Is the US prepared for the next pandemic?
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In September 2021, the Biden administration introduced the American Pandemic Preparedness Plan, a proposal to transform the country’s capabilities to respond to future pandemics.
In it, the administration likened the danger posed by biological threats to the dangers posed by traditional weapons, terrorism and cyberattacks, and called for an effort to address pandemic preparedness on the level of the Apollo program that sent humans to the moon.
Noting that the next pandemic “will likely be substantially different” from COVID-19, the new plan — also known as AP3 — outlined dozens of goals, including upgrading the country’s medical defenses by improving vaccines, therapeutics and diagnostics and strengthening relevant stockpiles and supply chains. It also called for improving public health systems in the United States and internationally.
“It really outlined this very bold agenda of not just research, but the whole gamut of what is needed to prepare for and respond to potential pandemic threats,” Jane Knisely, PhD, pandemic preparedness strategy coordinator at the National Institute of Allergy and Infectious Diseases’ Division of Microbiology and Infectious Diseases, said in an interview. “Unfortunately, it was not resourced.”
The plan is one of several proposed initiatives intended to strengthen the country’s preparedness for future pandemics. Another initiative, the National Biodefense Strategy and Implementation Plan, builds off AP3 and includes what a senior Biden administration official called “a series of moonshot efforts ... that will help us accelerate the speed of our response and prepare for these unknown threats.”
“These science and technology goals lay out timelines that are not possible today, but these capabilities can be achieved and are within our reach with the right resources over the next 5 to 10 years,” the official said in a call with reporters to preview the strategy.
Biden launched the effort in a national security memo addressed to the heads of 20 government agencies, in which he wrote that “countering biological threats, advancing pandemic preparedness, and achieving global health security are top national and international security priorities for the United States.”
The administration said in October 2022 that it was already implementing parts of the plan with existing funding but would need Congress to allocate additional resources to fully achieve its objectives. Indeed, over the last 2 years, the administration has asked Congress for funding for these plans, including a 2024 budget request for $20 billion in new mandatory funding over 5 years to be allocated to various HHS public health agencies for pandemic preparedness and biodefense. The budget request includes $10.5 billion to improve public health infrastructure at the CDC and state and local levels, and to bolster surveillance, laboratory capacity and the public health workforce.
“The funding bills for fiscal year 2024 have not been passed yet. We're still operating under a continuing resolution,” Amanda Jezek, senior vice president for public policy and government relations at the Infectious Diseases Society of America, noted in an interview. “So, we're not quite where we need to be yet.”
This past summer, Biden picked surgeon and retired Air Force Maj. Gen. Paul Friedrichs, MD, to be the first director of a new permanent office in the executive branch that will oversee the country’s pandemic preparedness and response.
The Office of Pandemic Preparedness and Response Policy — which replaced the White House committees in charge of the COVID-19 and mpox responses — was established when Congress enacted portions of the PREVENT Pandemics Act as part of the 2023 budget. The office will coordinate the White House’s domestic response to pandemic threats, lead efforts at the federal level to develop new vaccines and technologies, and develop and provide periodic reports to Congress on the country’s level of preparedness.
Additional policies from the PREVENT Pandemics Act also passed as part of the 2023 budget — including one that makes CDC director a Senate-confirmable job, effective Jan. 20, 2025 — but Congress has so far not reauthorized the Pandemic and All Hazards Preparedness Act (PAHPA), a 2006 law that established an Assistant Secretary for Preparedness and Response position at HHS and supported the agency’s preparedness and response efforts.
Funding for PAHPA expired at the end of September, less than 2 months after a group of 19 Congressional Republicans said in a letter that the legislation should not be considered for a vote “without desperately needed reforms to protect the American people from tyrannical, incompetent and largely unchecked public health bureaucrats.” Among their list of demanded reforms, the lawmakers said PAHPA funding should return to pre-COVID-19 levels, that the U.S. should assert its authority over WHO, limit or ban Chinese-manufactured goods from the Strategic National Stockpile and restrict the government’s ability to issue vaccine mandates.
It has been 4 years since WHO declared COVID-19 a global public health emergency. The pandemic has many legacies, some of which we have covered in the first three parts of our ongoing “Life during COVID” series. For this fourth part, we checked in with experts to get their feedback on the country’s preparedness for the next pandemic.
