Trend: Keep calm and carry on, but also ‘be prepared’

A trend indicates a direction of change in values and needs which is driven by forces and manifests itself already in various ways within certain groups in society.

There are systems in place that monitor threats to society and provide support and funds in a crises. ‘Preparedness plans’ aim to protect the health, safety and resilience of communities and critical infrastructures. The WHO stated in 2018 that the biggest future health risk was the emergence of an unknown “Disease X”. In 2019, Disease X became COVID-19 and it exposed the vulnerabilities and ‘under-preparedness’ of the systems. Gaps were revealed in foresight, including demand/supply dimensions, preparedness and response tools. Older health crisis preparedness plans were designed to mitigate a crisis from a public health point of view. Post-COVID-19, much has changed, and preparedness plans now look to contain broader effects on society, and to increase societal resilience.

During the COVID-19 pandemic many countries faced (and continue to suffer from) shortages in capacities, including health care professionals, hospital beds, intensive care units, personal protective equipment, medicines and devices, diagnostics, laboratory material and oxygen. This was aggravated by the closure of borders and rupture of global supply chains. A new culture of preparedness relies on the accessibility of necessary equipment - a feature with different components.

COVID-19 is a reminder of the fact that most emerging infectious diseases in humans (> 60%) are of zoonotic origin (from animals), with the majority (70%) originating in wildlife. Zoonoses are significantly increasing in both frequency and severity and will have enormous long-term impacts. Zoonoses are driven by factors such as continued population growth, land use change, climate change, the intensification of food systems and habitat loss.Therefore, to better anticipate, detect and respond to new threats, a multi-sectorial approach that covers all of these is needed, based on the principles of ‘One Health’, i.e. where risks are assessed and mitigated in the context of the human, animal and environmental interphase. What the new threats will be is unknown, but candidates have been identified: for e.g. antimicrobial resistance is a very serious threat which will have a lasting impact.

This Trend is part of the Megatrend Shifting Health Challenges

Manifestations

Developments happening in certain groups in society that indicate examples of change related to the trend.

Epidemic intelligence

Epidemic intelligence is a science that uses a wide range of sources to identify signals of potential disease outbreaks. Detecting an outbreak as early as possible provides an opportunity to contain it and arrange timely countermeasures. Epidemic intelligence consists of analysing and reporting by public health institutions, global networks of health professionals, news scanning, social media monitoring, literature reviews, and so on. Epidemic intelligence activities have grown in parallel with increasing data, digitalisation and computer power. Traditional institution's methods are now complemented with new forms of epidemic and other scientific evidence-based and collective intelligence.The challenge of separating the 'signal from the noise’ remains and there is a need to optimize intelligence systems. Careful expert analysis is still needed to differentiate between real and unreal outbreaks. Reports in the media might represent unconfirmed cases.

Epidemic intelligence is extending to areas outside of the digital world and the pandemic has shown the relevance of wastewater surveillance in the context of public health intelligence.  Sewage water can be used to detect and monitor the spread of diseases (and chemicals). Monitoring SARS-CoV-2 and its variants in wastewaters can provide a reliable source of information about the spread and mutation of viruses. Linking public health and wastewater-encoded information better in the future could provide information about the presence of other pathogens, influenzas, pesticides, microplastics, or even drugs in the water. Epidemic intelligence must integrate findings from 'One Health' research to identify new sources of diseases earlier and to better understand their evolution in order bring out effective measures. See below and 'A healthy environment trend' for more.

Signals of change: WHO, RIVM, Studyfinds

Diseases and other threats

Alongside detecting threats, to be prepared relies on a mechanism to react to threats. Threats and (re-)emerging diseases can be man-made, of natural origin, old, or completely new. We increasingly rely on a multi-sectoral and multidisciplinary system and governance with strong leadership, which can be activated instantly and operationalised efficiently during a crisis to make decisions and act under pressure. Reactions to threats should include rapid and reliable testing and tracing infrastructure.

Preparedness for such events is an ongoing activity that comes at a cost, but COVID-19 has showed that the cost of preparation is smaller than the cost of no preparation. Advances in research methods that try to predict the next disease or pandemic threat have been accelerated. Future efforts could continue to concentrate on traditional health risk monitoring and surveillance, including of zoonosis, but such systems tend to become underfunded once the emergency fades and competing financial priorities appear. Experiments and simulations can indicate a threat’s potential effects to a certain degree, building anticipatory intelligence that aids preparedness. This plays an important role in mitigating a disease’s effect at the earliest stage possible, whereas an integrated approach linking human, animal and environmental factors in line with One Health principles is also key.

COVID-19 taught us that ongoing preparedness plans for SARS-CoV-2 needed continuous updating as the pandemic progressed, because new knowledge appeared and for e.g. initial assumptions that it would hit in a single wave and would not mutate were proven wrong. Artificial intelligence (AI) is increasingly being used to identify and predict new mutations. With the thousands of possible combinations, AI is an effective resource, but even AI cannot tell us which potential mutations will be the most dangerous. Other potential threats include chemical, biological and nuclear threats. Their impact on society could be extremely large and preparedness plans should also cover these situations.

