The COVID-19 pandemic has disrupted health and economic security, both directly and indirectly, for most of the planet. Inherent to this disruption are three systemic problems: (i) global and national leaders acted slowly to detect and contain the spread of the virus, (ii) global health organizations reacted slowly to contain the spread of the virus, and (iii) a mixture of factors caused the delayed response including late recognition of the threat and where it was circulating, slow incorporation of science and data into decision making, poor political will, and inconsistent messaging to citizens regarding the nature of the threat and precautions to take. The origin and spread of the coronavirus that causes COVID-19 also depended on a number of codependent factors—human encroachment on animal habitats, globalization and an interconnected world, and a global economy that ignored insufficient sanitation and public health standards. But, most importantly, it depended on a failure of adequate monitoring, data sharing, and early warning and mitigation systems.
Continuous global health protection builds upon a foundation of secure data and communications, rapid sharing of biological threat data across the globe, enhanced trust and confidence in the digital economy, and assured supply chains.
Viruses and other pathogens know no borders, nor do they discriminate by race or class. Though nations may adopt their own strategies to enhance resilience and future planning, a more global approach to this interconnected system will be essential to keep all humans safe. Continuous global health protection builds upon a foundation of secure data and communications, rapid sharing of biological threat data across the globe, enhanced trust and confidence in the digital economy, and assured supply chains.
Finding 5: There is a need for a continuous biological surveillance, detection, and prevention capability.
The design of a pandemic surveillance, detection, and prevention system would require a multipronged approach, comprising global monitoring, early detection, rapid warning, and capable mitigation and prevention strategies. The system would perform the following main functions: biothreat agent recognition, mobilization of defenses, containing the spread of the biothreat agent, administration of therapeutic treatment, and the ability to recognize new pathogens and form specific neutralizing responses.
Much of the integrative assessments performed by the system would need to rely on a network capable of receiving data from multiple, decentralized information sources, and converting that information into indicators that can be aggregated and evaluated to support decision making at the individual, local community, and population level.1National Syndromic Surveillance Program, “North Carolina Integrates Data from Disaster Medical Assistance Teams for Improved Situational Awareness,” Centers for Disease Control and Prevention, accessed March 26, 2021, https://www.cdc.gov/nssp/success-stories/NC-Disaster-Teams.html; “Influenza – Surveillance and monitoring,” World Health Organization, accessed March 26, 2021, https://www.who.int/influenza/surveillance_monitoring/en A global detection and response system could enable greater resilience and prevention, and decrease the potential that new outbreaks of pathogens lead to global pandemics.2“World Health Organization, Global Influenza Surveillance and Response System,” World Health Organization, accessed March 26, 2021, https://www.who.int/influenza/gisrs_laboratory/updates/GISRS_one_pager_2018_EN.pdf?ua=1
Finding 5.1: An early detection and warning system3“Toward the Development of Disease Early Warning Systems,” in Under the Weather: Climate, Ecosystems, and Infectious Disease, National Research Council (US) Committee on Climate, Ecosystems, Infectious Diseases, and Human Health [Washington, DC: National Academies Press (US), 2001], https://www.ncbi.nlm.nih.gov/books/NBK222241/ requires global data collection of pathogen-related indicators, sometimes requiring novel sources to address information gaps.
