Envisioning a World Without Emerging Disease Outbreaks

Feature Envisioning a World without Emerging Disease Outbreaks

by Catherine Machalaba and William B. Karesh

UNMEER An Ebola treatment unit in Freetown, Sierra Leone.

In Brief Recent outbreaks of emerging infectious diseases (EIDs) have seemingly appeared without warning and have resulted in resource-intensive responses. With our current public health systems largely emphasizing reactive approaches without a lens to ecological links and anthropogenic pressures causing their appearance, new approaches are urgently needed. In the short- term, systems can look toward strengthening capacity for surveillance of infectious disease in human populations, including more rapid and precise detection of cases, effective reporting channels, and collection of samples to document pathogen evolution and guide vaccine or other potential therapeutic development to yield greater infrastructure for early detection of and efficient response to outbreaks. As a long-term goal, public health systems can include paired human-wildlife surveillance and utilize sentinel monitoring toward pre-emption of spillover in humans. While these approaches will require upfront investments, cost-savings can be seen from more integrated and more preventive approaches that can benefit both human and animal health. To support these operational advancements, governance structures are needed that enable a ‘One Health’ approach that proactively considers connections between human, animal, and environmental health across disciplines.

www.thesolutionsjournal.org | March-April 2015 | Solutions | 63 uman outbreaks of emerging Where to Start: Our Current appearance in North America through infectious diseases (EIDs) Public Health Systems the investigation of avian die-offs.3 may be relatively rare com- Preventing outbreaks of EIDs, such as Similarly, despite no prior outbreaks of H what pared to widely established diseases, but Ebola, requires knowledge of the Ebola in West Africa, a paper published as the Ebola outbreak in West Africa has risks are through routine surveillance during the current outbreak reported demonstrated, they can be catastrophic that detects new or evolving threats that Ebola virus antibodies had been to societies. They can also be vastly in a timely and actionable way. circulating in humans in Sierra Leone expensive. For example, the 2003 Severe from 2006 to 2008.4 There is an urgent Acute Respiratory Syndrome (SARS) need to collect this type of information outbreak, which caused fewer than Key Concepts systematically and in a timely fashion, 900 deaths, cost the global economy an and to convey research to government 1 estimated US $30 billion to $50 billion. • Current public health surveillance and other public health authorities. Ebola, SARS, and other EID outbreaks systems are highly reactive, Additionally, undiagnosed illnesses have seemingly appeared without warn- targeting control in humans rather (including viral hemorrhagic fevers) in than prevention of outbreaks at ing. An international spread of people their source. The Ebola crisis in many parts of the world compromise and goods, including wildlife trade, may West Africa highlights the need for knowledge on true incidence of be increasing their frequency and extent, strengthened global health capacity, disease, as well as potentially novel including a more coordinated, 5 or at least, detection and attention may proactive approach to EIDs. outbreaks. Imprecise or missing be increasing. During the Ebola outbreak diagnoses are largely a result of in West Africa, there was a concurrent • Conservation research has inadequate screening capacity, taxed (unrelated) outbreak in the Democratic yielded key information about healthcare systems, or resource ineq- Republic of the Congo (DRC), a case of EIDs, especially Ebola. Integrating uity. Infrastructure for detection and pathogen surveillance of wildlife into Marburg virus in Uganda, additional routine disease monitoring systems diagnosis are critical for identifying deaths from Middle Eastern Respiratory can provide information on pathogens and initiating proactive responses Syndrome (MERS) in Saudi Arabia, and circulating before humans are to disease risks.6 Boosting screening infected. the highly pathogenic avian influenza efforts for known pathogens and

