Preparing for the Next Pandemic

Introduction

During the last two years, everyday life has been defined by numerous challenges created by COVID-19, including societal restrictions, overflowing hospitals, and consistent illness and death. While COVID-19 itself seems to be here to stay at least for the foreseeable future, thankfully, the pandemic seems to be reaching its end with the help of vaccinations and gained natural immunity. It is an achievement worth appreciating, but we must also be mindful of the heavy cost the virus took on our society and the ever-present dangers that future pandemics pose.

There are many areas in which we can prepare for the next pandemic, even though the shape and nature of any potential inciting pathogen may be unknown. Utilizing scientific advances, harnessing the regulatory and spending power of the government, and investing in healthcare workers are three key areas that must be addressed before the next viral threat wreaks havoc on American life, with potentially deadlier consequences.

Scientific Advances

Genomic Sequencing

One of the main challenges of COVID-19 was being unable to anticipate the virus’s severity and transmissibility. Fortunately, there are methods that scientists can employ to preemptively identify new viruses before they pose a significant threat. One of these methods, genomic sequencing, is already in use by scientists to identify COVID-19 variants, track their spread, and evaluate their similarities and differences to other COVID-19 variants.

Genomic sequencing is a process that occurs when scientists collect and sequence viral specimens from people who test positive for COVID-19. Identifying and decoding the genetic material in this sample allows scientists to know the specific COVID-19 variant that has been collected. Genomic sequencing can predict the level of spread of a previously unknown variant and can determine how effective treatments, such as antibodies, are against these variants[1].

Genomic sequencing is an important tool that can be utilized in preventing future pandemics. Since the Centers for Disease Control and Prevention (CDC) created the SARS-CoV-2 Sequencing for Public Health Emergency Response, Epidemiology, and Surveillance (SPHERES) consortium, the United States has been able to detect variants that have infected as small of a sample as 0.1% of the U.S. population. Genomic sequencing has improved our understanding of COVID-19 variants, helped clarify treatment recommendations, and contributed to advances for variant specific vaccines. Since the start of the pandemic, approximately 3.8% of COVID-19 samples have been sequenced. In order to determine the existence and prevalence of undetected viruses, it is important that this process continues to be utilized[2].

Unfortunately, the United States still lags behind other countries in percentage of COVID-19 samples that have been sequenced. For example, the United Kingdom has sequenced over 10% of its COVID-19 cases[3]. Instead of expanding use of genomic sequencing, the United States has cut back on it, pulling genomic sequencing funding from the most recent Bipartisan COVID-19 Supplemental Appropriations bill passed in Congress. In order to anticipate future COVID-19 variants and other potentially threatening viruses, it will be important to increase usage of genomic sequencing rather than scale it down.

Vaccine Development

The COVID-19 vaccines created by Pfizer, Moderna and Johnson & Johnson were essential in helping our population gain immunity from COVID-19, but their development and distribution took time and were hindered by regulatory and logistical roadblocks. There are many ways that the United States can expedite the development of future vaccines to ensure a quicker process when the next viral threat arrives.

Operation Warp Speed provided funding for the United States to develop and distribute a COVID-19 vaccine more quickly than for any previous virus in history in human history, but it still took over a year for a majority of U.S. residents to have access to the vaccine[4]. When analyzing the elements of the vaccine creation and production process, it is evident that the development of vaccines can be done in a short amount of time; the multiple required trials to test the vaccine are the time-consuming aspect of the process. Different phases of trials are required, first to test the safety of the vaccine in small cohorts (20-80 people) and then to test effectiveness in larger cohorts (100-300 people). These Phase 1 and Phase 2 trials can take months to complete before Phase 3 trials can test effectiveness and safety in even larger samples, which slows down the timeline for potential vaccine approval by the FDA. In the future, there should be an emphasis on identifying which diseases will cause the next pandemic. If Phase 1 and Phase 2 trials are preemptively completed for vaccine candidates of identified viral threats, vaccine testing can begin with Phase 3 trials if required, expediting the process by months[5]. This is more costly in the short term but cheaper in the long run. Although the vaccines might not be necessary, having one on hand immediately ready to test could avoid the economic consequences that the COVID-19 pandemic wrought.

