100 Years after the Spanish Flu: Lessons Learned and Challenges for the Future

By Kelly M. Pyrek

Even with the 2017-2018 influenza season -- a high severity, H3N2-predominant season -- behind us, fall brings new anticipation of the next bout with an old foe. This year marks the 100th anniversary of the 1918 Spanish influenza pandemic, an event that experts have called the worst acute infectious disease outbreak in modern history. This pandemic, triggered by influenza virus H1N1 killed an estimated 20 million to 50 million people, with a high mortality in young adults aged between 20 and 40 years. A war-ravaged population was further decimated by this pathogen.  

As Sands, et al. (2016) reminds us, "Pandemics and epidemics have ravaged human societies throughout history. The plague, cholera, and smallpox killed tens of millions of people and destroyed civilizations. In the past 100 years, the Spanish flu of 1918-1919 and HIV/AIDS caused the deaths of nearly 100 million people. Advances in medicine have transformed our defenses against the threat of infectious disease. Better hygiene, antibiotics, diagnostics, and vaccines have given us far more effective tools for preventing and responding to outbreaks. Yet the severe acute respiratory syndrome (SARS), the Middle East respiratory syndrome (MERS), and the recent West African Ebola outbreak show that we cannot be complacent. Infectious-disease outbreaks that turn into epidemics and potential pandemics can cause massive loss of life and huge economic disruption. Indeed, Ebola demonstrated how ill-prepared we are for such infectious-disease crises. There were failures at almost every level. Identifying the outbreak in the community and raising alerts took too long. Local health systems were quickly overwhelmed. Response teams did not adequately engage communities and deepened distrust in health authorities. The international response was slow, cumbersome, and poorly coordinated. Rapid diagnostics, protective equipment, effective therapeutics, and a vaccine were lacking. Ultimately, the crisis was contained, thanks to the courage and commitment of medical staff and communities on the ground and a massive deployment of international resources. Yet the cost in human lives and economic and social disruption was far greater than it should have been."

Barclay and Openshaw (2018) point to 1918 as a lesson not soon forgotten: " A century ago, as the First World War drew to an end, Spanish influenza brought terror to an already shell-shocked world. Industrialized warfare had caused the loss of many young lives and there must have been a sense that things couldn't get any worse. And yet they did: a virus unlike any other in recent memory unleashed itself onto a weakened and highly mobile population, causing more than 50 million additional deaths. Now is a good time to reflect on this tragic episode and to apply knowledge gained from a century of progress to understand how it happened and to consider whether it could happen again. What do we know about the 1918 virus, where it came from and why the outbreak it caused was so devastating? Was the severity of the pandemic attributable to the susceptibility of the human population after four years of wartime stress, to other factors (such as co-infecting bacteria), or was the particular virus that emerged endowed with an unusual highly pathogenic phenotype?"

They add, "Understanding the exceptional impact of the 1918 influenza pandemic, including the immunological explanations for the atypical age-related sensitivity to virus infection, might have important implications for dealing with future influenza pandemics: at a time when the world is calling for new approaches to influenza vaccination, we are embarking on novel vaccination strategies that induce quite different arms of the immune response to those engaged by traditional vaccines or natural immune responses. It is important that we consider the possible immunological ramifications of these innovations on the outcome of infection by contemporary and future influenza viruses."

An editorial in The Lancet Infectious Diseases (2018) asks us to consider what we have learned from being unprepared: "Why the 1918 pandemic was so severe is still a matter of debate, but immunological factors and secondary bacterial infections were major contributors to the heavy death toll. Other influenza pandemics, albeit less severe, have then occurred in 1957, 1968, and 2009, so a new one appears inevitable at some point in the future. Thus, on the centenary of the 1918 pandemic, it is timely to ask ourselves whether the world would be prepared now for such an event. The answer sadly is no: we do not know what virus will cause the next pandemic, there is no way to rapidly develop and deploy an effective vaccine against a pandemic virus, differences in quality of health systems hamper a prompt response, and surveillance data on influenza have major gaps."

"We are probably a plane ride away from a major threat in the U.S.," says Keith Kaye, MD, MPH, president of the Society for Healthcare Epidemiology of America (SHEA) and professor of internal medicine and infectious diseases at the University of Michigan. "That sounds overly dramatic but it's true. One positive development that I have seen related to preparedness -- fueled by Ebola and conjointly with recognition of antimicrobial resistance and the CRE threat -- is a greater regional effort through with joint hospital and public health partnerships. I've noticed many more joint initiatives around either preparedness for pandemics or emerging infections as well as for more commonly encountered resistant organisms like CRE or Acinetobacter or even MRSA and VRE. One advantage that we have compared to five years ago, is stronger collegiality and cohesiveness between public health and healthcare, which puts us in a much better position to combat pathogens such as Ebola or SARS." 