H7N9 in China. The world was lucky • A One Health approach considering identifying causes of undiagnosed that SARS was controlled and has not human-animal-environment illnesses in human populations can be since reappeared in humans, although a connections provides a more robust implemented in the current system to recent study has found its causal virus in understanding of the dynamics more precisely identify current risks to leading to zoonotic disease 2 bats in China. The emergence of MERS threats, including the underlying populations on a local level. in 2012 continues to yield new human anthropogenic causes that facilitate At least some level of ongoing sur- cases, but the transmission pathway is disease emergence. veillance should encompass continued still not definitively known. The diffi- strain analysis to detect pathogen • Government ministries, IGOs and culty of anticipating EIDs is a symptom other sectors can maximize health evolution. Research opportunities are of the public health system’s emphasis system investments through cross- not always salvaged during outbreaks on response rather than prediction and disciplinary information sharing and in favor of response measures, but prevention. This status quo in public collaboration on surveillance and could provide crucial information. preparedness and response planning. health leaves us unequipped to address Public health surveillance can provide emerging disease threats. • Requiring health impact assessments samples from infected patients to be Genuine changes in the public before development project approval available rapidly for whole genome health system are needed to boost can help anticipate disease risks to sequencing that can detect specific allow for prevention or mitigation 7 surveillance efforts and to build measures. changes in a virus, as well as provide capacity to respond to early detection genetic material for vaccine develop- of disease risks through a ‘One Health’ ment or other therapeutics. approach. In doing so, innovative At present, most public health systems investments should be made to ensure have limited capacity for detecting Future Opportunities for environmental, financial, and capacity diseases that are known, but have not Public Health Systems sustainability. Enhanced understand- yet been seen before in a location. For More challenging is the detection of ing of EID risks and mechanisms for example, the precise cause of unusual zoonotic pathogens in other species detection can also provide benefit and encephalitis cases in humans in 1999 before they appear in humans so lessons for addressing related threats, was only identified as West Nile that outbreak prevention or early such as bioterrorism. virus after the first detection of its detection may occur. Pathogen

64 | Solutions | March-April 2015 | www.thesolutionsjournal.org NIAID An Ebola virus particle. Although there have been no prior outbreaks of Ebola in West Africa, a paper published during the current outbreak reported that Ebola virus antibodies had been circulating in humans in Sierra Leone from 2006 to 2008. surveillance of wildlife is not significantly in decades, despite surveillance, and also a testament to currently routinely conducted even the global burden of HIV/AIDS, its potential benefits. For example, as part of government activities, which emerged from non-human the limited knowledge available on despite over half of known human primates.10 Screening of wildlife the animal source of Ebola has been pathogens originating from animals for known and yet undiscovered largely generated by the conservation and approximately three-quarters pathogens would complement community through wildlife health of recent EIDs stemming from human health and veterinary health assessments and investigations of wildlife.8,9 Recent developments in surveillance activities. The relatively mortality in wildlife. Ebola has been diagnostic technology have enabled high risk of pathogen transmission recognized as causing severe declines sample screening for novel pathogen from bats, rodents, and non-human in great ape populations—especially discovery, and thus expanded public primates offers a starting point.11 the critically endangered wild lowland health horizons. However, on-the- Efforts from the conservation gorillas—and thus is a threat to ground capacity for the detection and community provide a platform conservation of biodiversity, as well as prevention of EIDs has not improved for implementing wildlife disease to human populations.12,13 Pathogen

