Preparing for the Next Pandemic — the WHO's Global Influenza Strategy

PERSPECTIVE Bracing for the Worst

different pathogens than those From the Department of Environmental tribution and establishment of the lone star Sciences (G.M.), the Center for Vector Biol- tick in Connecticut and implications for species, and alter the tickborne ogy and Zoonotic Diseases and Northeast range expansion and public health. J Med disease landscape. We believe it’s Regional Center for Excellence in Vector- Entomol 2018;55: 1561 -8. essential for practitioners and the borne Diseases (G.M., E.A.H.L., S.C.W., 3. Nelder MP, Russell CB, Clow KM, et al. K.C.S.), the Department of Entomology Occurrence and distribution of Ambylomma public to develop a heightened (E.A.H.L., K.C.S.), and the Department of americanum as determined by passive surveil awareness of the health risks as Forestry and Horticulture (S.C.W.), the Con- lance in Ontario, Canada (1999-2016). Ticks sociated with emer necticut Agricultural Experiment Station, Tick Borne Dis 2019;10:146-55. An audio interview and the Department of Epidemiology of 4. Jordan RA, Egizi A. The growing impor with Dr. Molaei is gent tick vectors such Microbial Diseases, Yale School of Public tance of lone star ticks in a Lyme disease available at NEJM.org as the lone star tick Health (G.M.) — all in New Haven, CT. endemic county: passive tick surveillance in and their potential Monmouth County, NJ, 2006-2016. PLoS One 1. Ogden NH, Radojevic M, Wu X, Duvvuri 2019;14(2):e0211778. for changing the dynamics of VR, Leighton PA, Wu J. Estimated effects of 5. Telford SR III, Buchthal J, Elias P. Early tickborne diseases in the north projected climate change on the basic repro questing by lone star tick larvae, New York eastern United States and else ductive number of the Lyme disease vector and Massachusetts, USA, 2018. Emerg Infect Ixodes scapularis. Environ Health Perspect 2014; Dis 2019;25:1592-3. where. 122:631 -8. Disclosure forms provided by the authors 2. Stafford KC III, Molaei G, Little EAH, DOI: 10.1056/NEJMp1911661

Preparing for the Next Pandemic

Preparing for the Next Pandemic — The WHO’s Global Influenza Strategy Mark Eccleston‑Turner, Ph.D., Alexandra Phelan, S.J.D., and Rebecca Katz, Ph.D., M.P.H.

ast year, the world marked arrived earlier in 2019 than in ing and responding to influenza, L100 years since the beginning the past 19 years. Australia had among them potential barriers to of the 1918 influenza pandemic. its highest number of confirmed pathogen sharing, use of influenza Over a little more than 2 years, influenza cases on record, most genetic-sequence data for vaccine the virus infected more than half of them influenza A H3N2, al development, and global response a billion people, spreading to re though it wasn’t a particularly capabilities, including medical mote parts of the globe and caus severe year in terms of the num countermeasures. Although these ing more deaths than either World ber of deaths and intensive care challenges may be addressed in War I or World War II — and admissions. Despite the common other ongoing initiatives, influ possibly more than both com belief that influenza trends in enza preparedness and response bined.1 There have been four ad the Southern Hemisphere predict strategies must be sufficiently ditional influenza pandemics in those in the Northern Hemisphere, agile for new technologies, trans the past century (the most recent there is no set pattern in the di parent for accountability, and being the 2009 H1N1 pandemic), rection of virus migration for the equitable for global health justice. although none has caused the current circulating H3N2. Rapid and comprehensive shar same scale of infection and mor Given the ongoing threat posed ing of influenza viruses among tality as the 1918 pandemic. Virol by influenza, the World Health countries, researchers, pharmaceu ogists studying influenza are clear, Organization (WHO) earlier this tical and diagnostic manufac however: another pandemic will year released its Global Influenza turers, and the WHO is vital to hit again. Strategy 2019–2030. Its goals in global pandemic preparedness. Seasonal influenza also repre clude reducing the burden of sea Virus sharing facilitates surveil sents an important yet often un sonal influenza, minimizing the lance of emerging and reemerg derestimated global health burden. risk of zoonotic influenza, and ing viruses with pandemic poten Although the annual cycle of in mitigating the effects of pandem tial, enables the development of fluenza seasons is predicable, the ic influenza. seasonal and pandemic influenza severity of a given influenza strain The new strategy is a welcome vaccines, and contributes to the and precisely when it will arrive step. However, we believe that it development of medical counter are less certain. The Southern should address several current and measures. Global pandemic re Hemisphere’s influenza season emerging challenges to prevent sponse also requires the equitable