Kaye continues, "With greater familiarity between these two entities comes more constructive work and improved communication; if you know the people in your local public health department, you are much more likely to pick up the phone and call them as opposed to not knowing them. Some hospitals now have experience with dealing with anxiety-provoking, relatively unknown or unusual foe like Ebola, so this is not brand new to them. We must ask ourselves, what percentage of hospitals could care for and manage a patient with an infectious disease such as Ebola virus infection safely for 48 hours -- that's where efforts must move toward as opposed to every hospital being expected to be able to care for Ebola patients endlessly. It's critical for regional centers to be able to recognize and manage patients with an emerging or re-emerging pathogen. Some hospitals have invested in preparedness and continue to conduct drills and continue to prepare; in many cases, there aren't enough resources or that focus, so I think in many settings, while we are better prepared, there is more work needed to be done. That only happens when hospital leadership is concerned about preparation for pandemics or outbreaks; without resources, that post-Ebola adrenaline and focus is waning, and we are drifting back into relative complacency about these threats -- not in all centers, but in many, I think. The challenge is addressing preparedness while still handling competing issues when you don't have unlimited resources; if you have other pressing issues, some of those lessons learned are forgotten or some of those sharpened skills become more and more dull."

Retaining capacity is key to preparedness for the future, says Matthew Zahn, MD, a pediatric infectious disease physician with CHOC Children's Hospital in Orange County, California. "We know a great deal of resources were invested into training for Ebola preparedness and boosting infection control capacity, so the million-dollar question is, how do we retain that critical capacity? A few Ebola patients presented in the U.S. as part of the large outbreak that originated in West Africa a few years ago. When it happened, it presented infection control issues beyond what we have dealt with before in this country. Maintaining the capacity to respond to such an event is extremely difficult for local public health departments and hospitals to work through; there is so much that goes into preparing for just one Ebola patient, as many personnel must be trained on relatively intricate processes including the proper donning and doffing of PPE. That level of training is a huge amount of work. How to maintain that preparedness while not drawing healthcare workers too far from the issues that they see every day is a big concern and it defies a simple answer." 

Zahn continues, "Engaging staff about something as exotic as Ebola teaches them good practices for infection prevention and control no matter what organisms you encounter every day, so that preparedness emphasis has merit. There is real value to maintaining that institutional level of knowledge because those experiences and those lessons learned are going to pay dividends in the future. Our experience with H1N1 and with Ebola add to our overall knowledge of how to prevent the spread of pathogens and emphasize the need to practice good infection control."

Earlier this year, Bill Gates presented a simulation by the Institute for Disease Modeling that found that a new influenza virus such as the one that caused the 1918 pandemic could kill 30 million people within six months. Gates was the featured speaker for the Shattuck Lecture, held during the annual meeting of the Massachusetts Medical Society and New England Journal of Medicine. Gates' lecture explored the lack of global preparation for a pandemic. To demonstrate the destructive power of an unchecked epidemic, Gates leveraged the modeling expertise of the Institute for Disease Modeling (IDM), which specializes in developing software for the mathematical modeling of infectious disease as well as researching the interventions and methodology necessary for interrupting transmission and eliminating pathogens. For this lecture, Dr. Hao Hu, the senior research manager of IDM’s epidemiology section, and Bryan Ressler, a senior software engineer at IDM, worked together to create simulations modeling pandemic scenarios for the spread of an influenza-like pathogen. 

Hu utilized IDM’s Epidemiological MODeling software (EMOD) to determine the likely outcome for the spread of an airborne virus. To capture the risk of a global pandemic, the model was configured to simulate what would happen if a newly emerged virus-i.e., one in which health systems are not prepared for and likely do not have a vaccine to prevent-appeared in southeast Asia. The model utilized typical SIR (Susceptible-Infectious-Recovered) dynamics: all individuals were assumed to be susceptible, and immunity to the virus did not wane. The virus was given an R0 (the basic reproductive rate, or the number of secondary infections caused by a typical case) of 2.1. For comparison, seasonal flu has an R0 of 0.9 – 2.1, with a mean of 1.3; the R0 of the 1918-1919 pandemic-causing Spanish flu is estimated to have ranged from 1.4 – 2.8, with a mean of 2. Individuals in the model could travel both locally and by airplane, thereby moving the virus within and across countries. With an initial seeding of about 800 infections, the simulation demonstrated how an unchecked epidemic can very quickly evolve into a pandemic within a wholly susceptible population.

