Pandemics–history, control, and prevention

Covid-19/coronavirus, China (New York Times)
New York Times

A pandemic is defined as a disease epidemic occurring over a widespread geographic area. Whether technically a pandemic or not, the world has experienced many large outbreaks of disease–examples include the Black Death (bubonic plague) which affected Asia and Europe and peaked in the mid 1300’s to the Spanish influenza outbreak of 1918-1919 which killed an estimated 20 to 50 million people to more recent widespread outbreaks including AIDS, the Ebola virus, SARS, the H1N1 strain of influenza A, H5N1 avian influenza, the Zika virus, and others including the covid-19 coronavirus.

What does history tell us about these outbreaks, and how can communicable disease pandemics be controlled and prevented?

Quick bibliography: Articles–classic and recent–about the history, control, and prevention of disease pandemics.

Greenberger, M. (2018). Better prepare than react: Reordering public health priorities 100 years after the Spanish flu epidemic.American Journal of Public Health, 108(11), 1465-1468. [PDF]

This commentary argues that 100 years after the deadly Spanish flu, the public health emergency community’s responses to much more limited pandemics and outbreaks demonstrate a critical shortage of personnel and resources. Rather than relying on nonpharmaceutical interventions, such as quarantine, the United States must reorder its health priorities to ensure adequate preparation for a large-scale pandemic. The lethal consequences of the onset of a modern full-blown pandemic cannot be ignored. Overreliance on the reactive and blunt use of nonpharmaceutical interventions (NPIs), such as quarantine, indicate the need for a serious and commonsense reordering of our public health priorities. If we continue on our current path and fail to make changes to meet the almost certain likelihood of future critical public health needs, we may, by virtue of policy negligence, be right back where we were in 1918. Even with the medical and scientific advances made since the Spanish flu, the public health emergency community’s approach to pandemics still follows a cycle of panic–neglect–panic–neglect, and, through inadequate and slow development of countermeasures, we remain dangerously vulnerable to the threats these pandemics pose. Changing this dynamic requires greater investment in global public health preparedness and medical and scientific innovation so that personnel and scientific resources can be devoted to combating the pandemic likely to come rather than scrambling to address the pandemic already upon us. If we were to once again have a severe, nationwide pandemic such as the Spanish Flu, our public health system would be ill prepared. The 2017 to 2018 flu season, along with rising concerns about other dangerous influenza strains such as H7N9, show that the question of preparedness is not academic: The answer has real, life-or-death consequences. Even with medical progress over the past century, the United States is not now as prepared as it needs to be for present-day threats, and quarantine and isolation will likely not be sufficient to stop a true pandemic.”

Monto, A. S., & Fukuda, K. (2020). Lessons from influenza pandemics of the last 100 years.Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America, 70(5), 951-957.

“Seasonal influenza is an annual occurrence, but it is the threat of pandemics that produces universal concern. Recurring reports of avian influenza viruses severely affecting humans have served as constant reminders of the potential for another pandemic. Review of features of the 1918 influenza pandemic and subsequent ones helps in identifying areas where attention in planning is critical. Key among such issues are likely risk groups and which interventions to employ. Past pandemics have repeatedly underscored, for example, the vulnerability of groups such as pregnant women and taught other lessons valuable for future preparedness. While a fundamental difficulty in planning for the next pandemic remains their unpredictability and infrequency, this uncertainty can be mitigated, in part, by optimizing the handling of the much more predictable occurrence of seasonal influenza. Improvements in antivirals and novel vaccine formulations are critical in lessening the impact of both pandemic and seasonal influenza.”

Parmet, W. E., & Rothstein, M. A. (2018). The 1918 influenza pandemic: Lessons learned and not–introduction to the special section.American Journal of Public Health, 108(11), 1435-1436. [PDF]

The lethality of the 2018 seasonal influenza outbreak provides a terrifying hint of the catastrophic potential of a 1918-type influenza pandemic. With unprecedented severity and speed, the H1N1 influenza virus spread across the globe to virtually every part of the Earth, killing at least 50 million people. It is easy to dismiss the carnage of the pandemic that was commonly called the Spanish flu as resulting from conditions unique to its time and to assume that because of medical advances, a similar pandemic would be significantly less lethal today. Today, three of the leading threats to global public health areattitudinal: hubris, isolationism, and distrust.