[Editor's note: Some responses have been edited for length and clarity, and some were broken up and organized based on topic.]
Is the US in a better or worse position to respond to the next pandemic compared with prior to COVID-19?
Jezek: It's a mix of both. In some ways, I think we're better prepared, and in some ways, we may be worse. We learned a lot from COVID-19. That is sort of the big advantage that we have now — we've had an opportunity to see what works well and what doesn't, where our strengths and gaps are. That presents a real opportunity to apply those lessons and make the investments that we've seen are necessary.
Jennifer B. Nuzzo, DrPH, director of the Pandemic Center at Brown University School of Public Health: Here's what I haven't seen that I would like to see ... I would like to see a bipartisan commitment to have a serious assessment of what went wrong during the pandemic. We need to get to the bottom of this in the same way that we wanted to get to the bottom of what went wrong during 9/11. A number of the United States’ challenges were probably as much about government effectiveness as they were about lack of resources, money, etc. We need to really, truly have an audit. Not necessarily in a punitive way, but a true audit.
Jay K. Varma, MD, executive vice president and chief medical officer at SIGA Technologies and former director of the Cornell Center for Pandemic Prevention and Response: Following 9/11, there was widespread political commitment and funding to strengthen intelligence and security, both domestically and globally, against violent threats. After COVID-19, we should have seen a stronger commitment to making similar investments in intelligence and security against biological threats, but they have not happened. That lack of action is concerning.
Amira A. Roess, PhD, MPH, professor of global health and epidemiology at the George Mason University College of Public Health: In most other aspects of life, when you know where your weaknesses are, you generally tend to address them. We haven't done that, and when we faced another infectious disease outbreak last year, we didn't do very well. We were lucky because the circulating mpox variant was the weaker one. We faced the same issues that we faced with the COVID-19 pandemic, including delays in recognizing the infection, delays in reaching people at risk, supply chain-related delays in getting vaccines and treatments to those affected. We had to rely heavily on nonprofit organizations and other nongovernmental organizations to respond to mpox. All of that highlights that our core public health infrastructure is still fractured and underfunded. Morale in many local public health agencies is low, and we continue to fail to provide adequate funding to support public health agencies.
Nuzzo: We are seeing a rollback in vaccination requirements across the country. So, at the kind of national policy level, I think we are less prepared.
[Editor’s note: CDC data published in November showed that kindergarten vaccination rates remained below pre-pandemic levels last school year and vaccine exemptions reached an all-time high, driven by nonmedical exemptions.]
Varma: The size and strength of the anti-vaccine movement is troubling. If more parents decline to vaccinate their children and more states relax vaccine requirements, we could see a resurgence of old diseases. One shocking example is the report of a case of polio in New York state. More vaccine-preventable infections means more ill health and more opportunities for viruses to mutate and put more people at risk.
Susan C. Kim, JD, MPH, MBA, principal deputy assistant secretary of the Office of Global Affairs at HHS: Misinformation and disinformation have become more prevalent and are undermining confidence in science and public health and weakening trust in governmental and other institutions. Addressing misinformation will require a true global collaborative effort to build trust in science.
Nuzzo: At the same time, we also have some advantages in that the pandemic brought us some remarkable scientific achievements. In less than a year, we developed multiple safe and effective vaccines and rapid tests so that now people have the power to test themselves for COVID in their homes completely confidentially.
Varma: The most important improvement is in awareness. Before COVID-19, most elected officials and citizens did not view pandemic preparedness as something that needed attention and action. Now there is much more widespread awareness that a large infectious disease outbreak — whether natural, accidental or deliberate — could greatly damage American health and our social and business systems.
Nuzzo: We have a public that just went through this and understands now what an infectious disease is and what steps they can take to protect themselves. We have businesses that have seen firsthand how disruptive this is to their livelihoods and the safety of their workers and their customers. Those are important assets that should not be squandered. I would point to that as a source of optimism.
Jezek: The systems that we've built are another big advantage. All of the clinical trial infrastructure that was stood up during COVID-19, how rapidly we were able to develop novel vaccines and therapeutics — that is a huge advantage. I think it's important to keep that going.