The Lancet Infectious Diseases editorial (2018) says that improving the preparedness of the global health community to a pandemic, requires diligence in three arenas: vaccination, surveillance, and building response capacity. The development of a universal influenza vaccine has been the focus of the most recent influenza research, but the development of an effective vaccine is expected to take another five to 10 years. Regarding surveillance for influenza, The Lancet Infectious Diseases editorial (2018) says this crucial task is complex because "it needs to cover two key populations: animals and humans. It is expected that the next pandemic influenza virus will originate from a spillover from birds, the natural reservoir of all influenza viruses, or pigs, in which avian and human viruses can coexist, thus favoring recombination." And finally, the editorial notes, "In case of an influenza pandemic, the capacity to respond promptly will play a key part because of airborne transmission. Antivirals and antibiotics to prevent secondary bacterial infections will be important, while awaiting development of an effective vaccine, but stockpiles of these are currently insufficient. Moreover, there is need to invest in strengthening health systems and microbiological capacities on the ground to enhance the rapid response to any outbreak."

Expectations for management of outbreaks are greater than ever before. As Gamhewage (2018) observes, "During the last two decades, several high-profile disease outbreaks have had a profound effect on public health's response to epidemics and pandemics. Today, in sharp contrast to the last century, there is an expectation that we detect outbreaks faster and manage them better. The response to health emergencies today is vastly different from previous eras where containment was a pre-dominant strategy. Today, for any outbreak, we need to systematically use the combination of modern epidemiology utilizing the power of technology; new and easy-to -use field-based rapid diagnostic tools; clinical care even in the harshest of conditions, vaccines and other medical counter-measures, rapidly developing them if they don’t already exist; real-time training of front-line responders; and effective risk communication and community engagement. This new recognition that we need to marry the social aspects of epidemic and pandemic response with an ever-stronger bio-medical response is changing the way disease outbreaks are being managed."

Dzau and Sands (2016) described the response effort to the most recent outbreak challenge, Ebola virus infection, "The battle to contain and ultimately defeat the Ebola epidemic of 2014-2015 has been vividly described. Caught off guard from the start and hindered by myriad coordination, communication, and other problems, a combination of local and international teams fought back with determination, courage, and eventually the deployment of substantial resources to stem the contagion and save lives. Yet more than 11,000 people died, and local economies were brought to a halt. The battle was won, but at immense cost. With the immediate crisis over, the world’s attention has moved on. Ebola has vanished from the headlines and seemingly from policymakers’ to-do lists. Attention has shifted to Zika and other competing priorities. Yet it would be a huge mistake to turn away and declare the war over, for West Africa remains vulnerable to a resurgence of Ebola. There will undoubtedly be new outbreaks; the only question is how well they will be contained."

Continued vigilance is key. In a report, Global Health and the Future Role of the United States, the Committee on Global Health and the Future of the United States, part of the National Academies of Sciences, Engineering and Medicine, made the case for the continued commitment to global health: "The tremendous growth in international travel and trade that has occurred over the last several decades heightens the urgency of continued investments in global health. The resulting increased interconnectedness of the world and interdependency of countries, economies, and cultures have brought improved access to goods and services, but also a variety of health threats."

Based on a rigorous and evidence-based consensus process, committee members formulated recommendations that, if implemented, would deliver a strong global health strategy and allow the United States to maintain its role as a global health leader. Let's examine a few of these recommendations:
- Achieve global health security: In the last 10 years, outbreaks of potentially pandemic influenza, Middle East respiratory syndrome coronavirus (MERS-CoV), Ebola, and most recently Zika have threatened populations around the world. In each case, global and national responses, including those of the United States, have been reactionary, uncoordinated, ineffective, and highly costly. Absent the establishment of fundamental public health protections and preparedness capabilities at home and abroad, the world will never be ready to prevent, detect, and respond to such outbreaks. A solid commitment in the form of a sustainable mechanism for addressing these global threats is a critical need. The committee urges the administration to create a coordinating body within the U.S. government with the authority and budget to develop a proactive, cost-effective, and comprehensive approach to preparedness for and response to international public health emergencies. In addition, the committee calls for continued investments at the national level-and increased investments at the international level-to improve capabilities to confront the growing and alarming threat of antimicrobial resistance. 
- Maintain a sustained response to the continuous threats of communicable diseases: Dedicated efforts of national governments, foundations, and the global community have resulted in millions of lives saved from AIDS, tuberculosis (TB), and malaria, yet all three diseases continue to pose immediate and longer-term threats to the health of populations around the world. More than 36 million people are living with HIV, with 2 million new infections occurring each year. TB disproportionately affects the poorest populations of the world, killing 1.4 million each year, while dangerous resistant strains are becoming more prevalent and easily spread. The mortality rate due to malaria has decreased by more than 60 percent in the last 10 years, but those infected can lose 25 percent of their family’s income as a result of their lost productivity, affecting the prosperity of the society at large as well. The committee believes that a sustained focus on HIV/AIDS and malaria and a reevaluation of the commitment to fighting TB are imperative to prevent reversal of the gains achieved in the last few decades and avoid the further spread of resistant strains for all three diseases.