Another solution to the problem of being unable to anticipate the next viral threat is to create universal coronavirus vaccines, or those which have some effectiveness against a large variety of coronaviruses. Although their effectiveness might not be as high as variant-specific vaccines, the ability to anticipate future COVID-19 variants or other coronaviruses and treat them with even a 50% efficiency rate would be a major improvement over having no available vaccine at all, as was the case in 2020. Additionally, having a vaccine with a proven immune response allows testing to commence at the variant-specific phase, saving a lot of time in the process[6]. Companies and agencies have already started attempting to implement this mindset when developing new vaccines. In 2017, the Coalition for Epidemic Preparedness Innovations (CEPI) was founded as an international alliance to develop vaccines against potential viral threats, and has already begun to study 25 “viral families” that pose a threat to cause another pandemic. In March of this year, Moderna announced that by 2025, it would begin trials of early-stage vaccines that targeted 15 high-priority pathogens.

Governmental Regulatory and Monetary Power

Removal of Regulatory Barriers

The integration of COVID-19 testing into the United States’ public health infrastructure had its share of challenges. Early in 2020, the United States knew that COVID-19 was becoming more prevalent but had no way of determining exactly how prevalent. The CDC mandated that all testing samples be run through their lab through February and the FDA mandated that all testing would require emergency use authorization, meaning that the requirements for laboratories to test were strict. The Seattle Flu Study, an early indicator of the severity of COVID-19, conducted tests despite the state of Washington and the FDA telling them to stop[7]. The difficulty of conducting COVID-19 tests early on in the pandemic severely handicapped our ability to predict the virus’s arrival and led to test shortages well into 2020. The United States proceeded to face test shortages whenever case counts surged, which proved to have a cyclical effect, as the lack of testing likely contributed to the viral surge.

In the future, the United States should make advance funding of diagnostics as high a priority as vaccine development. The elimination of “red tape” surrounding authorization and distribution of tests would have allowed for a much quicker diagnosis and understanding of the COVID-19 pandemic in early 2020. Programs like RADx, which allocates $1.5 billion for SARS-CoV-2 test developers, are a good start, but more must be done to bring diagnostic development programs like this in line with the commitment made by the U.S. government in Operation Warp Speed.

Increased Funding for Future Pandemics

Increased focus on scientific methods to detect dangerous viruses and removal of regulatory barriers for testing are important strategies for pandemic preparedness, but these strategies need the funding of the federal government to have any real effect. The federal government passed several pieces of legislation designating large amounts of relief funding to help address the COVID-19 pandemic, but they haven’t yet acted to ensure that this won’t happen again in the future.

Congress recently introduced the bipartisan PREVENT Pandemics Act, which, among other provisions, creates a commission to investigate the governmental shortcomings in the COVID-19 response and establishes a government office to focus on pandemic preparedness. The legislation also increases methods of information-sharing between the CDC and other agencies, which was a key area of failure during this pandemic. However, the bill only includes about $2 billion in new spending, when much more is required to address the problems that a future pandemic might cause. Additionally, this bill has not passed Congress yet, further delaying the positive effects its potential implementation might bring

The Biden administration has tried to address the looming threat of a future pandemic through increased budgetary funding for pandemic prevention initiatives. In putting together its FY 2023 Budget, the Biden administration incorporated multiple funding avenues for pandemic preparation, designating $88 billion across multiple agencies. These include:

$40 billion for the Department of Health and Human Services (HHS) to invest in advanced development and manufacturing of countermeasures against viral threats
$28 billion for the CDC to enhance public health system infrastructure
$12.1 billion for the National Institutes of Health (NIH) for research and development of vaccines and biological threats
$1.6 billion for the Food and Drug Administration (FDA) to expand regulatory capacity

Approval of this budget will deliver massive funding streams to ensure that testing capabilities are at an adequate level to prevent another pandemic on the level of COVID-19.

Additionally, evaluating the clinical trial infrastructure in place and providing funds to improve its effectiveness is an important aspect of pandemic preparation. Last year, Dr. Janet Woodcock, acting commissioner of the FDA, noted that only five percent of COVID-19 therapy clinical trials would yield useful information about safety and efficacy. This is due to low enrollment and lack of design focus on the evaluation of clinical benefits and risks. Combining these shortcomings with a lack of infrastructure to conduct large-scale clinical trials leaves plenty of room for growth. One model that the United States can look to is the U.K. RECOVERY Study, which collected data and identified COVID-19 treatments at a much faster pace than the United States. Although this was partly due to the U.K. nationalized health system, if the United States could figure out how to bridge data-sharing gaps, it could create a similarly scaled operation. Proactively enrolling people in trials and establishing data-sharing agreements would allow for the United States to prepare for action when a pandemic becomes a threat[8].

