Emerging Viruses are a Global Health Concern Requiring
Science-based Solutions and Local
Actions
Sioen, G. B.1,2,3* Daszak, P.4 Ebi, K.5 Wannous, C.6 Kone, B.7,8 Bowen, K.9 Gatzweiler, F. W.10
Harris, F.11 Boeckmann, M.12 Morse,
A.13 Watanabe, C.14
Jaakkola, J. J. K.15 Dida,
G. O.16 Ma, W.17
1. The United Nations University Institute for the Advanced Study of
Sustainability, Tokyo 150-8925, Japan;
2. The University of Tokyo, Institute for Future Initiatives, Tokyo 150-8925, Japan;
3. Future Earth, Tokyo 150-8925, Japan
4. EcoHealth Alliance, New York City 10001, the United States of
America;
5. University of Washington, Seattle 98195, the United States of
America;
6. Towards a Safer World Network, Stockholm, Sweden;
7. Université Péléforo Gon
Coulibaly, Korhogo, Côte d’Ivoire;
8. Centre Suisse
de Recherches Scientifiques en Côte d’Ivoire, Abidjan, Côte d’Ivoire;
9. Australian National University, Canberra 2600, Australia;
10. Institute of Urban Environment, Chinese Academy of Sciences, Xiamen 361021,
China;
11. University of Hertfordshire, Hatfield AL10 9AB, United Kingdom;
12. Bielefeld University, School of Public Health, Bielefeld D-33615,
Germany;
13. University of Liverpool, Liverpool L1 8JX, United Kingdom;
14. National Institute for Environmental Studies, Tsukuba 305-8506,
Japan;
15. Center for Environmental and Respiratory Health Research, University
of Oulu, Oulu FI-90014, Finland;
16. The Technical University of Kenya, Nairobi FI-90014,
Kenya;
17. Department of Epidemiology, School of Public Health, Shandong
University, Ji’nan 250012, China
Abstract: On 11 March 2020, COVID-19 was officially
characterized as a pandemic. By this time, the SARS-CoV-2 virus had already
spread across continents, causing significant morbidity and mortality, and
affecting social and economic systems. The complexities of the impact of
COVID-19 call for multidisciplinary to trans-disciplinary research that goes
beyond epidemiology research and practice. We aimed to (1) provide a narrative
review of scientific knowledge of COVID-19, (2) place the developments by
international organizations, governments, and individuals (including researchers
at all levels) into a wider context, (3) provide practical suggestions for all
actors to respond to the COVID-19 pandemic in the short term within the context
of large uncertainties, and (4) describe the need for systemic transformations
for sustainability using a trans-disciplinary systems approach. In summary, the
literature revealed that improvements of surveillance, prevention, and control
programs for the prevention of pandemics are needed to safeguard public health.
Embracing a trans-disciplinary systems-based approach with experts from a wide
variety of fields will be essential to prevent future outbreaks and other
health risks, taking into account the complexities of natural and social
systems.
Keywords: World Health Organization (WHO); COVID-19; pandemic; Future Earth
1 Introduction
The
first official report on 31 December 2019 of the novel coronavirus (COVID-19)
came from the city of Wuhan, Hubei province, China. In an emergency response,
the Chinese government mobilized more than 32,000 medical personnel to fight
the epidemic[1]. The government also built two 1,000 bed hospitals
and several mobile cabin hospitals[2] and put in place a series of
domestic travel bans[3]. As of 25 March 2020, there were 81,848 confirmed
infected people in China and rapid spreads according across other countries[4].
The disease hotspot changed to Europe and to the United States.
Activities led by
WHO include a strategic response and preparedness plan[5]. WHO also
activated the R&D Blueprint for action to prevent epidemics[6],
and produced a Research and Development Blueprint research agenda[7].
The agenda was intended to drive innovation in all aspects of outbreak control,
from clinical case management to vaccine development. Further, a master plan
was developed for coordinating clinical trials that could lead to potential
therapies for patients affected with COVID-19[8].
The causative
agent of COVID-19 is a coronavirus (single strand RNA virus with envelope).