Roess: We're better off in that we know how to distribute masks and other supplies in general. Medically vulnerable populations know a little bit more about how to protect themselves from infectious diseases. Some employers continue to use COVID-era protocols to scale back activities or modify operations to protect employees and those who come into contact with them when facing flu, RSV, COVID and other infectious diseases.
Jezek: In terms of where we are weaker, I think that there are serious trust issues with public health and with government, and we need to focus on rebuilding that trust.
Knisely: It's very clear that the COVID pandemic exacerbated this polarization and distrust in science and a lack of understanding of the scientific process. Political polarization of science is extremely troubling.
Varma: Several states have also removed the authority of public health agencies to quarantine and isolate people with infectious diseases or to make other important public health decisions. This will weaken the ability of state and local governments to respond during a future pandemic. Many public health and health care workers have chosen to leave the field and are not being replaced. Many local health agencies have 20% to 30% vacancy rates. We need trained health care professionals to help us fight the next infectious disease threat. Without them, there will be even more illness and death.
What is the biggest lesson COVID-19 taught us?
Varma: That advanced health care services do not automatically protect a population against a pandemic. We need to invest in public health agencies and social support services to defend ourselves against pandemics.
Jezek: To me, the biggest lesson is that, with a novel virus, information is going to change over time. The public and the medical community and public health and government need to be transparent about that and need to be nimble, to be able to change course as the trajectory of a pandemic changes and as we learn more.
Knisely: From a biomedical research standpoint, I think there are three things. One, we can develop safe and effective vaccines in a fraction of the time that it typically takes. We just need to have investments in what we call plug-and-play vaccine platforms. Messenger RNA is a great example of that. Second, we need close collaborations with academic researchers, large and small companies, and regulators, which happened during COVID. That there were folks at the FDA who worked very closely with study teams on the vaccine and drug trials to navigate a path forward, and do it very quickly, was really essential. The other thing that was really critical that we need to sustain support for is having pre-existing preclinical and clinical trial infrastructure that can rapidly pivot to conduct the research that is needed.
Roess: The biggest lesson might be that we prioritize political affiliation over human lives. Before the pandemic, we knew how to respond to outbreaks and what measures can be effective to prevent transmission, but we were ill equipped to deal with combating anti-public health rhetoric, and we still are. The pandemic highlights our lack of support for public health infrastructure, education and minoritized communities. Unlike other high-income countries, we don't think these are important things to support and the results are demonstrated every day.
What lessons have we not learned?
Varma: I think that many elected officials and the general public believe that the key to stopping a pandemic is advanced technology. While tests, treatments and vaccines are critical, we actually relearned a lesson that has been evident as far back as the 1918 influenza pandemic: Advanced health care technologies work best only when they are layered on top of a strong foundation of social and health care support for all people, so there is access to care for everyone who needs it, as well as housing, paid sick leave, child care services and workplace safety programs.
Knisely: The cycle of panic and neglect is the big one. This needs sustained funding and attention. It's not something where you can just come in and mount an effective response after years of neglect. Public health has been chronically underfunded. Sadly, I don't think we have learned that lesson.
Roess: We seem to play the short game. We've known that we've been underfunding public health infrastructure and yet have not done anything meaningful for decades to address shortages in public health workers and our limited infrastructure to prevent outbreaks.
Is pandemic preparedness taken seriously in the US?
Jezek: It is by many. If we're thinking specifically about the federal government, the ability to take something seriously is not always matched with the necessary funding to really put in place the kind of infrastructure that's required.
Roess: Our ever-decreasing attention span suggests that as a populous, we have a hard time taking much seriously for a long period of time. What's taken decades to dismantle will take a serious and thoughtful investment to rebuild, and I don't think our leaders will prioritize this.
Knisely: The current administration certainly has prioritized pandemic preparedness in multiple ways, and there are many members in Congress who take it very seriously.
Kim: The United States is the world’s leading funder of global health and pandemic preparedness. Since 2021, we’ve committed nearly $48 billion to global health, including nearly $16 billion globally to end the acute phase of the COVID-19 pandemic. We provided hundreds of millions of vaccine doses to over 100 countries, as well as therapeutics.