www.thesolutionsjournal.org | March-April 2015 | Solutions | 65 surveillance suggests that some bat From 2009 to 2014, the United Mortality Monitoring Program in species are the natural reservoir for States Agency for International Uganda, with park rangers submit- the virus, harboring it without signs of Development Emerging Pandemic ting reports of animal morbidity or disease. Investigations of wild animal Threats PREDICT program imple- carcasses via a mobile phone-based carcasses have detected infection and mented pathogen surveillance template. Trained responders can mortality in chimpanzees, gorillas, programs in 20 developing nations follow up on reports to collect and duiker antelopes, and evidence that were considered ‘hotspots’ for dis- specimens as needed, allowing col- from human outbreaks suggests that ease emergence. It generated protocols lection of information that benefits they have served as brief intermedi- for sampling and screening for 25 viral the conservation of wild species, ate hosts for human infection when families at high-risk interfaces (such and potentially informs assessment hunted or handled.14,15,16 The 2014 DRC as hunting and wildlife markets), and of public health risks. This activity outbreak and prior Ebola outbreaks worked with local partners to create is not resource intensive, allows for elsewhere have also been linked to the a system for sharing findings across targeted data collection within the hunting or handling of wild animals human health, agriculture, and envi- workflow of park officials, and can (with subsequent human to human ronment or forestry ministries.23 These provide rapid access to information transmission). approaches can serve as best practices from remote areas. Wildlife may thus provide sentinel value. While Ebola virus outbreaks in humans are typically seemingly sporadic, information Screening of wildlife for known and yet undiscovered generated from recent surveillance studies in Gabon and the Republic of pathogens would complement human health and Congo suggest that surveillance for veterinary health surveillance activities. the Ebola virus circulating in wildlife may enable early detection or prevention of outbreaks in humans.17,18 Testing of great ape fecal samples for continuation and for implementa- Costs and Benefits for traces of the virus may provide a tion in additional countries. Recent response costs for EIDs have cost effective public health surveil- The benefits seen from the few exist- totaled in the hundreds of billions lance method, while simultaneously ing pathogen surveillance programs of USD over the past two decades.26 providing data that could benefit have been encouraging. For example, Ebola’s persistence for more than 15 conservation strategies.19 the 2014 Ebola outbreak in the DRC, months in humans in West Africa has Such information can yield public where there is in-country capacity for been massively disruptive to trade net- health action. To manage and reduce viral screening of known and novel works, tourism, and the capacity for risks from Ebola virus transmission viruses, led to early detection and treatment of other diseases. A prelimi- from one species to another (patho- containment of the outbreak through nary assessment by the World Bank gen ‘spillover’), reporting of deceased swift and thorough science-based action estimated short- and mid-term losses or sick animal sightings by hunters by the government and its partners. through 2015 of up to US $32 billion if and foresters can provide important The ultimate aim should be to get far Ebola spread from Guinea, Liberia, and sentinel or early warning benefits enough ahead of viruses to prevent Sierra Leone to neighboring nations.27 for public health and conservation their emergence in humans, but DRC’s Ebola-related disruption could result monitoring.20,21 This allows for example shows that effective surveil- in much higher actual long-term costs preventive actions prior to transmis- lance systems can provide benefits for from hits to other medical condition sion of Ebola to humans. Educating early detection and control. campaigns, such as vaccination for people living in areas where Ebola Leveraging global mobile phone preventable diseases and treatment of occurs about how they can avoid the infrastructures can promote the malaria and HIV, educational attain- disease from both wildlife and ani- efficient communication of health ment from school closures, declining mals can prevent deadly outbreaks. information.24 Mobile reporting is trade and travel, and perceived ongo- Reducing hunting and other contact not only useful for tracking human ing risks for business investments. with infected non-human primates cases of disease, but also for reporting Implementing enhanced disease may especially reduce contact oppor- disease in animals.25 For example, surveillance in humans and pathogen tunities that can result in human partners under the PREDICT program surveillance in wildlife will also have outbreaks.22 rolled out an Animal Morbidity and a price tag, but warrants cost-benefit

66 | Solutions | March-April 2015 | www.thesolutionsjournal.org UNMEER Temperatures are monitored as spectators enter a stadium in Mali in January 2015. Boosting screening efforts for ongoing, rather than merely reactionary, surveillance of diseases could improve early detection and response. considerations for investments. A addressing the human-animal inter- ‘roller coaster’ funding cycles that study based on viral screening findings face, and cross-disciplinary control and occur in response to each new EID in one bat species from a surveillance prevention approaches. threat. Donor engagement is crucial program estimates that 85 percent A challenge remains in paying for to meet this goal, since funding of mammalian viral diversity could this global good. Ideally, budgeting for streams and investments themselves be captured through investments wildlife disease surveillance would are often siloed. Investments must of approximately US $1.4 billion be implemented through national ensure a solid foundation upon over 10 years, or approximately 100 health ministries in partnership which to build capacity, with realistic percent through investments of US with animal health and environment attention to the basic needs of a $6.3 billion.28 This information would ministries, to promote cross-sector functioning system. For example, potentially provide value for assess- sharing of results, and to demonstrate specimen storage and timely diag- ing and prioritizing zoonotic disease the sentinel and preventive value of nostics may not be practical when a risks. A recent analysis suggests that this information for human health. laboratory’s power is intermittent. As implementing interventions now to The information generated through of the end of August 2014, a high level mitigate emerging zoonotic disease surveillance findings may also inform of Ebola treatment facilities and inter- risks, compared to response policies, on practices that present EID risks, vention strategies (e.g., safe burial would yield a cost saving of more than providing opportunities for future cost access) in West Africa were reported US $340 billion over the next cen- shifting. as only partially functioning, and tury.29 The assessment was based on Importantly, addressing EID risks the course of upkeep of facilities mitigation policies including building requires sustained investments to post-outbreak for future outbreaks or capacity for surveillance and diagnos- build One Health systems, which other healthcare needs is unknown. tics to prevent new emerging diseases, cannot be achieved through the Innovative approaches may be