This is a commonly found virus type. SARS is another coronavirus. SARS 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 asymptomatic in some
people who can still transmit the virus. Direct exposure through droplets
causes person-to-person transmission, with the potential to seed further
outbreaks. Preliminary data in China showed a national average case fatality
rate of 2.3%[8], with a higher rate in Wuhan and lower in other
provinces[9] and increased to 3.8% in China and 3.4% worldwide. A
higher average rate of 5.7% is being reported in Europe (10.6% in Italy) that may
be because of community infections in areas with a large elderly population.
Based on observations made at the end February 2020, researchers recommend
using a wide range (0.25%–3.0%) of COVID-19 case fatality rates because of the
uncertainties in data and case reporting[10]. This is less than the
7%-10% cited for SARS and could decline as data become available on the
numbers of less severe cases, as was the case with the H5N1 avian influenza[11].
An increasing
number of patients are recovering in China, where the virus was first detected,
but simultaneously, the number of cases in other parts of the world has been
increasing. Fear of further spread of COVID-19 led to international travel
bans, despite WHO advising against the application of any inappropriate travel
or trade restrictions. The scientific community is providing the knowledge for
a more coordinated response and prevention across borders.
The COVID-19
outbreak is causing a great deal of worldwide worry, panic, and concern. In a
global population of almost 8 billion people, the number infected by COVID-19
who are in critical condition is extremely small and is dwarfed by other more
common diseases such as influenza, malaria, and diarrheal disease that kill
thousands or even millions of people each year (the number one cause of death
in the year 2017 was cardiovascular disease, which claimed the lives of 17.79
million people[12]. For people who live in countries and regions
with high numbers of COVID-19 cases (Italy, USA, Spain, Germany or other countries
and urban centers), and for front-line responders and others who expect to come
into contact with infected people (e.g. airport workers), good science-based
information on how to avoid infection is crucial.
2 Responses Outside of the Hotspot
Zone
Since
the Public Health Emergency declaration for COVID-19 on January 30th,
2020, many countries have introduced travel restrictions and other measures to
reduce disease spread. Several organizations and countries repatriated their
citizens to avoid exposure and placed them under quarantine. In some instances,
ethical considerations were raised. For example, the Australian government
announced that citizens repatriated from Hubei province would be placed in
quarantine on Christmas Island, within an immigration detention center intended
for asylum seekers[13]. Wearing masks in public has limited benefits
but can be helpful for infectious patients to prevent disease spread in
crowded, poorly ventilated spaces. In many countries, fear of exposure is
resulting in shortages and massive price-hikes of surgical masks[14],
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 reduce exposure risks.
3 What Scientists Have Found
Coronaviruses
(CoV) are zoonotic[15], which means they were originally transmitted
from animals to humans. There are many coronaviruses circulating in animals
that have not yet infected humans; the degree of their infectiousness is
unknown. SARS-CoV and MERS-CoV were transmitted from civet cats to humans and
dromedary camels to humans, respectively[15]. SARS-CoV like viruses
can spread to humans from bat populations[16].
Dr. Peter Daszak from the Ecohealth Alliance
and the one HEALTH Global Research Project has been studying zoonotic diseases
for over two decades[17-18]. Examples of zoonotic diseases
that have caused turmoil around the world include SARS-CoV, Ebola, MERS-CoV,
avian flu (HPAI Asian H5N1), Nipah (NiV)[19], and now SARS-CoV-2.
Dr. Peter Daszak and his team found that close human-wildlife interactions are
key to novel viral emergence[20], driven by demographic and
anthropogenic change primarily of environmental nature (e.g. rapid
urbanization, agricultural intensification, logging and mining activities
destroying biodiversity and disrupting ecosystems, population growth) and increased
mobility from previously remote regions—these increase the risk of viruses
spilling over and spreading within our globalized population[20-21]. Over the past 10 years, Dr. Peter
Daszak and his team identified >500 novel coronaviruses with the purpose of
focusing surveillance, prevention, and control programs before they emerge[22].
Bats are a reservoir of a number of important zoonotic viruses and although
confirmation is needed, a species of Rhinolophus bat is most likely the natural
reservoir of the SARS-CoV-2 virus that causes COVID-19[23]. Such
scientific information, when appropriately adopted into international policies,
can help prevent future pandemics. One of the challenges lies in the
availability of infrastructure and capacity to prepare for and manage outbreaks
of novel viruses in the areas where humans and biodiversity interact so closely
that spillovers can occur[24].