The committee also identified three areas for action to maximize the returns on investments, achieve better health outcomes, and use funding more effectively: 
- Catalyze innovation through both the accelerated development of medical products and integrated digital health infrastructure;
- Employ more nimble and flexible financing mechanisms to leverage new partners and funders in global health
- Maintain U.S. status and influence as a world leader in global health while adhering to evidence-based science and economics, measurement, and accountability 

As the committee noted, "Achieving true improvements in global health will require changing the way global health business is conducted to better enable innovation. Adequately protecting U.S. citizens at home and abroad necessitates not only investment in U.S. infrastructure, but also continued awareness of global issues and active engagement in the international global health arena ... To these ends, a change in approach and long-term visioning across the various U.S. agencies involved in global health will be necessary, with an emphasis on integration and partnership."

Federal entities in the U.S. have responded to the call for action. For example, last year, the Department of Health and Human Services (HHS) updated its Pandemic Influenza Plan, highlighting both the progress and remaining gaps in preparedness and response capabilities for pandemic influenza. It outlined seven domains for 2017-2027:
1. Surveillance, Epidemiology, and Laboratory Activities: Better detection and monitoring of seasonal and emerging novel influenza viruses are critical to assuring a rapid recognition and response to a pandemic. Over the next decade, HHS will increase use of new gene sequencing technologies for detecting and characterizing influenza viruses in the U.S. and globally. Candidate vaccine viruses will be more rapidly developed and synthesized when needed, to speed manufacturing of vaccines. Greater use of ‘big data’, analytics, and forecasting will enhance surveillance and planning.
2. Community Mitigation Measures: Incorporating actions and response measures that people and communities can take to help slow the spread of novel influenza virus. Community mitigation measures may be used from the earliest stages of an influenza pandemic, including the initial months when the most effective countermeasure-a vaccine against the new pandemic virus-might not yet be broadly available.
3. Medical Countermeasures: Diagnostic Devices, Vaccines, Therapeutics, and Respiratory Devices: Aggressive translation of applied research in diagnostics, therapeutics, and vaccines may yield breakthrough MCMs to mitigate the next influenza pandemic. Building on existing systems for product logistics, as well as advances in technology and regulatory science, can increase access to and use of critical countermeasures to inform response activities.
4. Healthcare System Preparedness and Response Activities: Delivery system reform efforts of the past decade have made today’s healthcare system dramatically different from 2005. The next 10 years will bring even more changes to delivery settings, provider types, reimbursement models, the sharing of electronic health information, referral patterns, business relationships, and expanded individual choice. Despite these changes, healthcare systems must be prepared to respond to a pandemic, recognizing that potentially large numbers of people with symptoms of influenza, as well as those concerned about the pandemic will present for care. Systems must implement surge strategies, so people receive care that is appropriate to their level of need, thereby conserving higher levels of care for those who need them. HHS must keep abreast of these changes and adapt tools and strategies accordingly.
5. Communications and Public Outreach: Communications planning is integral to early and effective messaging when a pandemic threatens, establishes itself, and expands. Accurate, consistent, timely, and actionable communication is enhanced using plain language and accessible formats. Testing messages and using appropriate channels and spokespeople will enhance our ability to deliver consistent and accurate information to multiple audiences.
6. Scientific Infrastructure and Preparedness: A strong scientific infrastructure underpins everything HHS does to prepare for, and respond to, pandemic influenza and other emerging infectious diseases. Strong scientific foundations are needed to develop new vaccines and therapeutics, and to determine how well other control efforts are working. Rigorous scientific methods applied during a pandemic response yield information to improve both ongoing and future responses.
7. Domestic and International Response Policy, Incident Management, and Global Partnerships and Capacity Building: HHS will continue to coordinate both domestic and international pandemic preparedness and response activities. This will include having clearly defined mechanisms for rapid exchange of information, data, reagents and other resources needed domestically and globally, to prepare for and respond to an influenza pandemic outbreak.