www.thesolutionsjournal.org | March-April 2015 | Solutions | 67 sought when increasing structural from diseases, such as measles and One Health Governance capacity, for example, at the 2014 UN pneumonia, acquired from humans Despite the existence of strong wildlife Climate Change Summit, the WHO’s through ecotourism and research. health and zoonotic disease expertise, Director General, Dr. Margaret Chan, The direct collaboration between current policy structures do not suggested developing solar power human, domestic animal, and wildlife provide formal governance around infrastructure to equip the 40 percent health experts can have synergies wildlife diseases nor a mechanism for of hospital facilities in parts of Africa in disease understanding, detection, integrated human-animal-ecosystem that lack access to reliable power. and control for humans, livestock, approaches. Although the World and conservation not yet seen from Organisation for Animal Health (OIE) A ‘One Health’ Approach currently siloed approaches. These stipulates requirements for certain Looking to the source of new potential collaborative approaches can also diseases in relation to international EIDs can help move towards a ‘One be applied to address other health trade in animals, the movement of Health’ perspective that can elucidate concerns, such as vector-borne and most wildlife is not covered beyond connections between humans, ecotoxicology threats. the officially listed diseases, nor is animals, and ecosystem health. The One Health approach recognizes the integral health links and dependencies among different species, as well as The nature of ecology-health connections and dynamics the ecological dynamics that provide protection from or introduce risk of lends itself to a holistic, broader, and integrated approach pathogen transmission. By taking into for cross-disciplinary collaboration, co-investments and account information from multiple disciplines, we would gain a fuller co-benefits. understanding of disease ecology that would allow us to better monitor risks and intervene earlier.30 Where available, archived or Development of One Health wildlife disease reporting required on prospective clinical specimens from capacity for EID prevention requires non-listed diseases. OIE’s recent devel- paired human-animal surveillance understanding and addressing the opment of a voluntary wildlife disease can be screened to inform on patho- underlying drivers of disease emer- reporting system (WAHIS-Wild) is gen spillover dynamics. One unique gence. Wide-scale land use change, a step in the right direction to help opportunity for paired sampling and intensified food production, trade monitor wildlife diseases, but incen- consideration of human-animal- and travel, climate change, and other tives are needed to encourage wildlife environment links is via One Health pressures on the environment to disease surveillance and reporting. clinics. A One Health clinic in Bwindi, meet increasing societal demands are Similarly, the World Health Uganda, on the border of the Bwindi resulting in significant changes in eco- Organization’s (WHO) focus has Impenetrable Forest, was developed logical dynamics that place people and limited attention to animal diseases, in the community hospital. Given the animals in novel contact, and facilitate despite the zoonotic origin of many proximity to the forest, the commu- pathogen transmission.31,32 Rather priority human diseases. The WHO’s nity has close contact with and direct than viewing disease transmission as International Health Regulation (IHR) dependency on the local environment isolated random events, the impact can be formally expanded to more fully for the provisioning of resources, of ecological changes on disease risks incorporate animal health consider- including food and tourism. At can be quantified and risks prioritized. ations through emphasis on the role of the same time, the introduction of Risk analysis infrastructure can also be veterinary services and environmental domestic (e.g., pet or feral dogs or developed within economic planning authorities as allies and participants in cats) or agricultural species (live- sectors to ensure risks are anticipated the public health system. The IHR can stock, e.g., cattle, goats, sheep, swine) and mitigated. While development also emphasize the need to move from in a new location, some that may and uptake of voluntary guidelines reactive to proactive public health become invasive, may introduce new should be encouraged directly with risk assessment and interventions, pathogens and transmission dynam- corporate and other development and the importance and responsibility ics. Similarly, wildlife in the region, stakeholders, compliance across indus- of numerous sectors in moving this including highly threatened gorilla tries will likely require mandates from forward. For example, investment and populations, have suffered declines policy makers. approval policies can be enacted to