Fortunately, the
severity of COVID-19 is lower compared to other emerging pathogens; however,
the virus is spreading at very high speed, affecting entire societies. Over 80%
of the cases are mild, with the severe cases primarily among older adults or
people with serious chronic prior illnesses such as heart or lung disease, or
diabetes. Patients that develop acute respiratory distress syndrome are at the
highest risk, requiring ICU admission and oxygen therapy[25].
Symptomatic treatment of respiratory failure places a severe strain on health
care systems world-wide, especially to provide intensive care beds and ventilators.
It is difficult to diagnose COVID-19 based on symptoms because of its
similarities with other common diseases. Polymerase chain reaction (PCR) tests
are needed in a laboratory setting to test for genetic material (RNA); doing
so, takes time and resources. Therefore, identification of cases, making it
challenging to react quickly while world experts and funders set priorities to
identify the best approaches for infection prevention, control, and response[26].
4 Suggestions for Responses to
the COVID-19 Outbreak: a Global Problem Requiring Global Solutions That are
Implemented Locally
Effectively
addressing the COVID-19 outbreak will require global solutions that are implemented
locally, based on scientific evidence that takes into consideration
uncertainties and assumptions. Closing down the city of Wuhan in an emergency
response may have reduced the spread but may also have had unintended
consequences, an approach that was later implemented in many other cities
around the world to flatten the curve of the number of patients[27].
Some places where community infections have occurred experienced an overflow of
patients in hospitals, with challenges around provisioning (e.g. surgical masks
and other medical equipment). These cities and countries also experienced an
unprecedented social and economic impact. Before gradually reopening the city,
and to avoid stigmatization, communication with the public is needed[28].
For this purpose, and in the context of uncertainty, we suggest
scientifically-driven actions to reduce the spread, lessen the impact, and
avoid further outbreaks for governments, organizations, and individuals.
Accumulated benefits of adapting these suggestions across sectors early on may
reduce the impact of COVID-19.
4.1 Governments
l Adopt a whole-of-government and whole-of-society approach to
responding to the COVID-19 pandemic, including involvement of the private
sector and civil society organizations.
l Work collaboratively and transparently with other countries to
support efforts to deal with the COVID-19 outbreak across countries including
regarding quarantine procedures and international transportation, to ensure
that cross-border medical and other essential goods supply chains are able to
function effectively and efficiently and streamline importation of critical
goods and experimental products.
l Ensure free and open reporting of outbreak data and sharing of virus
samples, genetic information, and research results to facilitate vaccine and
treatment development and ensure equitable and transparent allocation processes
for diagnostics, therapeutics and vaccines.
l Develop and implement national research plans and facilitate health
care workers and institutions engagement in priority research at regional and
global levels.
l Health is central for people’s wellbeing and livelihoods; therefore,
governments and other decision makers need to support the health sector in
designing and implementing preventative control measures. Policies based on
scientific evidence are needed to enable 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 yet another global outbreak.
l There is a 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.
l National governments should shift their operational stage from
regulating points of entry to reflect the situation where more infection is
spreading widely within the community. This calls for social distancing as a
preventive strategy and an urgent scale-up of aggressive measures to combat
COVID-19.
l Prevention and response measures within countries.
4.2 Organizations
l We call on scientific, governmental and non-governmental
organizations in the field of conservation, ecology, epidemiology, public
health, mathematics and computer science, governance, planning, geography, the
science of cities, sustainability science, and 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 (EcoHealth, One Health,
Planetary Health, and Urban Health communities).
l Research organizations can improve understanding of the causes,
risks, infectiousness, severity and threats of a pandemic in communities.
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.
l Reassure the public, including that ownership of pets, livestock,
and presence of wildlife in a community is not necessarily a public health
risk, and that the key issue in an outbreak or a pandemic is transmission from
person to person through contact with infected people. Emphasize infection
prevention and control measures, especially when caring for the sick.
l Actions could protect your employees and your business.