Are there other countries that are better prepared for a pandemic?
Varma: There are so many factors involved in assessing pandemic response that it is difficult to call out one country as being much better prepared. The countries that did best in responding to the COVID-19 pandemic had a strong foundation of social and health support for all people, including universal health care, housing and sick leave, as well as two important social factors: trust in government and trust in each other — social cohesion. This is what the U.S. should strive to achieve.
Nuzzo: The U.S. definitely underperformed, given its pre-pandemic advantages. We're arguably one of the better prepared countries in the world. I co-lead the Global Health Security Index with the Nuclear Threat Initiative and Economist Impact. It measures countries’ capacities to be able to respond to pandemics, and the U.S. has more capacity than others. I think what we saw during COVID was that we really didn't take advantage of what we had, and in some instances, we chose not to use what we had. What that meant was that the U.S. had more pandemic-related mortality than what other highly prepared countries had. To me, that seems like there were some real failures in our response. No country was fully prepared for pandemics at the start of COVID, and still no country is fully prepared for pandemics.
Jezek: I do think that the U.S. has some unique challenges in that we are very large and very diverse, and we have a wide array of beliefs and attitudes about public health and preparedness. All of that presents both opportunities and challenges. Something else that is unique among the U.S. and other high-income countries is that we have a responsibility not only within our borders but to support preparedness in the rest of the world, particularly among low- and middle-income countries. It's important that we invest in preparedness throughout the world because we know that infections that originate anywhere across the globe are just a plane ride away from the U.S. In terms of thinking about preparedness within the U.S., we have to think globally.
What’s the most likely cause of the next pandemic?
Nuzzo: Statistically, it's an influenza virus, only because we tend to have three per century and the last one was in 2009. But coronaviruses are like, “Hold my beer.” They're trying to give flu a run for its money.
Knisely: We know influenza can cause pandemics. It evolves rapidly. It's zoonotic in origin. Many different species can harbor influenza. The viruses can reassort their genes. So, we are always investing in understanding influenza transmission and evolution and developing countermeasures.
Kim: Many pandemics in history, including the recent COVID-19 pandemic, have originated from zoonotic diseases ... which are very common, both in the United States and around the world. Scientists estimate that more than six out of every 10 known infectious diseases in people can be spread from animals, and three out of every four new or emerging infectious diseases in people come from animals. As such, a One Health approach — which recognizes the interconnectedness of human health, animal health and environmental health — is a critical component of pandemic prevention, preparedness and response efforts.
Varma: We can say with certainty that we are entering a new age of pandemics where the risk is higher and potentially more deadly. I am particularly worried about diseases transmitted by mosquitos, ticks and other insects. Climate change is rapidly altering the landscape of diseases — those that were once considered “tropical” and can now be found in places where they were not seen previously. This is true with dengue virus, chikungunya virus, and even malaria.
Nuzzo: It also depends on what you call a pandemic. I haven't really used the word pandemic to describe the Zika virus situation, but it circulated in multiple regions of the world and caused serious health effects. A pandemic is not a really clear scientific term. It's something we use to describe geographic spread. It doesn't describe severity. Zika was an enormous health challenge but I'm thinking more of a no-notice, destabilizing type of event, and which pathogen is most likely to cause it. It's probably a respiratory virus.
Varma: We also cannot underestimate the risk associated with either accidental or deliberate bioterrorism-related epidemics. As the world conducts more research on viruses, there is an increasing risk that a rogue actor could synthesize a new virus or a previously eradicated one, like smallpox, and release it accidentally or deliberately. As the world conducts more research and conflict between countries grow, there is an increasing risk that the next epidemic could be made by man, rather than by nature.
Knisely: At NIAID, we have a pandemic preparedness plan with two different approaches when we're thinking about this question. The first we call priority pathogens — things that are always lurking in the background, posing a threat, like influenza. Similarly, coronaviruses are clearly a threat. We've had three major ones emerge in the last 20 years. What those share in common is that they are RNA viruses capable of rapid evolution and respiratory transmission. They’re at the top of a lot of people's list. We're trying to cover the bases so that we can be prepared, no matter what emerges.