Investment in Healthcare Workers

Removal of Barriers to Working

Relaxing regulations that prevent people from practicing medicine is the first step the United States can take toward fixing our healthcare staffing problem. Currently, providers must be authorized to work in a certain state and in a certain type of medicine. During the public health emergency, many states took steps to remove these barriers to make it easier to practice medicine. Easing these requirements would allow providers to practice with out-of-state licenses, doctors from other countries to practice in the United States, and Registered Nurses (RNs) to perform their duties without a doctor on hand. This would increase flexibility and thus staffing for hospitals that are understaffed during future public health emergencies[9].

Because of the rise in telehealth during the last two years, many states have waived these requirements for telemedicine appointments or have lifted the requirements completely. Additionally, 22 states and the District of Columbia have granted “full practitioner status” for nurses, meaning they can “assess, diagnose, interpret diagnostic tests, and prescribe medications independently.”[10] To ensure that all patients can be seen in situations where healthcare staff capacity is low, more states should pass laws or implement waivers to remove barriers to allow for this staffing flexibility.

Invest in Increasing Capacity

Although PPE and testing shortages were major limiting factors during the pandemic, it was the strain placed on the human infrastructure that proved to be the greatest burden. At multiple points throughout the last two years, the surge in COVID-19 cases threatened to overwhelm hospital staff. ICUs were often overflowing, and drastic measures were taken to free up bed space, including rescheduling or cancelling all elective procedures[11]. It is incumbent upon the U.S. government to provide more funding to increase hospital staffing capacity during periods like this. With additional funding, a reserve of public health workers and community workers could be created to supplement existing healthcare staff in the event of rising pandemic-related hospitalizations. These workers already assist by shouldering some of the burden that the healthcare system carries during times of crisis and providing more funding to hire more of them would further assist with this problem. Additionally, closing the gap between spending on nursing education (about $260 million) and graduate medical education (about $15 billion) would create more opportunities for nurses to supplement hospital staff in this manner. Finally, creating a national coordination system for traveling nurses and doctors, rather than leaving this task up to independent agencies, would allow for a more targeted approach to aiding areas of the country in need of assistance[12]. An increase in patients must be met with an increase in staffing, which can only occur through additional funding and coordination on the part of the government.

Avoid Burnout

Hospital staff burnout has been an ongoing concern of the COVID-19 pandemic, as the combination of staff turnover and COVID-19 cases have put a strain on hospital workers. This has created a cycle where healthcare workers are driven from the industry, thus placing additional strain on their peers. As detailed in the January Health Policy News article “The Hidden Costs of COVID-19,” healthcare worker burnout was a major pre-pandemic concern and has only intensified since then. One Morning Consult poll found that since February 2020, 18% of healthcare workers surveyed had quit their job and another 12% had been laid off. Of those healthcare workers who were still employed, 31% of them had thought about quitting their jobs at one point, with 19% of those workers having thought about leaving the healthcare field entirely. This burnout epidemic should be a major priority to address before the next health crisis. The American Rescue Plan designated $103 million for the Health Resources and Services Administration to strengthen resiliency and address burnout in the healthcare force. More funding should be pledged for additional interventions at the hospital level, which can be tailored towards the specific needs of a given hospital’s staff.

Conclusion

The COVID-19 pandemic has exposed structural weaknesses in the U.S. healthcare system and government emergency response but has given us a chance to fix these weaknesses before a future pandemic exposes them even further. Addressing shortcomings in our pandemic response will be essential in fighting future battles instead of being mired in dealing with the problems of the past. To accomplish this, the United States must focus on harnessing scientific advances, removing regulatory barriers, and utilizing government spending power for a pandemic response, as well as preemptively bolstering the healthcare workforce. It is impossible to solve future challenges that cannot be anticipated; indeed, who would have predicted in 2019 that a respiratory virus would shut down society for the better part of two years? However, we have it within our power to learn lessons from the last two years to best prepare us for any similar events in the future and avoid some of the catastrophic outcomes that will forever define the COVID-19 pandemic.