As the Committee on Global Health and the Future of the United States observe, "Expanded global influenza surveillance and laboratory capacity provide a clearer picture of evolving influenza A viruses and the occurrence of novel viruses with pandemic potential. Forecasting, modeling and planning tools now facilitate dynamic estimates of pandemic virus spread, burden and impact. The National Pre-Pandemic Influenza Vaccine Stockpile (NPIVS) has been established and satisfies requirements for vaccine and adjuvants to address influenza viruses that are assessed to be the highest risk for human infection. Modifications made to respiratory devices-both respirators and ventilators-should ensure better availability and improved technology in a future pandemic. Influenza vaccines can be produced more rapidly, and there is now sufficient domestic manufacturing capacity to make influenza vaccine for every person in the United States. The goal of a 12-week timeframe for first doses of vaccine is now within reach, compared with the typical six- to nine-month time for seasonal vaccine production, though challenges may persist in ensuring enough supply of pandemic vaccine is immediately available for the entire population. Influenza antiviral drugs are available in many formulations, including some specifically for children. Federal stockpiles of antiviral drugs have increased to levels projected to meet treatment needs across multiple pandemic scenarios. Vaccines are now more broadly available in many settings, including pharmacies and retail clinics, to improve access to these countermeasures and reduce the surge on hospital and emergency care centers during a pandemic. Social media messaging channels now reach millions of Americans directly, and expanded partnerships with an array of nongovernmental organizations can deliver influenza pandemic-related messages through those channels. Robust population-based surveillance and evaluation networks capture influenza-associated hospitalizations and monitor the effectiveness of influenza antivirals and vaccines. Finally, State, Local, Tribal, and Territorial governments (SLTT) have developed, and many have exercised, pandemic influenza preparedness plans, supporting global commitments made by the United States to pandemic preparedness planning."

The committee adds, "Complementing progress on the domestic front, HHS has made significant improvements in strengthening global capacities to prevent, detect, and respond to an influenza pandemic. A robust international surveillance network has been established by partnering with more than 50 countries to build capacity to detect novel influenza viruses wherever they emerge. HHS participated in the development and adoption in 2011 of the WHO Pandemic Influenza Preparedness (PIP) Framework for the Sharing of Influenza Viruses and Access to Vaccines and Other Benefits. In addition, expanded international coordination on pandemic preparedness and response has been facilitated by HHS’s continued support to the WHO Global Influenza Surveillance and Response System (GISRS). This system not only allows for the capture of more viruses from more places for greater ability to detect an emerging pandemic threat, but also to produce timely seasonal and pandemic vaccine candidates. HHS also supported the development of influenza vaccine manufacturing capacity in developing countries, creating a rapid response capability of over 500 million doses of pandemic influenza vaccine in remote regions where previously there was none. Finally, HHS has integrated its domestic and international pandemic response policies and operations to minimize duplication of effort. HHS led the development of the North American Plan for Animal and Pandemic Influenza (NAPAPI), which launched in 2012 as the primary framework for pandemic influenza preparedness and response through collaboration among the U.S., Canada, and Mexico. The Global Health Security Agenda, which officially launched in 2014, and the continued efforts to implement the International Health Regulations (IHR), published in 2005 by the WHO, both highlight the ongoing need to establish or improve the global capacity to prevent, detect, and respond to biological threats such as pandemic influenza."

Despite efforts to shore up preparedness, concern exists. Two years ago, the international, independent Commission on a Global Health Risk Framework for the Future issued a sobering report on the estimated global economic loss from potential pandemics that could average more than $60 billion per year. However, a report from the commission noted, nations devote a fraction of the resources to preparing, preventing, or responding infectious disease crises as they do to strengthening national security or avoiding financial crises. The commission recommended an investment of approximately $4.5 billion per year – which equates to 65 cents per person – to enhance prevention, detection and preparedness. The biggest component of this investment is to upgrade public health infrastructure and capabilities for low- and middle-income-countries, which is estimated to cost up to $3.4 billion per year. The second biggest component of the $4.5 billion figure is $1 billion per year to fund accelerated research and development in a wide range of medical products. The balance relates to financing the strengthening of the World Health Organization (WHO)'s capabilities and funding WHO and World Bank contingency funds.
“We have neglected this dimension of global security,” said commission chair Peter Sands. “Pandemics don’t respect national boundaries, so we have a common interest in strengthening our defenses against infectious diseases in every part of the world. Preventing and preparing for potentially catastrophic pandemics is far more effective – and ultimately, far less expensive – than reacting to them when they occur, which they will.”

The commission suggests that at least one pandemic will emerge over the next 100 years, with a 20 percent chance of seeing four or more. To protect against these threats, the top priority must be to reinforce the first line of defense against potential pandemics, public health capabilities, and infrastructure at a national level, even in failed or fragile states, because regional or global capabilities cannot compensate for deficiencies at a national or local level. This requires governments to prioritize investment in their health systems, as part of their fundamental duty to protect their people, the report says. It also requires effective engagement of communities, given the vital role they play in outbreak detection and response. 

The commission said stronger international coordination and response mechanisms are also essential, given the significant shortcoming revealed during the Ebola outbreak. The commission also called for the acceleration of research and development across a wide range of medical products – including vaccines, therapeutics, diagnostic tools, personal protective equipment, and instruments. 