Early detection would require the funding of a global, interconnected system that relies on partnerships among national governments and regional partners. Where there are gaps in collecting and sharing preferred data, e.g., when a nation or region does not participate, alternative indicators would need to be developed.4Sylvia Mathews Burwell et al., “Improving Pandemic Preparedness: Lessons From COVID-19,” Independent Task Force Report No. 78, Council on Foreign Relations, October 2020, accessed March 26, 2021, https://www.cfr.org/report/pandemic-preparedness-lessons-COVID-19/pdf/TFR_Pandemic_Preparedness.pdf; Elias Kondilis et al., “COVID-19 data gaps and lack of transparency undermine pandemic response,” Journal of Public Health, February 9, 2021, fdab016, https://doi.org/10.1093/pubmed/fdab016; Kamran Ahmed et al., “Novel Approach to Support Rapid Data Collection, Management, and Visualization During the COVID-19 Outbreak Response in the World Health Organization African Region: Development of a Data Summarization and Visualization Tool,” JMIR Public Health and Surveillance 6 (4) (Oct-Dec, 2020), accessed March 26, 2021, https://publichealth.jmir.org/2020/4/e20355/; Sameer Saran et al., “Review of Geospatial Technology for Infectious Disease Surveillance: Use Case on COVID-19,” Journal of the Indian Society of Remote Sensing 48 (2020): 1121–1138, accessed March 26, 2021, https://doi.org/10.1101/2020.02.07.20021071
The development of novel, authenticated data sources is a key risk factor for pandemic warning systems. As seen at the start of the COVID-19 pandemic, relying on government-provided information led to a delay in identifying the unusual pneumonia-like illness in Wuhan, China, and ultimately in releasing the genetic sequence of the virus.5Associated Press, “China didn’t warn public of likely pandemic for 6 key days,” April 15, 2020, accessed March 26, 2021, https://apnews.com/68a9e1b91de4ffc166acd6012d82c2f9 It cost lives, delayed warnings and the ability for others to detect the circulating virus, delayed containment and mitigation strategies (e.g., vaccine and therapeutic development), and enabled the virus to spread globally via human vectors.6Jin Wu et al., “How the Virus Got Out,” New York Times, March 22, 2020, accessed March 26, 2021, https://www.nytimes.com/interactive/2020/03/22/world/coronavirus-spread.html; Zhidong Cao et al., “Incorporating Human Movement Data to Improve Epidemiological Estimates for 2019-nCoV,” medRxiv, https://www.medrxiv.org/node/71912.external-links.html
Authenticated data sources from different decentralized sources and edge devices could include both traditional (e.g., positive viral tests, hospitalization rates, excess death rates) and nontraditional sources of health information (e.g., passive monitoring of environment, wastewater, satellite data, human migration trends, market signals) that can be overlaid, combined, and aggregated to understand current public health conditions and to have predictive value.
Finding 5.2: An elevated capacity on the global stage is required.
The components of global capacity in a pandemic include the ability to quickly identify and sequence novel pathogens; to quickly share that information with the world; to rapidly ramp-up testing; to develop and approve targeted vaccines and therapeutics; to have medical supply chain, manufacturing, and distribution capabilities in place; to have sufficient capital health equipment, medical consumables, and healthcare personnel in place; and to provide access to healthcare and reliable health information to all those in need.
These specific functions for creating a comprehensive global alert and response system and coordinating actions, as well as supporting localized capacity strengthening,7“Strengthening health security by implementing the International Health Regulations (2005), Country capacity strengthening,” UN World Health Organization, accessed March 26, 2021, https://www.who.int/ihr/capacity-strengthening/en/ were made part of the World Health Organization’s (WHO’s) updated 2005 International Health Regulations (IHR)8“Strengthening health security by implementing the International Health Regulations (2005), A global system for alert and response,” World Health Organization, https://www.who.int/ihr/alert_and_response/en/; Apoorva Mandavilli, “239 Experts With One Big Claim: the Coronavirus Is Airborne,” New York Times, updated November 19, 2020, accessed March 26, 2021, https://www.nytimes.com/2020/07/04/health/239-experts-with-one-big-claim-the-coronavirus-is-airborne.html and its pandemic preparedness plan.9World Health Organization, WHO global influenza preparedness plan: The role of WHO and recommendations for national measures before and during pandemics, 2005, accessed March 26, 2021, https://www.who.int/csr/resources/publications/influenza/WHO_CDS_CSR_GIP_2005_5.pdf “To help countries review and, if necessary, strengthen their ability to detect, assess, and respond to public health events, WHO develops guidelines, technical materials, and training and fosters networks for sharing expertise and best practices. WHO’s help supports countries in meeting their commitments under the IHR to build capacity for all kinds of public health events.”10“Strengthening health security by implementing the International Health Regulations (2005), Country capacity strengthening,” UN World Health Organization, accessed March 26, 2021, https://www.who.int/ihr/capacity-strengthening/en/
To achieve the fullest potential of these approaches, there need to be investments on a global scale to support expanded detection, mitigation, and capacity-building strategies. These efforts should be conducted through public, private, and government partnerships based on mutual agreements to share data and report issues early. These should be multinational collaborations that would be able to overcome the limiting factors discussed in the next section. In developing these approaches, a priority is to strengthen transparency and accountability within the United Nations (UN) system, including at the WHO.11Chairman Michael McCaul, China Task Force Report, U.S. House of Representatives, 116th Congress, September 2020, accessed March 26, 2021, https://gop-foreignaffairs.house.gov/wp-content/uploads/2020/09/CHINA-TASK-FORCE-REPORT-FINAL-9.30.20.pdf
Finding 5.3: There are several limiting factors.
