The speed of your response to the initial outbreak is the most influential factor in pandemic prevention (not vaccines, funding, 'messaging', or anything else). Speed alone can be the difference between success and failure. The quicker you react, the smaller the outbreak will be at the time, and the easier it will be to bring it under control. The slower you react, the less likely you are to ever see the end of it, as the Covid-19 pandemic showed. Building speed into national pandemic response plans should therefore be a priority for pandemic policy-makers worldwide.
The speed of your response is determined by two factors: how long it takes you to identify the pathogen (reaction speed) and how quickly you can implement and complete your plan (execution speed). We will need significant improvements in both areas if we are to protect the world from the most dangerous pathogens. Fortunately, significant improvements to both are achievable, as outlined below.
This post will take the form of a compare / contrast exercise. It will first present a typical timeline of an outbreak as it grows from a single infection into a wider regional epidemic, noting the major milestones along the way. It will then consider an alternative timeline, in which speed has been prioritised in the outbreak response.
The first timeline represents the current approach to pandemic risk management in most western countries, and the second is an optimistic vision of where we could be 10 years from now. This exercise should help us to identify where time could be saved and how it could be done.
I will finish by summarising the key lessons: the policies that can improve our reaction and execution times, the resources needed to do so, the tools and techniques currently available to us, and the innovations that might help. If we can learn these lessons and make these changes, we will have gone a long way towards making pandemics a thing of the past.
The outbreak begins with Patient 0. This is first person to be infected by this novel pandemic-potential pathogen ('PPP'). We won’t know when it has happened, and we’ll probably never know who Patient 0 was, but this is the literal beginning of the outbreak and the clock is now ticking. The first infection leads to a second and then a third. The PPP is now spreading in the community and some people start to notice flu-like symptoms.
At Timepoint 1, someone feels sick enough to consult their GP. This will happen a couple of weeks after the initial infection. The GP, seeing the flu-like symptoms, will suggest that the patient go home and get some rest. Perhaps the patient recovers over the next few days, or perhaps their symptoms deteriorate and a further consultation will be required. Either way, the PPP has been given more time to spread in the local community and beyond.
The next major milestone occurs when the first patient goes to a hospital. At this stage it is still assumed that the patient is suffering from a bad flu or something else ‘normal’. The patient will probably be older too, so these kinds of cases are to be expected. The hospital will continue to monitor the patient’s condition over the next few days. Hopefully by then they’ll be through the worst of it and can be discharged, and perhaps that is what will happen.
In the meantime however, the PPP continues to spread. We are 3 or 4 weeks into the outbreak, and the pathogen has certainly passed along national transport networks and is likely present in all major cities.
By now, we are a month or so into the outbreak and there will be several patients in hospital suffering from this mysterious pneumonia. They won’t all recover. At Timepoint 3, one of these patients will be admitted to the ICU. This is usually the first time that the patient will be tested for the pathogens which are most likely to be the cause of their disease – the influenza viruses, rhinoviruses, RSVs, HPIVs, bacterial infections, and maybe even the more exotic pathogens like SARS. When they all come back negative, the doctors will scratch their heads. It is only at this point that they may begin to consider the possibility of a PPP.
While there may be only a handful of cases in the hospitals at the current juncture, the seeds of a much larger outbreak have already been sown and it's only a question of time before a bigger wave hits.
At Timepoint 4, which would be 4 to 8 weeks into the outbreak, the first person will die from this novel PPP. Most likely it was one of the ICU patients. With other patients in the ICU and several more in the hospital, more deaths will soon follow. Despite the mystery surrounding the cause of death, it still may not be clear to the medics that there is something anomalous, as the symptoms aren’t much different to the symptoms of the other less-dangerous diseases they see every day. It may take several more deaths before the medics and officials initiate a more formal investigation of the matter.
By now, the pathogen has likely crossed international borders. Depending on the proximity of the initial outbreak to major travel hubs, the pathogen may have spread to multiple countries but, since no one is even aware that it exists, there is no way of knowing where it is or how far it has spread. This outbreak will surely go on to become a regional epidemic and, with no immediate response in sight and all the momentum on its side, a pandemic seems likely.
