-to-day flow of infectious disease information has seemed as compromised as it is today. 

Since the global emergence of COVID-19 last spring, reporting and surveillance on other emerging disease threats has declined sharply. While some of this may be due to prioritization of already scarce resources to the pandemic, that doesn't change the fact that we are flying blind in many parts of the world. 

A few examples include:

Saudi Arabia hasn't updated their MERS-CoV surveillance page since Epi Week 22 (May 31st), when they were reportedly dealing with a hospital outbreak. Worse, WHO EMRO - which had managed to post monthly reports of MERS in the Middle East even during past `information blackouts' by the Saudi MOH, hasn't posted an update since January 2020.


The World Health Organization did publish a DON report in early July (see WHO DON: Middle East respiratory syndrome coronavirus (MERS-CoV) – Saudi Arabia), which provide details on the cases reported in May. No other Middle Eastern countries have reported any MERS-CoV cases since March. 

While it is possible MERS-CoV activity has vanished, it isn't terribly likely.  And prior to January of this year, MERS-COV was considered the coronavirus with the greatest pandemic potential. 

Moving on to influenza. For months global reporting of influenza has been practically non-existent.  The latest `map' of flu activity (see below) is blank, with the exception of North America.  

All summer, the WHO Influenza report has carried a disclaimer:

The current influenza surveillance data should be interpreted with caution as the ongoing COVID-19 pandemic have influenced to varying extents health seeking behaviours, staffing/routines in sentinel sites, as well as testing priorities and capacities in Member States. The various hygiene and physical distancing measures implemented by Member States to reduce SARS-CoV-2 virus.
The most recent Influenza Report out of WHO EMRO was from Epi week 11. 

While we are getting somewhat better information out of the ECDC (see ECDC: Influenza Virus Characterisation - Summary Europe, July 2020), the number of samples submitted by EU countries has been far lower than normal this summer.  

Although influenza activity may be truly suppressed globally, we are going into the next flu season with a dearth of data on its evolution since last winter. 

Even reporting on serious agricultural diseases - like African Swine Fever - has fallen by the wayside, particularly in Asia.   

The UN FAO's most recent update on ASF in Asia was released on March 5th, with the next update promised in 2 weeks time.  Since then . . . silence. 

African Swine Fever has killed somewhere between 1/3rd and 1/2 of the world's swine, has increased food insecurity around the globe, and poses a constant threat to spread to the Americas (see USDA Enhances Domestic ASF Surveillance Efforts).   

Six months without an update from the FAO is less than reassuring. 

According to Hong Kong's CHP, there hasn't been an H7N9, H5N6, or H5N1 human infection reported globally in over a year.  While that may very well be true, against the backdrop of diminished reporting on African Swine Fever since March, one has to take any other absence of data with a grain of salt. 

With the world reeling from COVID-19, supply chains badly disrupted, and many economies teetering on the brink we find ourselves in a precarious position. One that would be only worsened if we get blindsided by another emerging disease threat. 

Whether `reasonable', unavoidable, or simply politically expedient, the growing lapses in disease reporting around the world should give us all pause.  As should our general lack of preparedness for the `next one'.

The notion that we won't get hit again is only a continuation of the years of magical thinking that left us unprepared for COVID-19. 

And given we are solidly in the age of emerging infectious diseases,  we simply can't afford any more of that.