4.3 Individuals
l Individuals can protect themselves from infection and also support
government and organizational efforts to deal with the pandemic.
l Individuals should wash their hands frequently, avoid touching their
mouth, eyes, and nose too often, avoid dense concentrations of people, maintain
social distances of at least 1 m (3 feet) from others who 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, and avoid staying in poorly ventilated areas with those persons.
l Follow good respiratory hygiene practices by covering your mouth and
nose with your bent elbow or tissue when you cough or sneeze. Then dispose of
the used tissue immediately.
l Wearing a mask is unnecessary unless you are in contact with
infected people, or if you have symptoms of a respiratory infection—this will
help reduce shortages and free up masks for people who critically need them.
l
Stay home if you feel unwell
and seek medical care promptly if you experience fever, cough, and difficulty
in breathing as this may be due to a respiratory infection or
other serious condition; use a telephone or other means of remote
access (e.g., apps) when available.
l As a general precaution, practice good hygiene when visiting live
animal markets, wet markets, or animal product markets and avoid consumption of
raw or undercooked animal products.
l Follow reputable sources of information to stay up to date on the
developments and suggestions through your national and local public health
authorities.
l 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. Follow advice given by your
healthcare provider.
l Take corrective action on any discriminatory posts and wrong
information occurring in social media to prevent delays in responding to the
outbreak.
5 Transformation Needed
We
call on scientific, government and NGO in the field of conservation, ecology,
epidemiology, public health, clinical medicine, 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.
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. Social scientists can provide understanding about the ways to
introduce policies that would enable improved identification, prevention, and
control of emerging infectious agents with a potential to cause pandemics.
Further
transformations towards a healthier world, may require 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. The transmission of emerging
scientific research to decision makers and the general public is a complex
process, in which uncertainties need to be communicated clearly to provide a
basis for decision making. International organizations and multiple sectors of
government and society need to coordinate to resolve urgent issues and jointly
identify the most appropriate responses. Governments and other decisionmakers
to 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[29]. 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[30].
6 Importance of Well-functioning
and Resilient Healthcare 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. It is likely that there are undiscovered person-to-person
transmissions ongoing 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 on the most vulnerable. This presents an obvious
need for increased investment to build well-functioning and resilient health
systems in low- and middle-income countries that can detect, prevent, respond,
and quickly recover from outbreaks and other health emergencies. While the
current priority for health systems 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 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[31].
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 research, 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[32] 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 million viruses that are able to infect people likely
exist in wildlife around the world and that investments to prevent this from
happening would provide rapid health benefits[33-34].
Actions for
implementing a systems-based approach for the prevention of pandemics include:
1) build 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 identification and prediction of emerging disease hotspots, and for building
capacity for the prevention of pandemics[33].
Globalization has
changed the way we are connected. The increasing interconnectedness of complex
urban systems[35] requires a systems approach and preparedness for
the prevention and effective management of population health emergencies. The
need for such a systems approach is widely discussed, for example under the
Urban Health and Wellbeing programme of the International Science Council
(2020). To do so, a learning cycle that combines knowledge, decision-making,
and action in society is needed. The Anthropocene requires planetary health
approaches[36] with hygienic standards, infection prevention and control
standards, and rules to facilitate a healthy life[37]. The standards
and rules need to be based on scientific evidence and behavior that can be
implemented while taking into account different needs across regions and
cultures and desirable futures.
At present, the
global interconnected system is experiencing a social and economic shock. The
impact of that requires interventions by governments, institutions, and
individuals. There is hope that interventions will lead to changes in the way
we operate and consume but the changes underway may not necessarily lead to
resilience and sustainability[38] without intentional actions to do
so.
There are
challenges that need consideration in decision making[39] and
forecasting in a high-stakes, fast-moving situation. Challenges include rapidly
changing information, uncertainties, a range of values and concerns, and a need
for the decisions to be made urgently. A transdisciplinary approach can support
decisionmaking that takes into account insights into the development of the
virus; medical information about contagion, treatment, and avoiding infection; and
the possible economic impacts of the outbreak. It takes a truly transdisciplinary
team of people from a range of disciplines and sectors, end-users, policy
makers, and practitioners to effectively manage a complex situation. These
science-based activities linking global environmental change to health have
been conducted under the Future Earth Health Knowledge-Action Network[40].
Acknowledgements
The
authors would like to acknowledge the Future Earth Health Knowledge-Action Network
under which this manuscript was initiated, framed, and developed. Furthermore,
the authors acknowledge the Health Knowledge-Action Network Advisory Group for
the valuable inputs; they provided that improved this manuscript. The authors
also acknowledge the National Committee of Future Earth China for translating
the English manuscript into Chinese. Furthermore, Sioen would like to acknowledge the
International Research Fellow program of Japan Society for the Promotion of
Science.
Conflict
of Interest
None.
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