Hubris–our technology remains woefully ineffective in preventing influenza. Moreover, many people [today] have limited or no access to the medical advances that we do have. In many parts of the world, hundreds of millions of people live in rampant poverty, do not have modern sanitation, endure a lack of health care infrastructure, face cultural barriers to public health interventions, and live in societies without social structures capable of responding to a public health emergency. These conditions support the rapid spread of infectious diseases.

Isolationism–some world leaders erroneously believe that they can seal off their nation’s borders after a public health threat emerges and thus escape the ravages of epidemics in other parts of the world. Public health experts universally reject this naive approach. More than ever, a public health event in any part of the world can create a public health threat everywhere. Airplane travel facilitates the rapid spread of pathogens, and even faster communication technology enables the spread of fear and misinformation. Without public health capacity building and disaster preparedness around the globe, each novel disease outbreak means “reinventing” public health policy. Often this requires balancing protecting public health with respecting civil liberties.

Distrust–in our era of political polarization, “fake news,” and tribal politics, trust in the media, government officials, and even science is fading. This can be catastrophic if an influenza or another type of pandemic arises. Under such circumstances, the public’s failure to trust the guidance offered by public health officials may well make a bad situation worse.”

Watkins, J. (2020). Preventing a covid-19 pandemic.BMJ : British Medical Journal (Online), 368, m810. [PDF]

“We need to think beyond containment. In 2009, considerable time and effort were spent on a catch, isolate, and treat approach in the early stages of the emerging pandemic, and public health teams were expending considerable energy with, as it turned out, little effect. Experience with SARS and the 2009 influenza pandemic showed that containment can buy us some time, and it has done so with covid-19. But containment in the face of a pandemic will go only so far, and we must use this time wisely. Bhatia and colleagues estimated that, although travel restrictions with China may have reduced transmissions, two thirds of all cases exported from China remain undetected. In one of the most cited research papers from the 1990s, Watts and Strogatz showed that the “small world” structure of society facilitates rapid disease propagation between distant and apparently unconnected communities, resulting in sporadic outbreaks that seem to start spontaneously, undermining even the most stringent attempts at containment. The clinical features of covid-19 are well documented, with most people displaying mild symptoms or none at all and deaths occurring mainly in elderly and chronically ill patients. This is not the public perception as played out in the media and reinforced by gunpoint quarantine. We should plan on the assumption that most of the population may contract the virus with few or no long term effects, while harnessing vital secondary healthcare resources to treat the small percentage of people who become seriously ill.”

Watts, D. J., & Strogatz, S. H. (1998). Collective dynamics of ‘small-world’ networks.Nature, 393(6684), 440-442. [PDF] [Cited by]

Networks of coupled dynamical systems have been used to model biological oscillators, Josephson junction arrays, excitable media, neural networks, spatial games, genetic control networks, and many other self-organizing systems. Ordinarily, the connection topology is assumed to be either completely regular or completely random. But many biological, technological and social networks lie somewhere between these two extremes. Here we explore simple models of networks that can be tuned through this middle ground: regular networks ‘rewired’ to introduce increasing amounts of disorder. We find that these systems can be highly clustered, like regular lattices, yet have small characteristic path lengths, like random graphs. We call them ‘small-world’ networks, by analogy with the small-world phenomenon (popularly known as six degrees of separation). The neural network of the worm Caenorhabditis elegans, the power grid of the western United States, and the collaboration graph of film actors are shown to be small-world networks. Models of dynamical systems with small-world coupling display enhanced signal-propagation speed, computational power, and synchronizability. In particular, infectious diseases spread more easily in small-world networks than in regular lattices.”

Welfare, W., & Wright, E. (2016). Planning for the unexpected: Ebola virus, zika virus, what’s next?British Journal of Hospital Medicine, 77(12), 704-707 [PDF] [Cited by]

“Since 2000 we have witnessed global pandemics and public health emergencies of international concern. This review details which viruses are likely to caused further outbreaks and looks at the strategies and tools available to UK medical professionals to mitigate the threat posed. Emerging viruses are going to be a continuing threat for a number of reasons. A growing global population and urban spread means that more people are living in closer proximity to the natural reservoirs of these viruses and each other. Greater mobility and connectivity allows these infections to spread more rapidly across the globe. As bat species are the reservoirs for a number of these viruses it would be very difficult, if not impossible, [to] eradicate the viruses from these hosts and stop the initial spillover events. Pandemics in the 21st century are predicted to wipe USD$6tn off the global economy.“

For additional research about the history, control, and prevention of disease pandemics , please see the Science Primary Literature Database.

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