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sharing of vaccines, diagnostics, aren’t included in the framework’s demic. However, scholars have antivirals, and data resulting from access and benefit-sharing regime, expressed concern that during a virus sharing. and the WHO’s strategy gives severe pandemic, countries with The Nagoya Protocol could com limited recognition to the cur the capacity to manufacture pan plicate the virus-sharing process, rent and potential effects of the demic influenza vaccines may re however. This agreement among use of genetic-sequence data on strict vaccine exports until domes 123 countries, which entered into influenza preparedness and re tic demand has been satisfied.5 force in 2014, aims to ensure sponse. These concerns aren’t reflected in that the benefits that arise from The strategy notes that the the strategy. To model scenarios the use of genetic resources are “underpinning principle” of the in which governments might con shared equitably. But a study pre PIP Framework is that “rapid and sider restricting exports, the WHO pared by the WHO noted con timely sharing of influenza virus could conduct robust, open simu cern that implementation of the es with human pandemic poten lations of the effectiveness of the protocol could slow or limit virus tial and genetic sequence data PIP Framework that involve vac sharing.2 Although the agreement must be pursued on an equal cine manufacturers, governments, excludes resources that are spe footing with the sharing of bene and the WHO. We believe that the cifically covered by other legal fits.” We believe, however, that WHO should develop strategies instruments — as pandemic in long-term planning for influenza for mitigating the effects of vac fluenza viruses are by the WHO’s needs to anticipate changes in vi cine-export restrictions and for Pandemic Influenza Preparedness rus sharing and the challenges distributing vaccines once com (PIP) Framework — consensus and opportunities associated with mitments are met. on the exclusion of such viruses the use of genetic-sequence data. Once a pandemic begins, a vac hasn’t been made explicit. In ad In particular, if vaccine manufac cine probably won’t be available dition, the terms of the Nagoya turers are increasingly able to rely for at least several months. Non Protocol still apply to seasonal solely on genetic-sequence data to pharmaceutical interventions will influenza viruses. The WHO’s develop products, they will no therefore be crucial, particularly strategy states that the agency is longer need to provide benefits in in developing countries that are to “provide leadership on global accordance with the PIP Frame especially vulnerable to pandemic public health matters regarding work.4 Since the adoption of the influenza. Although nonpharma the sharing of influenza data framework, 13 vaccine and anti ceutical interventions form part and viruses, including within the viral manufacturers have entered of the response outlined in the context of other international bod into agreements that the WHO strategy, the document offers little ies and agreements,” such as the has reported would provide the guidance or detail regarding these Nagoya Protocol, but no addition agency with 400 million doses methods. We believe that the WHO al details are provided regarding of pandemic influenza vaccine, should commit to providing tech how the WHO will seek to limit 10 million treatment courses of nical support for social-distancing the protocol’s effect on virus shar antiviral drugs, 250,000 diagnos measures and community-based ing and pandemic preparedness. tic kits, and 25 million syringes interventions during a pandemic. The move toward using influ in the event of a pandemic. As vac Guidance could address not only enza genetic-sequence data for cine development and manufactur the public health elements of a developing vaccines represents an ing using genetic-sequence data response but also the importance other challenge affecting influen move closer to becoming viable, of evidence- and human-rights– za preparedness and response. In both virus-sharing obligations and based approaches to nonpharma 2016, the PIP Framework review the millions of vaccine doses that ceutical interventions. group noted that genetic-sequence have been committed to the WHO Finally, the strategy misses an data could in some cases be used could be under threat. opportunity to address ongoing instead of virus samples during Access to countermeasures is at barriers to executing components pandemic risk assessment and for the heart of the WHO’s strategy, of the International Health Reg vaccine development.3 The PIP which includes objectives of ex ulations (IHR), an agreement Framework encourages all coun panding seasonal-vaccine uptake adopted in 2005 with a goal of tries to share genetic-sequence and ensuring equitable access to preventing, detecting, and respond data. But unlike pandemic influ vaccines and antiviral drugs and ing to the spread of disease with enza virus samples, such data other treatments during a pan out unnecessarily interfering with

