The World Health Organization (WHO), under the International Health Regulations (IHR 2005), declared the emergence of COVID-19 a Public Health Emergency of International Concern. Systemic issues led the virus outbreak to create a substantial impact on political and social systems. Despite scientists raising the flag on threats of pandemics for the past 15 years, the outbreak has now spread to at least 26 countries, impacting global health and economic prosperity. What could have been done better to prepare for and reduce the risk of this event? What does science suggest for governments, organizations, and individuals in response to this outbreak? This article discusses how we can safeguard people’s health moving forward and in the future while lowering the economic and social costs.

Context

The first official report on December 31st, 2019 of the novel coronavirus (COVID-19) came from the city of Wuhan, Hubei Province, in the P.R. China. In an emergency response, the Chinese government mobilized more than 34,000 officials and government workers to fight the epidemic. The government also built two 1,000 bed hospitals and several mobile cabin hospitals and put in place a series of domestic travel bans. As of February 19th, there were 74,280 confirmed infected people in China and 924 across 25 other countries.

On Feb. 3rd, 2020, WHO detailed a strategic response and preparedness plan. WHO also produced a Research and Development Blueprint research agenda to drive innovation in all aspects of outbreak control, from clinical case management to vaccine development, and developed a master plan for coordinating clinical trials that could lead to potential therapies for patients affected with the COVID-19 disease caused by the SARS-CoV-2 virus.

The causative agent is a coronavirus (single strand RNA virus with envelope). This is a commonly found, virus type; SARS is another coronavirus. SARS, which also originated in China, took 6 months to affect 5,000 people; COVID-19 reached that number in one month. Symptoms reported include mild to severe respiratory illness with fever, cough, and difficulty breathing, although COVID-19 may be symptomless in some people. Only direct exposure through droplets can cause person-to-person transmission, with the potential to seed further outbreaks. Preliminary data in China show a national average case fatality rate of 2.3%, with a higher rate in Wuhan and lower in other provinces. This is less than the 7-10% cited for SARS, and might further decline as data become available on the numbers of less severe cases, as was the case with the H5N1 avian influenza. 

Fortunately, the number of patients recovering from this coronavirus has been increasing (see the online dashboard maintained by Johns Hopkins CSSE and the dashboard by WHO). Fear of further spread of COVID-19 has led to international travel bans, despite WHO advising against the application of any inappropriate travel or trade restrictions. The scientific community therefore needs to provide the knowledge for a more coordinated response and prevention in the future.

The COVID-19 outbreak is causing a great deal of worldwide worry, panic, and concern, much of which is unwarranted and not based on scientific facts. Remember that in a global population of almost 8 billion people, the number infected by COVID-19 is extremely small, and is dwarfed by other more common diseases such as flu, malaria and diarrheal disease that kill thousands or even millions of people each year. For people who live in regions with high numbers of COVID-19 cases (e.g. Hubei Province China, or some urban centers in Asia), are front-line responders, or otherwise expect to come into contact with infected people (e.g. airport workers), good science-based information on how to avoid infection is available from reliable websites with good science-based information on how to avoid infection. These include the WHO, National Health Commission of China, Hong Kong University, US CDC, EU ECDC and from other resources such as Lancet Coronavirus Resource Centre and Elsevier’s Novel Coronavirus Information Center. Media outlets and organizations also help to disseminate scientifically correct information (US, UK, China, ESRI).

Responses outside of the hotspot zone

Since the Public Health Emergency declaration for the COVID-19 outbreak by the WHO on January 30th, 2020, many countries introduced travel restrictions and other measures to try and reduce spread of the disease. Several organizations and countries repatriated their citizens to avoid exposure and placed them under quarantine. In some instances, ethical considerations were raised of such interventions. For example, the Australian government announced that citizens repatriated from Hubei province would be placed in quarantine on Christmas Island, within an immigration detention centre intended for asylum seekers. Wearing masks in public has limited benefits but can be helpful for infectious patients to prevent disease spread. In many countries, fear of exposure is resulting in shortages and massive price-hikes of surgical masks, despite WHO recommending these only for people with respiratory symptoms or healthcare workers dealing with patients. Clear guidance from governments, scientists and other stakeholders is vital to ensure that individuals understand the appropriate measures to take.

What scientists have found

Coronaviruses (CoV) are zoonotic, which means they are transmitted from animals to humans. There are many coronaviruses circulating in animals that have not yet infected humans. Similar viruses, SARS-CoV and MERS-CoV were transmitted from civet cats to humans and dromedary camels to humans, respectively.