There often is a lack of trust among groups, institutions, and governments. Governments do not always trust other governments; countries do not always trust global health bodies; nationally, states do not always trust each other or the federal government; and individuals do not always trust governments or health entities or officials. This lack of trust is well-documented. According to the 2020 Edelman Trust Barometer,12“2020 Edelman Trust Barometer,” Edelman, accessed March 26, 2021, https://www.edelman.com/trust/2020-trust-barometer “no institution is seen as both competent and ethical,” an opinion that includes government, business, nongovernmental organizations (NGOs), and the media. In the statistical model Edelman provides, government is widely seen as the most unethical, and the least competent, institution of the four. According to the International Development Association of the World Bank Group, half of the global population does not trust government institutions.13“Governance and Institutions,” International Development Association, World Bank Group, accessed March 26, 2021, https://ida.worldbank.org/theme/governance-and-institutions Similarly, both individual citizens and countries may lack trust in national and global health bodies.
Health institutions are concerned about sharing data on health outbreaks too early, as this could make them look underinformed, or to be “crying wolf” before the true measure of an outbreak is known.14Stephen Buranyi, “The WHO v coronavirus: why it can’t handle the pandemic,” Guardian, April 10, 2020, accessed March 26, 2021, https://www.theguardian.com/news/2020/apr/10/world-health-organization-who-v-coronavirus-why-it-cant-handle-pandemic Governments may be incentivized to withhold information on outbreaks to maintain appearances of strength and ultimately to control medical supplies to keep their own people safe. Withholding immediate access to information can severely affect outcomes, such as the spread of the virus, allowing it to gain a foothold in other countries unaware. It also prevents the type of global and interdisciplinary cross-collaboration that has been so effective at advancing science, research and development (R&D), and progress toward solutions.
The cost of developing and operating a global pandemic surveillance, detection, and warning and response system must be borne by all nations in an equitable manner. A recent study15Dimitrios Gouglas et al., “Estimating the cost of vaccine development against epidemic infectious diseases: a cost minimisation study,” Lancet Global Health 6 (12) (E1386-E1396, DECEMBER 01, 2018), October 17, 2018, DOI: https://doi.org/10.1016/S2214-109X(18)30346-2, accessed March 26, 2021 estimates “[t]his cost includes the cumulative cost of failed vaccine candidates through the research and development process. … [P]rogressing at least one vaccine through to the end of phase 2a for each of the 11 epidemic infectious diseases would cost a minimum of $2.8–3.7 billion ($1.2 billion–$8.4 billion range).” According to a 2002 study, the cost of developing a vaccine—from research and discovery to product registration—is estimated to be between $200 million and $500 million per vaccine.16Irina Serdobova and Marie-Paule Kieny, “Assembling a Global Vaccine Development Pipeline for Infectious Diseases in the Developing World,” American Journal of Public Health 96 (9): 1554–1559, https://doi.org/ 10.2105/AJPH.2005.074583, accessed March 26, 2021. Due to the high costs of developing vaccines and current therapeutics, developing an equitable funding model will rely on new research to make vaccines less expensive to develop, new technologies to conduct wide-area detection of signatures of biological activity, and new techniques for inexpensive diagnostic testing worldwide. The supply chains, manufacturing capabilities, vaccines, and therapeutics must be developed in such a manner that all nations are protected by such a global pandemic prevention system. The concern extends beyond vaccines which have been developed. Some diseases, like Zika, for which no vaccines exist, continue to be studied; and parasites, such as those that cause malaria, may become more widespread due to global climate change.