By the time the first person dies from this novel PPP, at least a month has passed since the initial infection, and it could be a few more weeks before someone suggests that these mysterious pneumonia cases might be connected. If the outbreak started overseas and there have been reports of mysterious cases abroad, that should happen sooner. Otherwise, or until then, the PPP will continue to spread from person to person, from community to community, and from country to country.
But even if the medics did act immediately on their earliest suspicions, the outbreak would continue to grow because there’s still no way to identify the pathogen. It will take several more weeks again for samples to be taken, genomes to be sequenced, tests to be designed and approved, and then manufactured and distributed in bulk to where they are needed. And that assumes the politicians don’t get in the way and slow things down.
All told, it could easily be 2 or 3 months from the time of the initial infection until the novel PPP has been identified, tests have been manufactured, and a comprehensive response can even begin. If the outbreak is growing by a factor of 2 every week, then a 3-month head start translates to about 8,000 cases. If it’s growing by a factor of 3 (as Covid-19 was early on) then it will be more like 1.5 million cases, which is game over.
We cannot chase down an outbreak of 1.5million cases, so we cannot afford to give novel PPPs such a big head start. If we are to permanently protect humanity from these threats, it is essential that we respond to the risk sooner.
So, let’s consider how we might do that…
I don’t have anything to say about how to prevent the initial infection. And that’s not because there’s nothing to say about the sources of these threats, be it high-risk research, lab leaks, bioterrorism, climate change, or anything else. There’s plenty that could be said and that should be done, but it is not the topic of this piece. My priority here is to develop a robust pandemic response framework that can protect us from any pathogen, no matter how dangerous it is or where it comes from. So I take the first infection as given, and focus instead on our actions from that point on.
The GP assumed that the patient was infected with something typical or common, but what if he didn’t have to assume? What if he could have tested the patient to establish exactly which pathogen it was, or more accurately, which pathogens it wasn't? If the patient tests positive for one the usual pathogens that cause colds, seasonal influenzas, and other common Winter ailments diagnosis, it will provide clarity and may inform the course of treatment. But what if all those tests come back negative? That wouldn’t prove that there is a novel pathogen on the loose, but it would be a warning sign and perhaps grounds for further investigation. The GP may not change the course of treatment, but he could inform the relevant infectious disease departments within the national health service. As more people get infected and go to their GPs, more of them will produce negative test results and the warning signs will accumulate.
The hospital should be able to run all the same tests as the GP (assuming they hadn’t been done already) plus more again for the rarer pathogens: the nosocomial diseases, Legionnaires’, TB, H5N1, H7N9, or MERS. Given that the patient is infected with a novel pathogen, these tests will also come back negative. With this additional information, the risk of a novel pathogen grows. The national health service should be informed of these negative test results, and it should update its pandemic readiness levels (eg like DEFCON 1 in US defence readiness). GP surgeries around the country should be informed and on the lookout for more cases. Senior hospital staff should have conversations about readying spare capacity.
The hospital should also take a sample of this mystery pathogen and keep it in storage for a few months. If a novel PPP is subsequently discovered, they can go back to the stored samples and retest them, some of which will surely be positive. This will help us to understand when the pathogen first entered the country, it will give us early genomes and other information to add to the global dataset, and it will help us to backward trace the outbreak so that we can find current cases and suppress transmission.
By the time the first patient arrives in the ICU, the alarm bells should already be ringing all across the nation’s health service. Many patients with severe symptoms will have produced negative test results, and with a patient now in the ICU, it is possible that this novel pathogen could be deadly.
Pandemic risk management plans should be in operation and protective measures should be increased again (eg DEFCON 2 or 3). If there has been a lot of testing and sampling as described above, then there should be plenty of data for outbreak investigators to work with, and they can start putting the pieces together.
If there have been reports of mystery cases abroad, then both the national health service and the government should be in regular contact with all the major global health organisations as well as governments in the affected regions to gather additional information and update their plans accordingly.