Earlier this year, the Government Accountability Office (GAO) issued a report, Funding and Performance of Key Preparedness and Capacity-Building Programs, to reinforce the critical importance of ensuring sustainable, predictable, and robust public health funding for both routine surveillance and reporting activities, as well as emergency preparedness.

The GAO report analyzed preparedness funding for three programs within the Department of Health and Human Services (HHS) from 2002-2017: Epidemiology and Laboratory Capacity (ELC), Public Health Emergency Program (PHEP); and the Hospital Preparedness Program (HPP). These programs carry out public health preparedness and response efforts that are funded substantially through annual appropriations. The remaining is funding is from supplemental appropriations to respond to specific infectious diseases threats, including Zika and Ebola. The report was developed based on data provided on awards, as well as measurement data on awardees’ infectious diseases preparedness capacity. Federal and non-federal stakeholders were interviewed for additional insight.

"This report demonstrates that awards from annual appropriations are not enough to support the resources needed during an infectious diseases outbreak," says Keith Kaye, MD, MPH, president of the Society for Healthcare Epidemiology of America (SHEA). "In emergency response efforts, communities are left vulnerable to every day infectious diseases threats while precious funds are redistributed to outbreak response. It is critical to establish mechanisms for robust and timely supplemental funding for outbreak situations."
In this 15-year review, the three programs that support infectious diseases emergency preparedness saw a net decrease in federal investments that were course corrected through supplemental funding when an outbreak occurred. Additionally, HHS officials and non-federal stakeholders noted in the report that the timing of supplemental awards limited the public health response since funding took an average of four months to be received. The lag often resulted in removing resources from routine activities and personnel hires to remedy the gap between the outbreak onset and receipt of the funding. This causes public health departments to decrease their normal functions to address the outbreak, which leaves the locality or region vulnerable to other outbreaks unrelated to the emergency.

Evidence of this issue was highlighted in a study published in the journal Infection Control and Hospital Epidemiology titled, "Lessons Learned from Hospital Ebola Preparation." The study found that hospital Ebola preparations required extraordinary resources, which were diverted from routine infection prevention activities. During a sample week of preparations, 80 percent of hospital epidemiology time was reported as committed to Ebola, amounting to a median of 160 hours of staff time per hospital. During the time that such effort was focused on Ebola, only 30 percent of routine infection prevention activities were completed.

"This report demonstrates the need to increase funding overall for emergency preparedness, and the importance of fully funding programs such as the Prevention and Public Health Fund,” says Kaye. “Doing so will help ensure healthcare epidemiologists and other infection prevention and control professionals have the resources available to support critical ongoing infection prevention and response efforts, as well as the ability to respond quickly during an unexpected outbreak. This will ultimately save lives and reduce the burden of infectious diseases on the healthcare system."

HHS has three key preparedness and capacity-building programs-Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), the Hospital Preparedness Program (HPP), and Public Health Emergency Preparedness (PHEP). These three programs awarded about $21.2 billion to states and other jurisdictions from 2002 through 2017 to carry out public health preparedness and response efforts, including those related to infectious diseases, natural disasters, or terrorist events. Of this amount, $18.4 billion were awards funded from annual appropriations. The remaining was funded from supplemental appropriations to respond to specific infectious disease threats, including Zika, Ebola, and H1N1 pandemic influenza. HHS officials and non-federal stakeholders told GAO that supplemental appropriations were important for supporting necessary surges in capacity, but the timing of additional awards can limit response.

HHS's three key preparedness and capacity-building programs measure performance in four areas that directly relate to infectious disease preparedness capacity-electronic lab reporting, epidemiology capacity, laboratory capacity, and responder protection. Most awardees (states and other jurisdictions) met targets for all nine measures in the responder protection area, which measures activities related to safety and coordination for responders. However, awardee performance in the other three areas was mixed:
- Electronic lab reporting. One of two measures were met. This area relates to the sending of laboratory reports to public health agencies via electronic means (as opposed to traditional, paper reports).
- Epidemiology capacity. One of three measures were met. This area relates to awardees' ability to identify and respond to infectious disease outbreaks.
- Laboratory capacity. Five of six measures were met. This area relates to both laboratory testing of certain pathogens, and communication between laboratories and other public entities.

With a key provision supporting the development of a trained and ready public health workforce, and new efforts to combat antimicrobial resistance, the Pandemic and All Hazards Preparedness Act reauthorization bill approved by the House Energy and Commerce Committee in July addresses issues that are essential to ensuring the U.S. will have the resources and capacities necessary to confront emerging threats to public health. The Infectious Diseases Society of America (IDSA), which has led efforts to make lawmakers aware of needs to strengthen the workforce of expert responders, and to address the growing threat of antimicrobial resistance, including in this legislation, urged the full House and Senate to move forward with a strong reauthorization that contains these critical provisions along with increased resources for public health emergency preparedness programs.