References:
- Association of American Medical Colleges. Pandemic preparedness measures passed as part of FY 2023 omnibus. https://www.aamc.org/advocacy-policy/washington-highlights/pandemic-preparedness-measures-passed-part-fy-2023-omnibus. Published Jan. 4, 2023. Accessed Dec. 31, 2023.
- Background press call by senior administration officials to preview the president’s national biodefense strategy. https://www.whitehouse.gov/briefing-room/press-briefings/2022/10/18/background-press-call-by-senior-administration-officials-to-preview-the-presidents-national-biodefense-strategy/. Published Oct. 18, 2022. Accessed Jan. 1, 2024.
- CDC. 1918 pandemic (H1N1 virus). https://archive.cdc.gov/#/details?url=https://www.cdc.gov/flu/pandemic-resources/1918-pandemic-h1n1.html. Last reviewed March 20, 2019. Accessed Dec. 29, 2023.
- Congressional Research Service. PREVENT Pandemics Act (P.L. 117-328, Division FF, Title II). https://crsreports.congress.gov/product/pdf/R/R47649. Published Aug. 15, 2023. Accessed Dec. 31, 2023.
- Fact sheet: Biden administration to transform capabilities for pandemic preparedness. https://www.whitehouse.gov/briefing-room/statements-releases/2021/09/03/fact-sheet-biden-administration-to-transform-capabilities-for-pandemic-preparedness/. Published Sept. 3, 2021. Accessed Dec. 29, 2023.
- Fact sheet: Biden-Harris administration releases strategy to strengthen health security and prepare for biothreats. https://www.whitehouse.gov/briefing-room/statements-releases/2022/10/18/fact-sheet-biden-harris-administration-releases-strategy-to-strengthen-health-security-and-prepare-for-biothreats/. Published Oct. 18, 2022. Accessed Dec. 29, 2023.
- Fact sheet: White House launches Office of Pandemic Preparedness and Response Policy. https://www.whitehouse.gov/briefing-room/statements-releases/2023/07/21/fact-sheet-white-house-launches-office-of-pandemic-preparedness-and-response-policy/. Published July 21, 2023. Accessed Dec 29, 2023.
- HHS. Fiscal year 2023 budget in brief. https://www.hhs.gov/sites/default/files/fy-2024-budget-in-brief.pdf. Accessed Dec. 29, 2023.
- National Institute of Allergy and Infectious Diseases. NIAID pandemic preparedness plan. https://www.niaid.nih.gov/sites/default/files/pandemic-preparedness-plan.pdf. Published December 2021. Accessed Jan. 2, 2024.
- Roy C, et al. Letter to Speaker of the House Kevin McCarthy. Aug. 2, 2023. https://roy.house.gov/sites/evo-subsites/roy.house.gov/files/evo-media-document/final-pahpa-reauthorization-letter-pdf.pdf.
- White House. American pandemic preparedness: Transforming our capabilities. https://www.whitehouse.gov/wp-content/uploads/2021/09/American-Pandemic-Preparedness-Transforming-Our-Capabilities-Final-For-Web.pdf. Published September 2021. Accessed Dec. 29, 2023.
- White House. Budget of the U.S. Government for fiscal year 2023. https://www.whitehouse.gov/wp-content/uploads/2022/03/budget_fy2023.pdf.
- White House. First annual report on progress towards implementation of the American Pandemic Preparedness Plan. https://www.whitehouse.gov/wp-content/uploads/2022/09/09-2022-AP3-FIRST-ANNUAL-REPORT-ON-PROGRESS.pdf. Published September 2022. Accessed Dec. 29, 2023.
- White House. National Biodefense Strategy and Implementation Plan. https://www.whitehouse.gov/wp-content/uploads/2022/10/National-Biodefense-Strategy-and-Implementation-Plan-Final.pdf. Published Oct. 18, 2022. Accessed Dec. 29, 2023.
- White House. National security memorandum on countering biological threats, enhancing pandemic preparedness, and achieving global health security. https://www.whitehouse.gov/briefing-room/presidential-actions/2022/10/18/national-security-memorandum-on-countering-biological-threats-enhancing-pandemic-preparedness-and-achieving-global-health-security/. Published Oct. 18, 2022. Accessed Dec. 29, 2023.
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