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Marion Koopmans: greater regional capacity to fight disease outbreaks Marion Koopmans tells Fiona Fleck why the world needs a publicly-funded network of hubs in all regions with local experts able to respond to infectious disease threats as they emerge.

Q: What is an emerging infectious dis- ease or pathogen and why are these Virologist Marion Koopmans has devoted the last three important for public health today? How decades to responding to human and animal disease did you become interested in researching outbreaks. She is the director of the department of these diseases? Viroscience at Erasmus University Medical Center in A: An emerging disease or patho- Rotterdam, the , where she also heads a gen is a disease that is new, or has been World Health Organization (WHO) collaborating centre detected in a new region or with mani- for emerging viral diseases. She is a WHO advisor on festations that differ from what was previ- foodborne diseases and emerging disease outbreaks. ously recognized. I’ve been investigating Courtesy of Marion Koopmans outbreaks for much of my career, but I Marion Koopmans Koopmans is a member of the Scientific Advisory Group first experienced the major public health of the WHO Blueprint Initiative, head of the national impact of an emerging infectious diseases reference centre for high threat viral pathogens for the European Commission outbreak in 2003, when we had a large and coordinates the global Noronet collaboration. She graduated in veterinary avian influenza (A) H7N7 outbreak in medicine in 1976 (bachelor’s degree), in 1979 (doctoral degree) and in 1990 the Netherlands and I was responsible (PhD) from Utrecht State University. for national laboratory preparedness and response. I realized how fast such events can develop, the difficulty of working with an unknown disease and the chal- reasonably funded networks and labo- That avoids the need for “flying laborato- lenge of ensuring a coordinated response ratories with defined roles and responsi- ries” and, of course, this requires reliable between veterinary and public health bilities for vaccine-preventable diseases, and long-term funding for the whole experts. We thought we were prepared, foodborne diseases, some blood-borne network. Some government and other but it was not easy. Since then, I found diseases and, increasingly, antimicrobial health funders have realized this need similar challenges in the responses to resistance. However, they are not set up and have recently set up a new funding the severe acute respiratory syndrome for general emerging disease prepared- mechanism to develop vaccines for pri- (SARS) outbreak in 2003, a Marburg ness and response. Our disease–specific ority emerging infectious diseases: the importation in 2008, other avian response is unsustainable and unneces- Coalition for Epidemic Preparedness influenza virus outbreaks when the influ- sary. A public health laboratory should Innovations (CEPI). We need something enza (A) H5N1 started to spread be able to detect many diseases with similar for generic preparedness. from China, and in the responses to Ebola the resources and manpower currently virus disease, Middle East Respiratory used for one disease, in collaboration Syndrome (MERS) and Zika. with animal and environmental health A public health experts – this is known as the One laboratory should be able Q: How were you involved in these Health approach. This generic model “ outbreaks? should be our goal. My view – and that of to detect many diseases A: When these outbreaks occurred, many of my colleagues – is that we need with the resources and laboratories in the Netherlands had to be a publicly-funded network of expert manpower they currently ready to test suspected cases. During the centres in all regions that work together use for one disease. SARS outbreak, I was involved in risk as- on a routine basis, not just when there sessments of the potential for foodborne is an outbreak, each working on many ” transmission. Regarding MERS and emerging infectious diseases. Zika, I was – and still am – involved in research with colleagues in the affected Q: Doesn’t the Global Outbreak Alert Q: During the SARS outbreak in 2003, countries. During the 2014–16 Ebola and Response Network (GOARN) do this? scientists agreed to share their findings, outbreak, the Netherlands donated three A: GOARN mobilizes experts from in particularly the genetic sequences of mobile laboratories to and Sierra its network of institutions and labora- the pathogen, leading to its identifica- Leone, which were deployed and staffed tories around the world to respond to tion. Is this a model that should be widely by our medical centre. outbreaks in other countries. But this replicated? mechanism wrongly assumes that con- A: The sharing of data for SARS was Q: What are the public health challenges tributing laboratories have funding for great and allowed scientists to identify posed by emerging infectious diseases? this response and lack only the means the pathogen causing SARS. Yet in re- A: The main challenge is the frag- to invest in long-term capacity build- ality this data sharing was limited to a mented way in which we do surveil- ing. The ultimate goal should be to have small group of scientists and WHO, until lance and respond to outbreaks of these sufficient regional capacity and links to their findings were published. At that diseases. We have well-established and centres of expertise around the world. time I was heading the emerging disease

