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Two decades ago, when H5N1 was making its initial threatening moves in Southeast Asia, countries around the world began crafting pandemic plans, and conducting preparedness drills. Here in the United States, every state and territory, and every major government agency, was expected to craft a plan.
There was admittedly a wide variance in the quality of these plans, and many assumptions were never tested, but it was seen as significant progress.
Following the unexpectedly mild 2009 H1N1 pandemic, many countries simply locked their plans away, and stopped preparing. Pandemics, they believed, had been over-hyped. Modern medicine (vaccines & antivirals) would save us.
When a novel coronavirus emerged in 2020, many countries were forced to rely on 15-year-old pandemic plans which only envisioned an influenza pandemic. Plans that often emphasized the rapid deployment of vaccines - that, in the case of COVID - wouldn't exist for at least a year.
Despite years of dire warnings that the world was ill-prepared for a pandemic, we went into that COVID pandemic with long predicted critical shortages of ventilators and PPEs (masks, gowns, gloves). Much of what was stored in our Strategic National Stockpile had deteriorated with age.
You'd think that after enduring COVID, the nations of the world would be rushing to update, and improve, their pandemic response plans. But once again most countries seem to be ignoring the threat. Surveillance and reporting on infectious diseases is, in many cases, worse than it was a decade ago.
We have seen a few bright spots.
Ten weeks ago South Korea's CDC unveiled a draft of their new `Influenza Pandemic and Response Plan' at an expert symposium, calling for comments.
Today they unveiled their final draft, which emphasizes the importance of `flattening the curve' during the opening months of a pandemic (see EID Journal: Evaluating Social Distancing Interventions To Delay or Flatten The Curve - COVID-19).
- Novel influenza is a strong candidate for the next pandemic, and the goal is to minimize health damage and social and economic impacts.
- A strategy to delay the peak of the epidemic from 110 to 190 days and reduce the maximum number of patients on the peak day by 35% in the worst-case scenario (high transmission rate and high mortality rate).
On September 6, the Korea Disease Control and Prevention Agency (KDCA) (Director Young-Mi Ji) announced the ‘New Influenza Pandemic Preparedness and Response Plan’ to prepare for the next infectious disease pandemic.
This plan is being completely revised for the first time in six years since it was established in 2006 and revised twice in 2011 and 2018, and reflects the recommendations of the World Health Organization, which strongly identifies a new type of influenza as the next pandemic and recommends that the country prepare for it as a priority in its national plan.
In particular, as the risk level is increasing due to the continuous reports of human infections with avian influenza, the need to prepare preemptively before the risk of avian influenza outbreaks, such as the influx of migratory birds in the fall, has arisen.
* A total of 907 cases of human infection with avian influenza A (H5N1) type reported in 24 countries since 2003 (`24.8.5., ECDC)
** Recent cases: Human infection from cattle (USA, April 24), Human infection with avian influenza death (Vietnam, March 24)
Before preparing the revision, the Korea Disease Control and Prevention Agency collected opinions from various experts and medical professionals regarding the limitations of the COVID-19 response and areas in need of improvement.
In addition, the scale of damage from a new or variant influenza pandemic was predicted. According to this, in a situation of high transmission rate and high fatality rate, if there is no quarantine intervention, it is estimated that up to 40% of the population will be infected within 300 days and it will take about 110 days to reach the peak. In this pandemic situation, a strategy was established to reduce the maximum number of patients occurring on the peak day to 35% through quarantine measures, delay the peak of the epidemic from 110 days to 190 days, and quickly develop a vaccine during that period.
This plan aims to minimize not only the health damage but also the social and economic impact in the event of a novel influenza pandemic, and includes the following as key tasks before a pandemic: ▲ surveillance system, ▲ resource securing, ▲ vaccine strategy, and ▲ establishment of a One Health integrated management system, as well as response strategies for each phase (initial phase, spread phase, recovery phase) in the event of an outbreak.
First, the surveillance system aims to detect the emergence of a new virus early, expand overseas information collection, establish an information verification system*, and expand the number of medical institutions conducting surveillance from 300 to 1,000 for domestic surveillance.
Laboratory surveillance for pathogen genetic analysis will also be expanded from the current 180 to 200 sites, and links between medical institutions and public testing agencies to identify avian influenza will be strengthened. In addition, a surveillance system for unknown causes for respiratory infection patients visiting emergency rooms and outpatient clinics will be newly established.
* Select local information → Request information from ODA agency → Analyze after verifying information through local dispatched personnel
In addition, we plan to develop a multidisciplinary prediction model using artificial intelligence and mathematics/statistics in collaboration with the private sector to improve the prediction of patient occurrence by epidemic stage, and to establish a basis for effective quarantine policies through analysis of the effectiveness of various pharmacological and non-pharmacological quarantine measures.
Second, in the resource sector, we will stockpile 25% of the total population of treatment drugs to be able to respond for the first six months, and we will also stockpile quarantine supplies such as protective gear and masks to enable rapid supply, and operate the Disaster Management Resources Integrated Management System*.
For rapid diagnosis, a new one-step test method** will be developed to enable confirmation within 12 hours, compared to the current 72 hours. In preparation for the demand for large-scale testing and hospital beds in the event of an epidemic, genetic-based testing and rapid testing infrastructure will also be expanded, and the number of infectious disease beds will be expanded from the current 1,100 to 3,500.
