PANDEMIC

Pandemics are large-scale outbreaks of infectious disease that can greatly increase morbidity and mortality over a wide geographic area and cause significant economic, social, and political disruption. Evidence suggests that the likelihood of pandemics has increased over the past century because of increased global travel and integration, urbanization, changes in land use, and greater exploitation of the natural environment (Jones and others 2008; Morse 1995). These trends likely will continue and will intensify. Significant policy attention has focused on the need to identify and limit emerging outbreaks that might lead to pandemics and to expand and sustain investment to build preparedness and health capacity (Smolinsky, Hamburg, and Lederberg 2003). The international community has made progress toward preparing for and mitigating the impacts of pandemics. The 2003 severe acute respiratory syndrome (SARS) pandemic and growing concerns about the threat posed by avian influenza led many countries to devise pandemic plans (U.S. Department of Health and Human Services 2005). Delayed reporting of early SARS cases also led the World Health Assembly to update the International Health Regulations (IHR) to compel all World Health Organization member states to meet specific standards for detecting, reporting on, and responding to outbreaks (WHO 2005). The framework put into place by the updated IHR contributed to a more coordinated global response during the 2009 influenza pandemic (Katz 2009). International donors also have begun to invest in improving preparedness through refined standards and funding for building health capacity (Wolicki and others 2016). Despite these improvements, significant gaps and challenges exist in global pandemic preparedness. Progress toward meeting the IHR has been uneven, and many countries have been unable to meet basic requirements for compliance (Fischer and Katz 2013; WHO 2014). Multiple outbreaks, notably the 2014 West Africa Ebola epidemic, have exposed gaps related to the timely detection of disease, availability of basic care, tracing of contacts, quarantine and isolation procedures, and preparedness outside the health sector, including global coordination and response mobilization (Moon and others 2015; Pathmanathan and others 2014). These gaps are especially evident in resource-limited settings and have posed challenges during relatively localized epidemics, with dire implications for what may happen during a full-fledged global pandemic. For the purposes of this chapter, an epidemic is defined as “the occurrence in a community or region of cases of an illness . . . clearly in excess of normal expectancy” (Porta 2014). A pandemic is defined as “an epidemic occurring over a very wide area, crossing international boundaries, and usually affecting a large number of people” (Porta 2014). Pandemics are, therefore, identified by their geographic scale rather than the severity of illness. For example, in contrast to annual seasonal influenza epidemics, pandemic influenza is defined as “when a new influenza virus emerges and spreads around the world, and most people do not have immunity” (WHO 2010). This chapter does not consider endemic diseases—those that are constantly present in particular localities or regions. Endemic diseases are far more common than pandemics and can have significant negative health and economic impacts, especially in low- and middle-income countries (LMICs) with weak health systems. Additionally, given the lack of historical data and extreme uncertainty regarding bioterrorism, this chapter does not specifically consider bioterrorism-related events, although bioterrorism could hypothetically lead to a pandemic. This chapter covers the following findings concerning the risks, impacts, and mitigation of pandemics as well as knowledge gaps: 

Risks

Pandemics have occurred throughout history and appear to be increasing in frequency, particularly because of the increasing emergence of viral disease from animals. Pandemic risk is driven by the combined effects of spark risk (where a pandemic is likely to arise) and spread risk (how likely it is to diffuse broadly through human populations). Some geographic regions with high spark risk, including Central and West Africa, lag behind the rest of the globe in pandemic preparedness. Probabilistic modeling and analytical tools such as exceedance probability (EP) curves are valuable for assessing pandemic risk and estimating the potential burden of pandemics. Influenza is the most likely pathogen to cause a severe pandemic. EP analysis indicates that in any given year, a 1 percent probability exists of an influenza pandemic that causes nearly 6 million pneumonia and influenza deaths or more globally.

Impacts

Pandemics can cause significant, widespread increases in morbidity and mortality and have disproportionately higher mortality impacts on LMICs. Pandemics can cause economic damage through multiple channels, including short-terfiscal shocks and longer-term negative shocks to economic growth. Individual behavioral changes, such as fear-induced aversion to workplaces and other public gathering places, are a primary cause of negative shocks to economic growth during pandemics. Some pandemic mitigation measures can cause significant social and economic disruption. In countries with weak institutions and legacies of political instability, pandemics can increase political stresses and tensions. In these contexts, outbreak response measures such as quarantines have sparked violence and tension between states and citizens. 

Mitigation

Pathogens with pandemic potential vary widely in the resources, capacities, and strategies required for mitigation. However, there are also common prerequisites for effective preparedness and response. The most cost-effective strategies for increasing pandemic preparedness, especially in resource-constrained settings, consist of investing to strengthen core public health infrastructure, including water and sanitation systems; increasing situational awareness; and rapidly extinguishing sparks that could lead to pandemics. Once a pandemic has started, a coordinated response should be implemented focusing on maintenance of situational awareness, public health messaging, reduction of transmission, and care for and treatment of the ill. Successful contingency planning and response require surge capacity—the ability to scale up the delivery of health interventions proportionately for the severity of the event, the pathogen, and the population at risk. For many poorly prepared countries, surge capacity likely will be delivered by foreign aid providers. This is a tenable strategy during localized outbreaks, but global surge capacity has limits that likely will be reached during a full-scale global pandemic as higher-capacity states focus on their own populations. Risk transfer mechanisms, such as risk pooling and sovereign-level catastrophe insurance, provide a viable option for managing pandemic risk.

Knowledge Gaps

Spending and costs specifically associated with pandemic preparedness and response efforts are poorly tracked. There is no widely accepted, consistent methodology for estimating the economic impacts of pandemics. Most data regarding the impacts of pandemics and the benefits and costs of mitigation measures come from high-income countries (HICs), leading to biases and potential blind spots regarding the risks, consequences, and optimal interventions specific to LMICs.