In relation to global health, how secure are we? As a global population, 2020 has given us an opportunity to reflect on our preparedness, resilience and capacity to respond to challenges. Whilst the COVID-19 pandemic may seem like the most immediate threat to our global health security, there are many other issues that have an effect as profound if not more so.  In this webinar, which is a collaboration between the Royal Society of Tropical Medicine and Hygiene (RSTMH), Health Professionals for Global Health and Pansurg (Imperial College London), a diverse panel of speakers discuss three major global health security threats: pandemics, antimicrobial resistance (AMR) and climate change.

At first glance, these three issues may seem disparate, however during the opening talk Professor David Heymann, Professor of Infectious Disease Epidemiology London School of Hygiene and Tropical Medicine and Policy Advisor at RSTMH, explained how the close interrelation between the environment, emerging infections and AMR come together to determine planetary health.  The Swiss Cheese model1 demonstrates how environmental issues, in particular those related to climate change and change in land use and animal husbandry align with human health issues to create an outbreak of an infectious disease.  The public health response to this must be twofold; through guidelines for mitigation as well as identifying and implementing political solutions.

 

As an example of this, AMR has been demonstrated environmentally in animal and plant agriculture and even in fish aquaculture. In order to action change we must re-evaluate our methods, as the agricultural industry depends on profit as well as saving lives.  As such, intervention must be cost-effective; an example of this is the vaccination of animals and fish which has been demonstrated to increase industry profit as well as reduce AMR in that context.

Dr Adam Roberts, Senior Lecturer at Liverpool School of Tropical Medicine and Policy Advisor, RSTMH, draws comparison between the COVID-19 pandemic and the pandemic of AMR. Dire predictions for case incidence and mortality have been made for both, albeit over different timelines. We have been aware of the AMR emergency for over a century, could there be learning from the COVID-19 response and a focus on preparedness with respect to AMR?  In addition, the COVID-19 pandemic may change the course of AMR. Whilst we have seen high usage of antibiotics to treat secondary bacterial infections or even COVID-19 itself we may see a change in overall rates of bacterial infection with the worldwide change in behaviour patterns. At a community level, we see changes in handwashing practice, social distancing and reduced global travel. In secondary care, the impact may be more complex with overcrowding of hospitals, diversion of personal protective equipment and distractions from antimicrobial stewardship balanced with strict cohorting of patients, early discharges and reduced elective work.  In summary, patterns of AMR will change but it will be years if not decades before we see this effect and our focus should be on improving and maintaining surveillance on a global scale to understand changes at a local level.

COVID Lead at the Program for Monitoring Emerging Diseases (ProMED) and WHO Pakistan, Dr Uzma Bashir Aamir discussed the importance of surveillance for detection and prediction of outbreaks as we remain firmly in the midst of this pandemic.  She calls for the support of a reporting channel that is linked to health facilities and a sound detection system with the ability to report through both governmental and informal means.  Dr Bashir highlights the challenges to surveillance which include reporting via two channels (informal and formal/governmental) as well as weak infrastructures and poor workforce training. In her region, as in many places in the world, detection is likely to become more difficult as we enter the monsoon season and other viral illnesses present to healthcare facilities.

The final member of the panel, Dr Truppa, Public Health Specialist & Health Coordinator International Committee of the Red Cross, brings experience from the field and discusses AMR in areas of armed conflict or areas of complex humanitarian emergencies. AMR in these contexts is a major problem particularly at the primary care level. The Swiss cheese model in the context of emerging infections and spread of a pandemic has more holes in a humanitarian setting; for example, no access to handwashing, overcrowding, lack of preparedness, less capacity to provide healthcare services.  Can we use lessons from the COVID-19 pandemic to strengthen health system resilience with respect to other threats in a humanitarian setting? We have seen that modelling predictions have not been fulfilled in low resource settings such as parts of Africa, which could be due to a heavy investment in primary health care services as it is the most sustainable use of limited resources. She suggests that the humanitarian sector could invest resources and resilience at the community level with regards to antimicrobial stewardship especially when responding to a complex emergency.  

 

Preparedness does not equal the number of resources but how the resources are mobilised against a threat. We have seen our pre-existing beliefs about individual countries’ preparedness challenged during this pandemic, as demonstrated by the inverse relationship observed with the global health security index and COVID-19 burden.2  The panel of speakers discussed the decentralisation of preparation and surveillance: this should be done at the level at which it is being implemented, i.e. regional or district level rather than national and international, and perhaps our indices are not sensitive enough to detect where real preparedness has to occur.  Global health security is about individual countries and investment should reflect this. Research opportunities and funding must be applied within a local context and focus on ways to implement change at the lowest level possible, such as developing point-of-care testing.

 

In summary, current global circumstances present challenges to be overcome, such as funding for surveillance and prevention of AMR and other infections, but also opportunities.  Never before has there been such global awareness of the spread of infections, including how they may spread from the environment.  We can use the present moment to re-evaluate our global health security and learn lessons about preparedness and resource management to improve our surveillance and management of future threats to our health and environment.

 

Dr Elizabeth Hardman

Communications Co-Lead for Health Professionals for Global Health

 

With thanks to our speakers and chair:

• Adam Roberts, Reader, Antimicrobial Chemotherapy and Resistance, Liverpool School of Tropical Medicine and RSTMH Policy Advisor on AMR 

• Claudia Trupper, Public Health Specialist and Health Coordinator, International Committee of the Red Cross

• David Heymann, Professor of infectious disease epidemiology, London School of Hygiene & Tropical Medicine and RSTMH policy advisor on climate change

• Uzma Bashir Amir, COVID lead at the Program for Monitoring Emerging Diseases (ProMED) and WHO Pakistan

• Chair: Aula Abbara, Consultant and Honorary Research Fellow in Infectious Diseases, Imperial College London

 

1Reason J. Human error: models and management. BMJ. 2000;320(7237):768-770. 

2Aitken T, Chin KL, Liew D, Ofori-Asenso R. Rethinking pandemic preparation: Global Health Security Index (GHSI) is predictive of COVID-19 burden, but in the opposite direction. J Infect. 2020;81(2):318-356.