Signals of change: EC, Nature, WHO, Guardian, Observer, EC, Cell, EC

One Health approach to pandemic risks

One Health calls for a holistic and systems approach to pandemics. It is not a new concept, but has evolved over the last decade because of the increased frequency and severity of threats linking the health of humans, animals, plants and the environment. Digital capabilities that connect databases from different domains for quantitative analysis is changing possibilities in this area too. Zoonotic disease threats: such as COVID-19, avian and swine flu, Ebola, AMR, water, and air soil pollution are examples of co-existing complex health challenges that are interconnected and threatening humans, animals, plants and the environment. They require holistic, integrated solutions with a systems approach that incorporates the wider structural factors and systemic prevention measures in line with One Health principles.

Professional segregation with limited cross-sectoral ways of working, inadequate representation of some sectors, disjointed legislative schemes, lack of data sharing and transparency, absence of multi-sectoral coordination mechanisms, silo-ed budgets and decision-making processes, and the lack of robust regulatory frameworks, legal support, mandates and enabling policies are barriers to the effective implementation of One Health. However, as part of the lessons learned from the COVID-19 pandemic there is an increased appetite by governments and demand by stakeholders and society to start implementing One Health solutions and this has manifested with the creation of the Quadripartite Secreteriate (FAO, OIE, WHO, UN) , WHO High Level Panel on One Health and other initiatives at forums such as the G7 and G20, together with national structures such as the One Health office at the CDC in the USA. (See also the trend on 'A healthy environment' for more on the ‘One’ and ‘Planetary health' concepts).

Signals of change: WHO, WHO, CDC

Supply Chains

Maintenance of the provision of services and products is critical for keeping society running during a crisis. The pandemic has highlighted the need for coordinated activities to share material between different countries, within and outside the EU in a crisis. It highlighted the EU’s dependency on others for many essential products, and shortages arose (some continue) for food, industrial components and medical equipment. Medical equipment shortages ranged from gloves, to tissues, to ventilator components. Widely used antibiotics (amoxicillin), painkillers (aspirin and paracetamol), as well as vaccines against hepatitis B and life-sustaining drugs to treat cancer (busulfan and zolendric acid) are all regularly at risk of shortages.

The crisis triggered a movement towards increasing and securing production and stockpiling capacity within the EU, alongside procurement and distribution mechanisms. Some multinational pharmaceutical companies have reviewed their global supply chains and moved the production of active pharmaceutical ingredients (APIs) back to Europe. Even if production costs in the EU are higher than Asia (for e.g.), the benefit of the shorter and reliable supply chain is an important part of securing the EU’s future preparedness. New policies for ensuring the supply of crisis-relevant medical countermeasures in the event of a public health emergency at EU level have been proposed. Discussing the trade-offs transparently with politicians and citizens is essential, because regaining more control over supply chains translates into higher prices. This will be an institutional and communication challenge.

A new preparedness culture could contribute to better identifying the crucial items/supply chains for ‘Strategic Autonomy’ (the concept that refers to the freedom and capacity to set and implement priorities independently and that looks at dependencies). It is likely that future health challenges will require different equipment to COVID-19, other drugs, and the application of other skills – hence the criticality of being agile and flexible in preparedness plans. Networking 3D printing and prototype manufacturing capabilities offer a wealth of innovative and reactive opportunity. In addition, frequent training and retaining spare capacity in the system will allow for a quick future response.

Signals of change: IMD, EC JRC, Wiley Public Health Emergency Collection, JRC Foresight On Health

Superbugs

Antimicrobial resistance (AMR) is a serious threat and The WHO has declared it to be one of the top 10 global public health threats facing humanity. AMR refers to the ability of some microbes (bacteria, parasites, viruses and fungi) to resist antimicrobial agents (antibiotics, antivirals, antifungals and antiparasitics). These are medicines used to prevent and treat infections in humans, animals and plants. AMR is estimated to be responsible for 33 00 deaths per year in the EU alone and was found responsible for approx. 1.27 million deaths globally in 2019. The inaction of regulators and society on AMR is projected to cause millions of deaths globally in the future: it has been estimated that AMR might cause more deaths than cancer by 2050.

Resistant organisms are found in humans, animals, food, plants and in the environment (water, soil and air). Overuse of antibiotics and a lack of compliance in their use by patients are some of the reasons for AMR. Antimicrobials are omnipresent in agriculture too. They are used to prevent disease in animals (including fish), in animal food and to stimulate animal growth. In some cases, antimicrobials are spread on crops. The estimated antimicrobial consumption in the livestock sector runs over 60,000 tonnes per year globally and is projected to grow steadily over the coming decades.

Resistant microbes can spread from person to person, between humans and animals, and can persist in food. In the EU the spread largely takes place in medical settings and there are measures to mitigate the spread of AMR by increased hygiene and enhanced infection prevention and control, (in particular in hospital settings). Importantly, while drugs against some resistant bacteria exit, there is a shortage and the few reagents under development are not sufficient to cope with the emergency. Bacteria are developing new resistance all the time. The development time for new drugs usually takes about 10 years, and success rates are low. There is an urgent need for increased investment in research and innovation in this field.

Signals of change: CDC, ECA, EFSA, FAO

Interesting questions

What might this trend imply, what should we be aware of, what could we study in more depth? What if......? Some ideas:

• What if the next pandemic is caused by a bacteria?
• What if we have another nuclear spill?
• Should we develop a set of criteria to overcome privacy issues when this is needed for epidemiology or rare disease studies?
• What if we have no energy for heating homes, or performing surgeries?
• What tools will we have if a shock event (mental health, health, energy, bioterrorism) hits tomorrow?