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laboratory response in the Netherlands Q: You have been involved in the WHO response will always be a low priority and we did not have access to the infor- R&D Blueprint project, can you tell what when there are so many more diseases mation we needed to do diagnostic tests this is? to deal with every day. This dilemma for SARS, for example, for travellers. A: The R&D Blueprint project set is not limited to low-income settings. Research and the public health response out to evaluate what went wrong with Clinicians and public health institutes need to be more closely linked as, for recent outbreak responses, and how across the world face the challenge of example, the EVD-LabNet in Europe these should be done in future and to working with limited budgets, shift- for emerging viruses and laboratory push for concrete action. The project’s ing the emphasis to chronic diseases preparedness, in which data is shared priority list of about 10 emerging (often from the same budget), and the promptly. There are similar regional pathogens and the CEPI initiative to growing costs of health care due to the networks in other parts of the world. start developing vaccines for some pri- ageing population. WHO relies on many ority diseases are good examples of such partners for the outbreak response, but Q: How can scientists be incentivized to action. However, it is important to keep does not have a mechanism to fund act in the interests of public health? up the momentum, particularly for those response activities. That situation A: Many scientists are interested in the practical side of preparedness and may have been acceptable in the past, public health, but may not be familiar response. Global health security is as but not for today’s emerging infectious with how the public health sector works. weak as the weakest links in the chain, diseases which require a more consistent The question of incentives is more com- so how do we build global disease pre- approach. plex than public health versus academia. paredness and response capacity that There is no single solution, but several combines diagnostic preparedness Q: WHO was accused of scaremonger- potential solutions. These include data with the ability to support outbreak ing during the A (H1N1) 2009 influenza sharing platforms that work within a research? Currently, the development pandemic, as the illness turned out to code of conduct and that facilitate the of laboratory capacity is a local or be mild and case fatality was lower than sharing and use of data among a range national responsibility. So here, again, expected. During the 2014–16 Ebola of stakeholders for public health action, the plea for a global, publicly-funded outbreak, WHO was accused of failing while retaining the right to publication network of emerging infectious disease to pay enough attention. How do you or set out rules for use by the private preparedness and response hubs. Such decide which emerging infectious patho- sector. An example of such rules is that a project needs dedicated staff, equip- gens and outbreaks present a major risk sharing needs to be immediate in the ment, facilities, data-sharing systems for humans and merit action, without case of a public health emergency. We prepared during “peace time”, so that scaremongering? are working on such a platform through they can be deployed during outbreaks. A: It’s easy to judge events with a collaborative group in Europe called Given that many new diseases arise hindsight. In 2009, the initial reports Compare. from our interaction with animals, a from Mexico were of great concern and significant part of this network should it was difficult to assess the risk because Q: Indonesia refused to share data on be dedicated to regionally dispersed there is no globally agreed way of assess- A (H5N1) influenza virus arguing that One Health centres of excellence. This ing severity during early stages of an its population would not benefit from project may seem expensive, but is not outbreak unless you do a series of stud- new, expensive vaccines produced using when compared to the economic costs ies. Fortunately, the pandemic turned their data. What is needed to incentiv- of recent major outbreaks. out to be milder than all the worst-case ize countries to share their data with scenarios. But while a situation is evolv- the international community to come ing, you still have to decide on vaccine up with shared solutions to emerging development for all scenarios. This was Global health pathogens? a global pandemic, so that assessment A: Withholding data is not the security“ is as weak as was right, although the severity predic- way forward, but the Indonesians had the weakest links in the tion was wrong. a point regarding affordability. On the chain. other hand, we need private sector Q: What is your view on the Global Virome expertise to bring vaccines, diagnostics ” Project to identify all potentially new and and therapeutics to the market, if their emerging viruses in the natural world? economic interests are not protected, A: This is an interesting research they may not be interested. So a middle Q: The 2014–16 West African Ebola project, but I am sceptical about the ground needs to be found. The current outbreak, which was not recognized claims made by some scientists that emphasis on access and benefit sharing, for months after the first cases, in- all emerging viruses can eventually be as envisaged by the Nagoya Protocol curred huge economic costs. How discovered. Virome studies are increas- on Access to Genetic Resources is a step can least-developed countries with ingly popular and reveal that we are far forward. This agreement makes national a weak infrastructure be expected to from understanding the full spectrum of authorities, not individual scientists or do the surveillance needed to detect viral diversity. That said, I do believe in institutions, responsible for deciding outbreaks? Is implementation of the the power of metagenomic sequencing what is shared and what is not shared. International Health Regulations (IHR) and other new technologies, preferably But not all countries are signed up to it the solution? when these activities are integrated into and the Nagoya protocol was not devel- A: IHR implementation is part the network that I would like to see oped with infectious diseases in mind. of the solution, but preparedness and develop. ■

Bull World Health Organ 2018;96:84–85| doi: http://dx.doi.org/10.2471/BLT.18.030218 85 News

86 Bull World Health Organ 2018;96:84–85| doi: http://dx.doi.org/10.2471/BLT.18.030218