There are many types and sources of data that need to be identified in order to effectively predict or fight an epidemic. One is vector tracking. It is difficult to track zoonotic vectors that lead to viral spread. It is estimated that wild animals, in particular mammals, harbor an estimated forty thousand unknown viruses, a quarter of which could potentially jump to humans;17C.J. Carlson et al., “Global estimates of mammalian viral diversity accounting for host sharing,” Nature Ecology & Evolution 3 (2019): 1070–1075 (2019), https://doi.org/10.1038/s41559-019-0910-6, accessed March 26, 2021. Global Virome Project / PREDICT has estimated that there are over 1.6 million unknown viral species in mammalian and avian populations, of which approximately 700,000 have the potential to infect and cause disease in humans. “Global Virome Project,” https://static1.squarespace.com/static/581a4a856b8f5bc98311fb03/t/5ada612470a6ad672eea01b3/1524261157638/GVP%2B2%2Bpager%2BFINAL.pdf it is also estimated that 75 percent of all emerging pathogens in the last decade have come from a zoonotic event.18Alex Long, “Zoonotic Diseases and the Possibilities with EBV Monitoring,” CTRL Forward, November 14, 2017, accessed March 26, 2021, https://www.wilsoncenter.org/blog-post/zoonotic-diseases-and-the-possibilities-ebv-monitoring. Further, it is complicated to surveil and track pathogen genesis, evolution, and global spread. Understanding of the science of viruses, other pathogens, and their mutation and evolution is incomplete, and research continues on new ways to monitor and spot outbreaks.
Insufficient public health infrastructures. A 2017 study conducted by the World Bank and the WHO points out that half of the global population does not have access19World Health Organization, “World Bank and WHO: Half the world lacks access to essential health services, 100 million still pushed into extreme poverty because of health expenses,” December 13, 2017, accessed March 26, 2021, https://www.who.int/news-room/detail/13-12-2017-world-bank-and-who-half-the-world-lacks-access-to-essential-health-services-100-million-still-pushed-into-extreme-poverty-because-of-health-expenses to necessary health services, and one hundred million people live in extreme poverty.20“Health Financing: Key policy messages,” World Health Organization, accessed March 26, 2021, https://www.who.int/health_financing/topics/financial-protection/key-policy-messages/en/
Approach 5: Develop a global pandemic surveillance, detection, and response system based on data sensing and integration via trusted networks.
Three important elements of this global system are the early detection and warning system, the rapid response and recovery system, and the elevated capacity building system.
Recommendation 5: Field and test new approaches that enable the world to accelerate the detection of biothreat agents, to universalize treatment methods, and to engage in mass remediation through multiple global means.
Recommendation 5.1: Develop a global early warning system comprised of pandemic surveillance systems coupled with an early warning strategy.
Congress should request the Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), United States Agency for International Development (USAID), United States Department of Agriculture (USDA), and other associated agencies to jointly develop an initial demonstration of this system in collaboration with the WHO, private institutions, and partner nations. The foundation is a surveillance system comprised of both active and passive monitoring of multiple environments and biomes—space, atmosphere, water, soil, animal reservoirs. Fundamental to the pandemic surveillance strategy is (i) training locals to conduct routine testing and genomic surveillance where spillovers occur and to regularly report incidences of novel illnesses, and (ii) increased genetic testing to track pathogens and to delineate what is coming from the natural environment versus being weaponized. Funding contributions and expert participation from other nations should be obtained.