Fortunately, the overall severity of COVID-19 is lower compared to other emerging pathogens. Over 80% of the cases are mild with the severe cases among older adults or people with prior illnesses. Patients that develop Pneumonia are at the highest risk. It is difficult to diagnose COVID-19 based on symptoms because of its similarities with other common diseases, therefore polymerase chain reaction (PCR) tests are needed in a laboratory setting to test the genetic material (RNA); doing so, takes time. Therefore, identification of cases as well as treatment is delayed. 

World experts and funders have set priorities for COVID-19 research to identify the best ways for infection prevention, control, and responses.

Suggestions for responses to the COVID-19 outbreak: A global problem requiring global solutions, implemented locally

Effectively addressing the COVID-19 outbreak will require global solutions that are implemented locally, based on scientific evidence. Closing down the city of Wuhan in an emergency response may have reduced the spread but may also have had unintended consequences. There was an overflow of patients in hospitals, challenges around provisioning (e.g. surgical masks), as well as a social and economic impact. Before gradually reopening the city, and to avoid stigmatization, communication will be needed for the public. For this purpose, the Health Knowledge-Action Network Steering Committee prepared scientifically-driven concrete action points to reduce the spread and avoid further outbreaks for governments, organizations, and individuals as well as to reduce the concerns of the wider population.

Governments

• Focus on the treatment of severe cases and take a holistic approach to the medical care system to maintain system functioning for the treatment for other diseases. The medical system should remain fully operational while responding to the serious cases of COVID-19.
• Develop guidelines and protocols based on sound scientific advice to 1) respond to the serious cases; 2) reduce further spread in society and among healthcare workers; and 3) increase early case reporting to avoid overloading hospitals.
• Where possible, maintain activities in society, including business activities because they are important for medical systems as well.
• Ensure the sharing of misinformation and discriminatory posts, especially on social media, intentionally or not, is halted through public education and outreach activities, because it can disrupt response efforts at managing the epidemic.
• Provide evidence-based information to organizations and individuals through health agencies and professional associations on websites, news, and local governments to explain the situation and to prevent potential spread within new communities.
• National governments should shift their operational stage from regulation that the points of entry to reflect the situation where more infection is spreading widely within the community.
• Provide an emergency call center number for people with questions related to their symptoms, what precautions they can take, and what protocol they should follow.
• Work collaboratively and transparently to support efforts to deal with the COVID-19 outbreak across countries regarding quarantine procedures and international transportation, including the free and open reporting of outbreak data and sharing of virus samples, genetic information, and research results.

Organizations

• Work collaboratively to provide information for employees and customers to avoid spreading the disease and its associated health impacts.
• Provide opportunities for hand sanitation with non-antimicrobial soap and water, alcohol-based hand rub, or antiseptic handwash.
• Adjust operations to avoid direct close contact among people to prevent spread when an organization or branch office is located in a high-risk zone.
• In general, COVID-19 is transmitted by close contact with infected people, e.g. within a household or in a healthcare center. If there is infection in your organization, then contact your government immediately.
• Reassure the public where possible, including that ownership of pets, livestock, and presence of wildlife in a community is not necessarily a public health risk, and that the key issues in an outbreak or a pandemic are contact with infected people. Emphasize infection prevention and control measures, especially when caring for the sick.
• Develop and use information and educational materials to address fears and attitudes within your organization. This will help focus efforts to prevent disruption from misinformation especially via social networks.

Individuals

• To reduce the risk of being infected or infecting others, individuals should wash their hands frequently, avoid touching your mouth, eyes, and nose too often, maintain social distances of 1 meter or more from others if they are coughing or sneezing or have other respiratory symptoms, have suspected COVID-19 infection with mild symptoms, or are caring for someone with suspected COVID-19 infection.
• Wearing a mask is unnecessary unless you are in contact with infected people, or if you have respiratory illness symptoms – this will help reduce shortages and free up masks for people who critically need them.
• Seek medical care only if you have fever, cough, and difficulty breathing for several days; use a telephone or other means of remote access (many organizations have apps).
• As a general precaution, practice hygiene when visiting live animal markets, wet markets, or animal product markets and avoid consumption of raw or undercooked animal products.
• Follow reputable sources to stay up to date on the developments and suggestions but continue your daily operations – with the additional points above unless requested otherwise by your local government, organization, or if you are based in a high-risk zone with known cases.
• Report any discriminatory posts and wrong information that found on social media to prevent delays in responding to the outbreak.

Transformation needed

We call on scientific, government and non-governmental organizations in the field of conservation, ecology, epidemiology, public health, governance, planning, geography, the science of cities, sustainability science, and many others to work collaboratively to prevent future outbreaks and other health risks and disasters to people and the planet, by applying a systems-based approach for preventing future outbreaks and other health risks and disasters. The EcoHealth, One Health, Planetary Health and Urban Health communities are committed and ready to coordinate such collaboration – a collaborative effort for which public resources are worthwhile investing in.