By the time the first person dies from this novel pathogen, the national pandemic risk management response should be well under way and it may already be having some effects on transmission. Medical stockpiles should be accessed, the public should be aware of the threat, and the health service should be expanding capacity wherever it could be needed (eg DEFCON 3 or 4). Depending on the information-flow from the rest of the world, the leaders may know what the pathogen is and they may even be able to test for it. If so, tests should be acquired and performed in great volume to find the pathogen wherever it may be and chains of transmission should be traced and cut.
From there, the domestic plan continues until the pathogen is eliminated and the global outbreak is conclusively and officially over. If everything has gone to plan at home and abroad, this shouldn’t take more than a few months. Nor should it require any serious impact on day-to-day civilian life.
In the original timeline, the first GP visit and the first hospital admission illicit no response from the public health authorities. These events are the first pieces of evidence pointing us to the existence of a novel pathogen, but we are effectively deaf to the warnings. We have no way to recognise that information because we have no way to test for it. It is only when a patient needs the ICU that a novel pathogen becomes a possibility.
In the alternative timeline we are doing more testing in the community, and though we still can’t identify the pathogen itself, we can whittle down the possibilities which brings the risk of a novel pathogen into consideration – if it’s not one of the most common viruses, then what is it? This question initiates our national pandemic response.
The increase in testing is a key difference between these two timelines. By bringing testing out of hospitals and into the community (bringing it ‘upstream’) we are getting more information and sooner. In the original timeline, a 3-month headstart translated to 1.5 million cases. If we can cut that head start in half by time, we can reduce the number of cases by a factor of a thousand or more– making it an eminently solvable problem.
In pandemic risk management, speed makes the impossible, probable.
So testing reduces our reaction time, but we still have to react with something, and that is the other key difference between the two scenarios. In the original timeline, the medics only started scratching their heads when the first person entered the ICU, and even when the first person died there was still no public health response. The warnings signs were there, but they had no plans in place so they couldn't respond.
In order to respond quickly and effectively to these threats, we need a tiered risk management plan with higher levels of preparedness and protection at each ascending tier (like the USA’s DEFCON system). We define the key ‘trigger’ events which prompt us to move from one tier to the next, so that as the risks increase, our defences increase with them.
The alternative timeline demonstrates the benefits of such a system.
The first patient who shows up to their GP with mystery disease is the first warning sign, and that should be officially recorded by some part of the national health system. It may not justify a public health response just yet, but it should be noted and accessible for further investigation.
When the first patient is admitted to a hospital with a mystery case, having had just about every possible test done, that’s when the initial public health response should be triggered. As more mystery cases are observed in community and start showing up in hospitals, that would be another trigger to raise the preparedness levels again. By the time the first patient enters the ICU, the public health response would already be well under way, and the ramping up of defensive measures may have already started to slow the outbreak.
In short, our speed in reaction and our speed in execution will determine whether we can protect ourselves from future PPPs. In the remaining sections, I will present and discuss some policy options that could improve the speed of both in our national outbreak response plans.
In order to cut our reaction time to these kinds of threats, we need to do more testing. There is no alternative. The more we test, the sooner we’ll find the anomalies, and the sooner we can begin our risk management response.
We should aim to bring as much testing as possible upstream and into the community. It should be easy for members of the public to get tested for common viruses, whether that is in their GP’s surgery, at local health care facilities, or even at pop-up testing facilities in shopping centres and other venues. We want to keep the test turnaround time short too so that people get their results back quickly and can take action if needed. Waiting until the first patients are in the ICU is too little too late.
We should look to introduce &/ expand forms of surveillance testing which can test large numbers of people in one go. Sewerage and wastewater testing would be prime examples. These methods allow us test whole communities and neighbourhoods for the presence of diseases, without having to test any (much less every) person individually. Environmental sampling, say of buses or trains at the end of their routes, would be another example. Surveillance testing at major airports and other ports of entry will help us to identify and suppressing international spread, and this will be key for pandemic prevention.