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international travel and trade. world can be better prepared for and pathogen sharing: public health impli cations: study by the secretariat. Geneva: Under the IHR, countries are re the next influenza pandemic and World Health Organization, 2016 (https:// quired to meet certain laboratory, the ongoing burden of seasonal www.who .int/ influenza/ pip/ 2016 -review/ surveillance, notification, and re influenza. But additional chal NagoyaStudyAdvanceCopy_full.pdf). 3. Review of the Pandemic Influenza Pre porting requirements. The strat lenges will test the effectiveness paredness Framework for the sharing of in egy notes that all state parties of the strategy unless efforts are fluenza viruses and access to vaccines and were required to meet these ob made to ensure that they are also other benefits: report of the 2016 Pandemic Influenza Preparedness Framework Review ligations by 2012; however, it addressed. Group. Geneva: World Health Organization, doesn’t address the challenges Disclosure forms provided by the authors November 18, 2016 (https://www.who.int/ most countries have experienced are available at NEJM.org. influenza/pip/ 2016 -review/ADVANCE_EB140 _PIPReview.pdf). trying to fully implement the IHR. From the School of Law, University of Keele, 4. Eccleston-Turner MR. The Pandemic In Acknowledging these challenges Newcastle-under-Lyme, United Kingdom fluenza Preparedness Framework: a viable would allow the WHO to evalu (M.E.-T.); and the Center for Global Health procurement option for developing states? Med Law Int 2017;17: 227-48. ate which core capacities might Science and Security (A.P., R.K.) and the O’Neill Institute for National and Global 5. Rourke MF. Access by design, benefits if be prioritized for influenza pre Health Law (A.P.), Georgetown University, convenient: a closer look at the Pandemic paredness. Washington, DC. Influenza Preparedness Framework’s Stan dard Material Transfer Agreements. Milbank In creating its Global Influenza Q 2019;97: 91 -112. Strategy 2019–2030, the WHO has 1. Taubenberger JK, Morens DM. 1918 In fluenza: the mother of all pandemics. Emerg DOI: 10.1056/NEJMp1905224 shown the ambition and fore Infect Dis 2006;12:15-22. CopyrightPreparing for the Next Pandemic © 2019 Massachusetts Medical Society. sight required to ensure that the 2. Implementation of the Nagoya Protocol

Sir William Osler (1849–1919)

History of Medicine Sir William Osler (1849–1919) — The Uses of History and the Singular Beneficence of Medicine Charles S. Bryan, M.D., and Scott H. Podolsky, M.D.

ir William Osler died on De the 1910 Flexner Report later for gave their countries: warm feel Scember 29, 1919, at his home malizing the Hopkins model of ings of togetherness, pride, and in Oxford from hemorrhage after critical, hospital-based teaching), purpose.1 He accomplished this surgery for loculated empyema. and his attempt to keep medicine task in part by deploying medical Two days later, Richard C. Cabot informed by a sense of human history and medical biography, (1868–1939) wrote in the New York ism, even as it became ever more which in his hands often amount Evening Post: “I doubt if any single scientific. ed to hagiographic endorsements man has ever so deeply influenced Osler was many things to many of what we would today call “role any other profession.” Cabot’s was people, but his ultimate gift to models.” among the first of more than physicians was the sense of be As Osler opined in his address 400 obituaries and posthumous longing to a splendid profession on “Books and Men,” at the dedi tributes, including a five-page committed to the public interest. cation of the new building of the obituary in the Journal. Few, if any, In addresses and essays, and in Boston Medical Library in 1901, physicians have been more wide taking a celebratory approach to the “higher” education of the phy ly loved by their contemporaries. the history of medicine, Osler sician “so much needed to-day” A century later, Osler is revered nurtured the notion of the medi is best achieved through “the silent for his efforts to place clinical cal profession as a global force influence of character on charac medicine on a rational founda for human betterment. He some ter and in no way more potently tion (in part through the multi times conceptualized the profes than in the contemplation of the ple editions of his Principles and sion as an apostolic succession of lives of the great and good of the Practice of Medicine, first published cultured clinicians dating back to past, in no way more than in ‘the in 1892), his transformation of Hippocrates. He gave physicians touch divine of noble natures graduate medical education (with what certain national historians gone.’ ” A year later, in an address

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