Research organizations can improve our understanding of the causes, risks, infectiousness, and threats of a pandemic. Health organizations can emphasize the importance of human behavior in disease emergence, and what can be done to avert the emergence and spread of these diseases. Conservation organizations can communicate openly about the fact that wildlife commonly carry pathogens that can be lethal to people and to increase awareness that the risks of pathogens affecting human health often results from unsustainable transformations of our natural environments and ecosystems that provide life-supporting services for our health.

For further transformations towards a healthier world, with changes in our social, cultural, and governance systems across scales. A scientific understanding of human and animal behavior and the dynamic relationship between them and the environment is needed to avoid spillovers. Despite health being central for people’s wellbeing and livelihoods, governments and other decision makers still need to support the health sector in designing and implementing preventative control measures. Policies based on scientific evidence are needed to support the transition to a safe and healthy way of living on this planet, if we are to be prepared for the next virus and to prevent it before it becomes yet another global outbreak. For more information, please see the Our Future on Earth report. To prepare and learn more about other global risks that researchers and experts perceive to be important, please refer to The Future Earth Risks Perceptions Report 2020.

Importance of good health care systems

WHO expressed concern about the impact the virus may have if it spreads to a country with a weak healthcare system or insufficient resources to prevent a pandemic. The first case was reported recently from the African continent, and some commented that there are likely to be person-to-person transmission ongoing, and as-yet undiscovered cases in countries located in Asia, Latin America, and sub-Saharan Africa; these are regions where the funds for monitoring are constrained. Thus, an outbreak reinforces the global commons problem – pathogens that emerge in resource-constrained countries can spread even more rapidly and have a more significant impact. This presents an obvious need for increased investment in capacity building for public health in low- and middle-income countries and building resilient health systems that can detect, prevent, respond, and quickly recover from outbreaks and other health emergencies.

How we can prevent future pandemics

While the current priority for public health is to control and contain this outbreak, there are important messages from the scientific community about how we could have done a better job at preventing diseases such as COVID-19 from emerging in the first place. 

The scientific evidence on emerging viruses demonstrates critical links between biodiversity loss and anthropogenic environmental changes, including deforestation, urbanization, agricultural intensification, and the wildlife trade and the impact of these changes on health, including infectious diseases. These systemic linkages need to be better understood and knowledge needs to be shared with all stakeholders to improve collective intelligence and action. Both elements are integral to a systems approach. To implement this approach to prevent future pandemics, further investments are needed in knowledge communication, coordination, teaching, and training. Investments are cost-effective considering the direct and indirect costs of emergency response measures.

Re-evaluating the hidden costs of pandemics and identifying more sustainable development pathways will mobilize resources to build knowledge and action. Furthermore, increasing donor support for sustainability and building resilient health systems in low- and middle-income countries with emerging infectious disease hotspots can lower the number of severe cases and casualties when an epidemic threatens. Estimates suggest that around 1.7 million viruses able to infect people likely exist in wildlife around the world. Southeast and South Asia, Central and West Africa, and Latin America have hotspots where new viruses are most likely to emerge. The human activities that drive disease emergence are largely known, including the impact of climate change on infectious diseases.

Actions for implementing a systems-based approach for the prevention of pandemics could include: 1) build public health capacity for better surveillance for known and novel pathogens in countries within emerging disease hotspots; 2) identify the hidden costs of pandemic emergence from activities that drive them – agricultural intensification, mining, deforestation, and global travel and trade — and work with those industries to reduce our global footprint; 3) request governments to strategically invest in a research program to discover the viruses related to those known to cause emerging diseases, to devise better tests, drugs, and vaccines; 4) work with the most vulnerable communities in these hotspot regions to reduce the risks associated with activities such as wildlife hunting and consumption, to promote acceptable  and sustainable alternatives; and 5) facilitate coordination and communication between different branches of health-related science programs, including all sectors of society, to increase the sustainability of individual consumption behavior, public awareness and engagement, business practices and trade, government interventions, and other activities.

These and other measures will improve our collective intelligence for prediction and identification of emerging disease hotspots, and for building capacity for the prevention of pandemics.

Authors:
Giles Bruno Sioen
Peter Daszak
Kristie Ebi
Kathryn Bowen
Chadia Wannous
Franz W. Gatzweiler
Frances Harris
Melanie Boeckmann
Kone Brama
Andy Morse
Chiho Watanabe
Jouni J. K. Jaakkola
Gabriel O Dida
Wei Ma