As the IDSA noted in a statement, "While physicians trained to detect, prevent, treat and contain infectious diseases are our frontline of defense against public health emergencies that can include outbreaks, natural disasters and bioterror attacks, support for training, including through medical education loan repayment, to enter a specialty that provides relatively low economic compensation for physicians has been notably lacking. The bill released by the committee today takes an important step toward bolstering our preparedness by providing loan repayment opportunities for individuals serving in Centers for Disease Control and Prevention Epidemic Intelligence Service, a program that provides expert responders and trains future public health leaders. In addition, while infections resistant to existing antibiotics pose increasing threats, with slow return on investments in antibiotic research and development, efforts to build the needed arsenal of new drugs have languished. The bill released by the committee today supports additional initiatives through the Department of Health and Human Services Biomedical Advanced Research and Development Authority to address antimicrobial resistance including with strategies to drive the development of new drugs. Importantly, the bill also codifies the expert council advising the federal government on AMR solutions. 

The Epidemiologist's Role
During an epidemic, how well prepared a facility is for an outbreak can mean the difference between lives saved or lives lost. Prevention of and preparedness for disease outbreaks require a commitment of resources so that healthcare epidemiologists and other healthcare professionals are equipped to prevent, identify, manage, and contain any outbreak at any time. In a disease outbreak, it is important to have a leader in place to coordinate the response by the healthcare team. With their exceptional command of data and unique analytical and investigative skills, healthcare epidemiologists are responsible for investigating the outbreak, containing further spread of the disease, and communicating with the community and health officials at a local, state, and national level. Late last year, SHEA, with the support of the CDC, issued a new expert guidance document for hospitals to use in preparing for and containing outbreaks.

"This guidance details the role of the healthcare epidemiologist as an expert and leader supporting hospitals in preparing for, stopping, and recovering from infectious diseases crises," says David Banach, MD, co-chair of the writing panel and assistant Ppofessor of medicine at the University of Connecticut and hospital epidemiologist at UConn Health. "Armed with the resources to develop and support key activities, healthcare epidemiologists can utilize their skills and expertise in investigation and response to infectious disease outbreaks within a hospital's incident command system."

SHEA and CDC collaborated in 2016 to form the Outbreak Response Training Program to guide healthcare epidemiologists in how to maximize their facilities' preparedness and response efforts to combat outbreaks such as Ebola, Zika, pandemic influenza, and other infectious diseases. The new document, Outbreak Response and Incident Management: SHEA Guidance and Resources for Healthcare Epidemiologists in United States Acute-Care Hospitals, leads epidemiologists through how to apply, use, and interact with emergency response structures, groups, and frameworks from the institutional to the federal levels, and provides an overview of essential resources. The principles in the guidance are intended for acute-care hospitals, but may apply to other types of healthcare facilities, such as free-standing emergency departments and long-term care facilities.

According to the guidance document, during a crisis the epidemiologist provides medical and technical expertise and leads infection prevention and control efforts, coordinates with institutional stakeholders, and provides input into internal and external communications.
"We will always be faced with new and re-emerging pathogens," says Lynn Johnston, MD, co-chair of the writing panel and professor of medicine and infectious diseases at Dalhousie University, Halifax, Canada. "This guidance is part of an ongoing effort to develop tools and strategies to prevent and manage contagious diseases to ensure patient and public safety."

The document is part of a partnership between SHEA and CDC to prepare for emerging and re-emerging infections by providing training, educational resources, and expert guidance for dealing with outbreaks in healthcare facilities. The program is designed to train U.S. healthcare epidemiologists, who oversee infection control programs, to have the skills, abilities, and tools available to implement infection control practices and provide a leadership voice in responding to infectious threats.

The Nurse's Role
Corless, et al. (2018) posit that, "The unpredictability of pandemic outbreaks (agents, time, and place) is a given in communicable diseases. The gap in the incorporation of nursing knowledge and skills related to screening, disease identification, rapid response, community involvement, inter and intra-agency communication, governmental notification, and coordination need not remain challenges to adequate and timely responses. The failure to develop a coordinated system of health care workers who understand the importance of detecting and forwarding information about the identification of an illness is a major gap in our ability to contain new infections. A key issue is the time delay in the early identification of infections that pose a threat to potential epidemics/pandemics. To mitigate the delay, it is essential that the healthcare professional who is the initial point of contact with the infected person, likely the community health worker in many global settings, communicate with the appropriate provider or agency to initiate the next steps including identification of the pathogen, initiation of appropriate treatment, and prevention of further dissemination. In addition, recognition of a pattern, alerting others as to the emerging disease, and preventive services will aid in preventing further diffusion of pathogens from isolated cases. A delay in such identification may lead to the development of epidemics/pandemics and be an impediment to the prompt initiation of treatment for the infected individual, appropriate interventions and protective devices, and efforts to curtail the spread of the epidemic."