We don’t need innovation in testing technology because our current tools and resources are sufficient, we just need to expand their use. That said, technological progress is always welcome. The areas where innovation might have the most impact include:
Our response to the pathogen – whether national or global – will depend on many factors that are beyond the scope of this essay, for example, national goals, national risk assessments and priorities, or the potential for international co-ordination. I won’t say much here about the plans themselves. Instead, I will discuss some of the tools and methods that can improve the speed and quality of any pandemic response plan, regardless of its goal.
We need to get the right people in the room at the same time to work through realistic pandemic scenarios. This will help us to develop high-level plans and to explore potential risks. Table-top exercises are cheap and easy, and a great way to get people together and talking to each other. They can also be more complex and realistic if needs be. We already do exercises and war games for contagious disease, which is good, but we should do more of them and we need to target novel PPP risk.
We can run real-world exercises and drills to get some real-world practice and familiarity, to identify weaknesses, and to sharpen our responses. These drills can be done on a small scale within individual facilities or departments, or they can be larger exercises which take place over several days across multiple departments and facilities, and can even involve members of the public as actors. Like table-top exercises, we already do some real-world exercises and drills, but we need a more structured approach and we need to prepare for the worst-case scenarios.
Medical stockpiles ensure that we have essential resources available at short notice. Those key resources include masks, PPE, multi-purpose medicines and therapeutics, and various vaccines (smallpox, H1N1, etc). At the slightest hint of danger, these resources can be distributed to every part of the country to protect from the initial shock. All nations should have stockpiles of medical resources to maximise the effect of their epidemic responses (as well as for general risk management purposes). We don’t want to be waiting on key resources in an emergency as that will cost lives. Equally, we don’t want our national risk management responses to be dependent on the global supply chain.
We need to establish domestic systems to store key information. For example, we need a database of mysterious cases to monitor risks and a storage facility for mystery samples so they can be retested when a novel PPP is confirmed. This will help us to understand the pathogen and track down the outbreak. We also need to establish international agreements to ensure that information will be communicated to the world in full and in a timely manner. For example, the pathogen’s genome is needed to design and produce tests. This is an essential piece of information and it is essential that it is supplied to the world as soon as possible.
Most important of all, we need to have goals for our pandemic responses, and we need to have plans to achieve them. This includes setting the trigger events which will initiate different parts of the plan, as well as the policy responses which should follow. Any plan is better than no plan. Once we have established a beta version, we can develop it through exercises, stress tests, and drills. Without even a sketch of a plan however, there is little we can do as we have nothing to work with.
Speed is the most important variable in outbreak control. Speed is the difference between throwing a fire blanket over a pan fire and ordering take-away, versus watching your home and everything you own go up in flames. The sooner we find the pathogen, the sooner we can respond to it. The better our plans, the faster we can end the threat.
In contrast, the slower we respond to the outbreak, and the more time we spend standing around, scratching our heads, looking for someone to give us guidance, the more damage the pathogen will do and the less likely we are to ever eliminate it. For a case study in the cost of sloth, see the Covid-19 pandemic.
How do we prevent such catastrophic outcomes in future?
More testing will find the pathogen sooner. Financial investments in testing technology and production capacity would be welcome. Planning and preparation make our responses quicker, stronger, and more effective overall. Investments of time rather than money are required to develop these plans.
If we can combine the two, we have the recipe for nipping the outbreak in the bud. If we can implement these changes across the developed world, then pandemic risk will start to become a thing of the past.
Practice, preparation, communication, exercises, drills, stress tests… pandemic prevention is a lot more like warfare and national security than it is like clinical medicine, lab science, or academic paper-writing. when you consider that the risks we'll need to manage include engineered pathogens, lab leaks, bioweapons, and bioterrorism, perhaps that makes sense.
Pandemic risk managers really do need to be more like the special forces: setting goals in advance, developing plans, brainstorming risks, and drilling key responses so that they can be quick, smooth and effective in the moment. By front-loading as many decisions as possible into their training and preparation, they free up time to make decisions in the heat of the battle, and that is exactly how successful pandemic prevention should work.
And that it how it could work too, if we prioritise speed in everything we do.