68 | Solutions | March-April 2015 | www.thesolutionsjournal.org John Atherton This photo from 1968 Sierra Leone shows children displaying freshly caught bats. Pathogen surveillance suggests that some bat species harbor the Ebola virus. Bats are a traditional source of food for many West African cultures, which could in part explain the link to human infection. require upfront health impact assess- investments that effectively span the on Biodiversity and Human health, ments for proposed extractive industry three sectors. At the UN Convention and engaging experts to establish best projects, and detection of risks can on Biological Diversity’s (CBD) Twelfth practice guidance for CBD Parties. inform mitigation strategies that can Conference of the Parties in October Implementation opportunities also be integrated into planning (such as 2014, CBD parties officially agreed to abound at the national level for requiring projects that place employees recognize the value of a One Health CBD Parties. CBD delegates, who are in forests to provide safe food sources approach, acknowledging the shared often based out of the environment in order to reduce demand on wildlife drivers of biodiversity loss and disease ministry, can form inter-ministry One for nutrition). emergence, and the urgent need for Health networks and task forces to To date, much of the push for an the world to address EIDs in light of promote discussion about zoonotic ecosystem perspective to promote the Ebola outbreak. The CBD can lead disease risks, and to identify a country health has come from the conservation meaningful engagement with the context-specific roadmap for zoonoses world. This is remarkable, given the public health sector by identifying prevention. These long-term plans can relatively limited investments in con- priority areas for collaboration, and inform investment requests and reduce servation versus veterinary and human by driving a research agenda through duplication of efforts by working in a medicine, and shows the potential of the CBD-WHO Joint Work Program cross-disciplinary and synergistic way.

www.thesolutionsjournal.org | March-April 2015 | Solutions | 69 The integrated policy approaches Most transmission has been focused is one of many zoonotic EIDs that needed for EID prevention could in Guinea, Liberia and Sierra Leone, present a risk to humanity, and their be prioritized through the pending but cases have spread thousands of impact may increase as we continue UN Sustainable Development Goals miles via international travel. Ending to fundamentally change our planet’s (SDGs). The current iteration of the the current outbreak has seen signs ecology and transmission dynamics. SDGs does not sufficiently capture of progress in Guinea and Liberia Getting ahead of EIDs requires urgent the complementarity and efficiencies through successful control measures upstream and systematic solutions that can be leveraged to maximize to reduce transmission and perhaps that realize the potential of our con- resources and outcomes. The nature through natural development of nected society, recognize integral of ecology-health connections and protective immunity. human-animal-environmental links, dynamics lends itself to a holistic, Response efforts have involved and promote sustainable and healthy broader, and integrated approach healthcare and public health provid- development. for cross-disciplinary collaboration, ers, military forces, and financial co-investments, and co-benefits. investments from around the world. For example, conducting paired Despite global concern, the situation Acknowledgments environment, health, and social has demonstrated major challenges The authors thank Marc Levy, Isabelle- risk assessments before approval in detection, reporting, and resource Anne Bisson, and Naomi Stewart for of development projects and ensur- mobilization, and widespread deficits their constructive reviews, which ing that results inform preventive in capacity and baseline knowledge of improved this paper. We are also or mitigative actions, may more Ebola virology. Its trajectory provides grateful for the generous support of effectively promote environmental insight on solutions to help prevent, the DIVERSITAS-Future Earth eco- sustainability, reduce disease threats, and more effectively respond to emerg- HEALTH project. and protect vulnerable populations ing diseases in the future. from worsening inequities. The first known human case in References Lastly, while international policy the current outbreak was traced back 1. The World Bank. People, Pathogens and Our Planet. and donor engagement are crucial to December 2013 in Guinea, but The Economics of One Health Volume 2 (2012). 2. Ge, XY et al. 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70 | Solutions | March-April 2015 | www.thesolutionsjournal.org UNMEER Traditional leaders in Sierra Leone meet in Freetown to discuss the Ebola response in October 2014. Local leaders with strong cultural awareness are integral to public health solutions.

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