Can we do better? A guide to pandemics - some Dos and Don'ts for the next one.

We read with interest the study by Aitken et al. on using the Global Health Security Index to assess a country's ability to respond to a pandemic. Although multiple national pandemic plans exist, clearly many of them (particularly in Western countries) have not worked well during the COVID-19 pandemic. Based on recent shared experiences and lessons learned from Southeast Asian countries, , we make some recommendations for a possibly more effective pandemic response.

Pandemics are defined as the global spread of an infection or disease across multiple countries and populations. As we saw with the 2003 severe acute respiratory syndrome coronavirus (SARS-CoV) outbreaks, and more recently with Ebola virus (West Africa), Middle East Respiratory Syndrome coronavirus (MERS-CoV) and Zika virus (South America), some outbreaks do not develop into true pandemics,4, 5, 6 unlike influenza A(H1N1)pdm09 and coronavirus disease 2019 (COVID-19).

So what are the main indicators for a pandemic threat of transmissible virus? These have been listed below in the form of a list of WARNING SIGNS (for policy makers, healthcare managers, clinicians):

An exponentially increasing number of cases within a district, region or whole country, with no signs of attenuation over multiple generations of infections;

An initial crude case fatality rate (CFR) of at least 5–10% (as CFRs are always higher at the beginning of a pandemic), showing potential for any illness to overwhelm local healthcare services;

Evidence for cases spreading overseas involving multiple countries in at least 3 continents (North and/or South America, Europe, Africa, Asia and/or Australasia);

Evidence for exponential increase of cases in other countries, demonstrating sustained transmission across multiple populations.

If a pandemic threat is taken seriously, then all interventions and actions need to be initiated quickly and comprehensively. If the threat turns out to be minor and localised, it is much easier to relax strict lockdowns and other interventions without significant harm to the economy, education, or psychosocial health. The following lists requirements for INTER-PANDEMIC PREPARATION (for policy makers, healthcare managers):

The rapid development of diagnostic testing capability. This capability should not be centralised, but devolved across the country's existing diagnostic laboratory network, with central support as needed. Non-conventional approaches should be explored whenever possible, to pre-empt and mitigate acute supply chain disruptions that may be associated with surges in demand.

The creation of additional capacity and resources in hospitals. These should include negative pressure isolation rooms, intensive care beds, diagnostic laboratories and infection control personnel. This should also include large-scale isolation and quarantine facilities, which can be mothballed or repurposed between pandemic threats but activated within a few days if needed.

A plan for purpose built ‘Nightingale’ hospitals and designated community isolation/quarantine facilities. These may include specific hotels adapted for quarantine, conference centres and other community facilities near hospitals, ports or airports that can accept large numbers of locally infected and/or returning travellers.

The maintenance (at least 6 months) of a stockpile of personal protective equipment (PPE). This should be sufficient to supply all hospitals and clinics, with supplies being distributed for routine use during inter-pandemic periods, prior to expiry dates.

The capacity to set up mobile and fixed-point (e.g. ‘drive-thru’) community sampling stations within a few days. Such sampling stations should be designed to be easy to set up near potentially vulnerable populations, such as areas of deprivation, prisons, high population densities, high concentration of older people and immigrant workers, etc.

Development and maintenance of a national test-track-trace team. These should be supplied with real-time data using suitable and secure mobile phone apps, security dongles, or other tracking devices, and run by local public health teams that can report back to a central command.

Supportive government funding. Substantial pandemic budget should be established to support businesses, maintain essential food supplies and other services such as water and sanitation, electricity, gas and other power sources – including WIFI, software and hardware support for home-schooling and university education during the pandemic during any national lockdowns.

Once a PANDEMIC has been declared, the above capabilities can be activated, with those below (for policy makers, healthcare managers, clinicians):

Rapid implementation of tiered, legally-enforceable social distancing, isolation and quarantine measures: including the closure of international borders, schools and universities, bars and restaurants, non-essential shopping outlets; emergency powers to initiate curfews and stay-at-home orders, and other restrictions as required. These measures should be initiated immediately once the pathogen is identified within the local population, without waiting for it to spread further.

Refocusing/repurposing of existing public health and epidemiological modelling teams: sharing real-time data and estimating important epidemiological parameters (incubation period, serial interval, basic reproductive number), applying a variety of modelling approaches to guide policy.

Refocusing/repurposing existing laboratory-based surveillance systems: including rapidly diagnostic PCR testing and viral sequencing to identify emerging variants of potential clinical and public health impact, which will also inform and aid appropriate infection control measures.

Refocusing/repurposing of existing anti-microbial therapies and vaccine development programmes: using existing basic and clinical trial research infrastructure already in place to deal with other disease-related therapies, with dedicated government funding and support.

Clear and concise messaging to the public from the government throughout the pandemic: allowing people to plan their livelihoods during any pandemic restrictions. Expert committees, including virologists, epidemiologists, clinicians, public health and infection control members, should be set-up to inform and review government public messaging and decision-making – including the combating of ‘fake information’.

The above list leads us onto a list of WHAT NOT TO DO when preparing for or when dealing with a current pandemic (for policy makers):

Do not underfund inter-pandemic preparedness.

Do not underestimate the threat.

Do not underfund intra-pandemic resourcing.

Do not delay population level interventions.

Do not relax the interventions too early.

Do not underfund, downgrade, close or centralise diagnostic laboratories.

This guide is not intended to be comprehensive or prescriptive, but highlights important points for future pandemic planning. Funding and resource allocation to support these pandemic-related activities will be decided by individual jurisdictions, depending on available resources and priorities.