The authors outlined several recommendations for the future:
- Encourage the International Council of Nursing (ICN), World Health Organization (WHO) Dept. of Pandemic and Epidemic Diseases, the U.S. Department of Health and Human Services Office of Pandemic and Emerging Threats, the U.S. Centers for Disease Control and Prevention (CDC), and national nurse leaders, to build an in-country community health worker-to-clinic nurse to physician/lab technologist network.
- Collaborate with identified country nurse leaders who have developed a national grounds-up nurse-coordinated network, advocate for funding from appropriate sources (e.g., the Gates Foundation, the World Bank) for the education of community health workers and for the distribution of cell phones or other devices to personnel likely to be first points of contact with infected individuals to facilitate rapid communication with next level providers.
- Encourage the ICN, the National League for Nursing, the Centers for Disease Control and Prevention, and community health worker representatives, to develop a curriculum for community health workers regarding the identification and reporting of infectious diseases.
- Urge global leaders (ICN, WHO, CDC) to develop a strategic plan for local distribution of resources (pharmaceuticals, lab equipment, and other treatment-related materials) in case of emerging epidemics.

Clinicians will always be on the front line against infectious threats, and the work is often invisible until a large-scale event occurs. "It's the classic conundrum that healthcare epidemiology and infection prevention face," says Kaye. "In prevention work, when things are going well, people don't think about you. But suddenly when there is an outbreak, everyone focuses on you and wants answers -- it's either all of nothing, unfortunately. And the strides we have made toward prevention takes time; for example, development of a universal flu vaccine, development of rapid field diagnostics for emerging viral and bacterial infections, and perfecting response and management in different settings and locales -- these advances take commitment over years and in some cases, decades, to move the needle. Regrettably, what happens is after three or four years with Ebola in our rearview mirror, or 10 years with an influenza pandemic in the rearview mirror, people develop short-term memory issues and pull funding and resources back. Like the old saying goes, 'an ounce of prevention is worth a pound of cure,' but it's hard to measure prevention in an impactful way; hospitals get the most attention when there is an outbreak or infection rates are high. Huge reductions in public health appropriations and funding is a significant issue that could have long-lasting adverse effects. By the time you have an outbreak, it's often too late -- not in terms of response, but you are simply putting out fires and playing catch-up, rather than preventing these problems in the first place. We fail to remember history -- even recent history -- and that's what effective prevention is about. I think that the only way to truly value prevention is to remember the bad outcomes when preparedness was lacking."

References:

Banach D, Johnston L, et al. Outbreak Response and Incident Management: Guidance and Resources for Healthcare Epidemiologists in United States Acute Care Hospitals. Online Nov. 30, 2017.

Barclay W and Openshaw P. The 1918 Influenza Pandemic: one hundred years of progress, but where now? The Lancet Respiratory Medicine. Vol. 6, No. 8. Pages 588-589. August 2018.

Corless IB, Nardi D, Milstead JA, Larson E, Nokes KM, Orsega S, Kurth AE, Kirksey KM an Woith W. Expanding nursing's role in responding to global pandemics. Nursing Outlook. online June 28, 2018. 

Department of Health and Human Services (HHS). Pandemic Influenza Plan: 2017 Update.

Dzau VJ and Sands P. Perspective: Beyond the Ebola Battle - Winning the War against Future Epidemics. N Engl J Med 2016; 375:203-204

Gamhewage G. Evolutions in global epidemic and pandemic preparedness. International Journal of Infectious Diseases. Vol. 73. Supplement, page 39. August 2018. https://www.ijidonline.com/article/S1201-9712(18)33595-1/fulltext

Government Accountability Office (GAO). Infectious Disease Threats: Funding and Performance of Key Preparedness and Capacity-Building Programs. May 2018.

National Academies of Sciences, Engineering, and Medicine. 2017. Global Health and the Future Role of the United States. Washington, DC: The National Academies Press. doi: 10.17226/24737. 

Sands P, Mundaca-Shah C and Dzau VJ. The Neglected Dimension of Global Security - A Framework for Countering Infectious-Disease Crises. N Engl J Med 2016; 374:1281-1287.

The Lancet Infectious Diseases. Editorial: How to be ready for the next influenza pandemic. Vol. 18, No. 7. Page 697. July 2018.