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

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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 are available at NEJM.org. Paddock CD, Karpathy SE, Labonte AM. Dis- CopyrightBracing for the Worst © 2019 Massachusetts Medical Society. 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 2192 n engl j med 381;23 nejm.org December 5, 2019 PERSPECTIVE Preparing for the Next Pandemic 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.
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