Early detection would be enhanced by increasing the ability to identify and aggregate known data signals, identifying novel data signals, and enabling the combination of these signals into meaningful public health insights. This requires data to be labeled in such a way that it is globally recognized, named, and usable. Detection and monitoring also depend on developing distributed networks upon which those secured signals can arrive, inform local testing and response activities, and eventually be aggregated, while protecting personal data privacy, so that insights can be extracted. Finally, after preliminary flags or warning indicators are observed, a threshold is crossed and the warning or alarm could be sent throughout the distributed network, rather than relying upon a single entity or body to release the relevant information.
Key development principles include:
- First determine a sufficient and obtainable set of data that the surveillance system should collect, and develop the local and regional capabilities to collect these data;
- Support a global, decentralized network that can authenticate data sources, and enable validated data-sharing amongst validated data producers;
- Enable cybersecure data aggregation and analysis capabilities while preserving personal data based on the terms specified in Recommendation 3.1 in this report;
- Empower a surveillance strategy commensurate with civil liberties and privacy protections;
- Facilitate a surveillance strategy comprised of both active and passive monitoring of multiple environments and biomes (space, atmosphere, water, soil);
- Facilitate a surveillance strategy comprised of monitoring of traditional health and nontraditional data sources [e.g., excess death rates, viral genome sequences, Internet searches, geographic information systems (GIS), market trends]; and
- Form distributed networks for global early warning system alerts.
Recommendation 5.2: Reestablish and realign existing pandemic monitoring programs.
The administration should provide R&D funding to current pandemic monitoring and response networks as part of the effort to build a system for continuous global health protection. The primary actions to consider include: reinstate the USAID PREDICT program21PREDICT, “Reducing Pandemic Risk, Promoting Global Health,” USAID, https://www.usaid.gov/sites/default/files/documents/1864/predict-global-flyer-508.pdf for tracking global zoonotic disease, provide additional funding to the EcoHealth Alliance22“EcoHealth Alliance,” website homepage accessed April 16, 2021, https://www.ecohealthalliance.org/, and utilize networks to combine data being accumulated through parallel observation networks—e.g., the Strategic Advisory Group of Experts on Immunization (SAGE),23“Strategic Advisory Group of Experts on Immunization (SAGE),” World Health Organization, accessed April 16, 2021, https://www.who.int/groups/strategic-advisory-group-of-experts-on-immunization/working-groups/cholera-(november-2015—august-2017) the National Ecological Observatory Network (NEON),24“The National Science Foundation’s National Ecological Observatory Network (NEON),” website homepage accessed April 16, 2021, https://www.neonscience.org/ Collective and Augmented Intelligence Against COVID-19 (CAIAC),25“CAIAC: Collective and Augmented Intelligence Against COVID-19,” website homepage accessed April 16, 2021, https://oecd.ai/wonk/collective-and-augmented-intelligence-against-covid-19-a-decision-support-tool-for-policymakers and the Epidemic Intelligence from Open Sources (EIOS).26“Epidemic Intelligence from Open Sources (EIOS): Saving Lives through Early Detection,” World Health Organization, https://www.who.int/initiatives/eios
Recommendation 5.3: Emphasize privacy protections in pandemic surveillance systems.
The administration should support initiatives that emphasize privacy protections in pandemic surveillance systems. These initiatives should be managed by NIST and NSF in collaboration with the Department of Health and Human Service’s Office of the National Coordinator for Health Information Technology and the lead science institutions in partner nations. The mitigation strategies will (i) identify infected individuals early through robust and frequent testing with a globally-recommended strategy; (ii) deploy contact-tracing strategies (commensurate with civil liberties); (iii) deliver consistent health messaging for disease prevention, spread, and treatment by coordinating centralized information and data reporting with local, on-the-ground, trusted community leaders; and (iv) provide consistent public health guidance for gatherings like air travel, cruises, sporting events, schools, restaurants, stores, and so forth.