* Distribution and logistics ICT-based system for real-time integrated management of national disaster management resource information
** Rapid diagnosis possible in case of human infection with subtypes (H5N1, H5N8, H9N2) that mainly occur in birds
Third, for vaccines, as a strategy to develop a vaccine within 100 or 200 days of an outbreak, we prepare for two situations: developing a vaccine or prototype* (trial product) for the predicted antigen type of the outbreak in advance and using it for rapid development (100 days) in the event of an outbreak, or starting from the strain introduction stage and developing anew (200 days) in the event of an outbreak with a strain different from the pre-developed antigen type.
Currently, the avian influenza H5N1 vaccine has been developed domestically, so if a pandemic occurs due to a subtype of this, a vaccine can be developed in just 90 days through the strain change procedure.
* Currently in possession of fertilized egg-based H5N1, pandemic H1N1, and additional development of H5N1, H7N9 based on various platforms
In order to secure an mRNA platform for rapid vaccine development, the government promoted the 'Pandemic mRNA Vaccine Development Support Project (hereinafter referred to as the 'mRNA Vaccine Project') through a Cabinet meeting last August, and the National Research and Development Project Evaluation General Committee of the Ministry of Science and ICT recognized the need for rapid vaccine development and acquisition, and selected this project as a project exempted from preliminary feasibility study.
Through this project, we aim to secure an mRNA vaccine platform by 2028, and in the first year, 2025, we submitted a government budget proposal to the National Assembly to invest 29 billion won to support non-clinical and clinical trials for mRNA vaccine development. The total project scale and period, etc. will be finalized after reviewing the feasibility of the business plan.
The fourth is One Health Integrated Management. Influenza is a zoonotic disease that infects both animals and humans. Influenza from birds such as chickens and ducks can spread to mammals such as cattle and pigs, and if it crosses the species barrier and infects humans, it can cause a pandemic. Therefore, One Health surveillance and response are required for the entire chain of infection transmission, including animals and the environment.
Surveillance of animal influenza will expand the current system centered on poultry and wild birds to include mammals and companion animals. In addition, an early warning system will be established to identify risks early and take preventive measures by tracking viruses originating from humans and animals and linking and analyzing information such as habitats and migratory bird movements.
In addition, we will regularize joint mock training among relevant ministries to strengthen real-time joint epidemiological investigations and responses to protect high-risk groups such as livestock workers or contacts in the event of an animal influenza outbreak. We plan to establish One Health policies and implementation plans and check their implementation through an inter-ministerial consultative body comprised of relevant ministries.
In response to an outbreak, strategies were specified according to the characteristics of each epidemic situation. In the early stages, plans were specified for minimizing transmission, preventing severe cases and deaths during the spread period, and effective recovery and reorganization during the recovery period. The “Initial 3 Days” plan was presented as an example to focus on rapid initial response.
In the early stages of an outbreak, pathogen characteristics and epidemiological information are insufficient, so pathogen information is quickly obtained through in-depth epidemiological investigations of early cases. A crisis response system is activated to establish a patient management system including screening and isolation of confirmed cases, and diagnostic testing methods are established and distributed, while crisis response R&D is activated to secure vaccines.
This is a time when stable medical resource management is required. In addition, the vaccination infrastructure prepared in the preparation stage will be activated for priority vaccination of high-risk groups and short-term, simultaneous, and rapid vaccination.
In the recovery phase, tasks are carried out to reorganize for the next pandemic, including effective damage recovery according to priorities and supplementary measures through response evaluation.
Meanwhile, on the morning of Friday, September 6, the Korea Disease Control and Prevention Agency reported on the “Plan to Prepare for and Respond to a Novel Influenza Pandemic” at the State Affairs Ministerial Meeting at the Government Complex Seoul, and held a public briefing on the plan with experts* that afternoon.
* Professor Jaegap Lee (Hallym University)
Ji Young-mi, the director of the Korea Disease Control and Prevention Agency, emphasized that “a pandemic can affect not only the health of the people but also essential social services, education, industry, and other areas, so advance preparation is important.” She added, “Since we have vaccines and antiviral drugs to respond to influenza, we will develop vaccine prototypes that match the characteristics (antigenic types) of new influenza and accelerate the development of vaccine platform technologies such as mRNA so that we can quickly secure vaccines in the event of a new virus outbreak.” She added that “We will also prepare by sufficiently stockpiling treatments and quarantine supplies in advance so that we can respond appropriately in the early stages of a pandemic.”
The Korea Disease Control and Prevention Agency requested cooperation from relevant ministries to ensure that the “Plan to Prepare for and Respond to a Novel Influenza Pandemic” is implemented well, and will continue to check for any obstacles in the field where the plan is to be implemented and evaluate its effectiveness. In addition, it explained that it will share this plan with the international community to support each country in establishing its own plan, and prepare for the next pandemic together.
While it is true that No Pandemic Plan Survives Contact With A Novel Virus, having a framework for dealing with a crisis, and running realistic exercises, can be invaluable in a crisis.
But most importantly, it provides a road map for what can be done today to prepare for the inevitable public health threats of tomorrow.
Which, based on our past performance, would be a novel response to a novel virus.