Recommendation 5.4: Increase resilience in medical supply chains.
The administration should fund R&D of cellular- and molecular-based manufacturing technologies27Megan Scudellari, “Step Aside, PCR: CRISPR-based COVID-19 Tests Are Coming,” IEEE Spectrum, December 21, 2020, accessed April 16, 2021, https://spectrum.ieee.org/the-human-os/biomedical/diagnostics/step-aside-pcr-crispr-based-covid-19-tests-are-coming that enhance supply chain assurance.28Nicholas A. C. Jackson et al., “The promise of mRNA vaccines: a biotech and industrial perspective,” npj Vaccines 5 (11) (2020), https://doi.org/10.1038/s41541-020-0159-8, accessed March 26, 2021; Giulietta Maruggi et al., “mRNA as a Transformative Technology for Vaccine Development to Control Infectious Diseases,” Molecular Therapy 27 (4) (April 10, 2019): 757–772, accessed March 26, 2021, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6453507/ Both cellular and molecular manufacturing are specific instances of synthetic biology. In some cases, they can be rapidly deployed by setting up the conditions for production, and then substituting in the genetic sequences of interest to go into high-gear production. This simplifies supply chain and production lead time, can increase capacity, and creates flexible supply chains by producing candidates that are thermostable.
Some of the more forward-looking technologies for bio-sensing, vaccine development, and therapeutics are amenable to this kind of manufacturing and stockpiling. The goal is to develop redundancy at a regional level (components/ingredients; manufacturing), adopt more rigorous methods for validation of authenticity, and support multiregional distribution chains.
Recommendation 5.5: Develop capacity building for vaccine and therapeutics discovery, development, and distribution.
The administration should establish PPPs to improve pandemic protection capacity building. There are three efforts: (i) biomanufacturing and synthetic biology innovations will create therapeutic discovery systems and speed vaccine discovery; (ii) vaccine discovery, development, and distribution coalitions like the Coalition for Epidemic Preparedness Innovations (CEPI) will enable equitable distribution; and (iii) information monitoring and distribution regarding consumables, capital equipment supplies, hospital resources, and healthcare workers will support public and organizational activities during a crisis.
Recommendation 5.6: Develop rapid responses to unknown pathogens, and supporting data collection networks.
NIH should develop and lead a program for the automated development of treatments for unknown pathogens. The goal is to universalize treatment methods; for example, by employing automated methods to massively select bacteriophages as a countermeasure to bacteria—or employ antibody-producing E. coli or cell-free synthetic biology as a countermeasure to viruses. Advanced computational methods such as computational modeling of the 3D molecules of novel pathogens, and AI-based selection of potential treatments, can help automate and speed up this process. New technologies that can change the time for the regulatory approval process, i.e., the time required for human clinical trials, should be researched—for example, in silico testing or artificial organ testing.29Committee on Animal Models for Assessing Countermeasures to Bioterrorism Agents, Institute for Laboratory Animal Research Division on Earth and Life Studies, “Chapter 5: Alternative Approaches to Animal Testing for Biodefense Countermeasures,” in Animal Models for Assessing Countermeasures to Bioterrorism Agents (Washington, DC: The National Academies Press, 2011), accessed March 26, 2021, https://www.nap.edu/read/13233/chapter/7
NIH should create a consortium of universities and biotechnology companies to develop rapid, wide-area distribution of vaccines. This program should consider approaches that distribute vaccines through conventional supply channels, and methods to make vaccines that are survivable and transportable in any environment. Treatments in addition to vaccines should be incorporated in this effort.
NSF should create a digital infrastructure that can connect diverse, independent observation networks, databases, and computers—including emerging biosensors and autonomous sequencers deployed in water systems, air filtration systems, and other public infrastructure—to integrate their diverse data for analysis and modeling with protocols for activating rapid analysis of new pathogens, including new strains of extant pathogens to evaluate ongoing vaccine efficacy.
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