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PANDEMIC-XX: What Will the Next Pandemic Look Like?

What if I told you that the world is about to enter the next pandemic? That humankind is entering a pandemic era?

COVID-19 is the most devastating pandemic in a century, but it was not an unusual occurrence. Pandemics and plagues have devastated the world for thousands of years. In the early 20th century, the Spanish Flu killed 50 million people. Yet, to many laypeople, pandemics seem like a thing of the past or at least something that only ravages distant societies in sub-Saharan Africa. 

With COVID-19, that false reality has been punctured. But, as we emerge from one global outbreak, we must remember that the next pandemic isn’t just a possibility—it’s a certainty.

The Coronavirus has impacted the world of public health in countless ways. It exposed problems with our current systems; it shed light on our strengths; it proved to the world that we can’t ignore the possibility of a future pandemic.

But, what have we learned from dealing with COVID? What is it about the modern world that makes us susceptible to these diseases? And what could the next global pandemic look like? 

To answer these questions, we’ll have to look back into the history of pandemics, public health, and antibiotics. But, we’ll also have to look forward to the handful of diseases that constantly threaten global outbreak.

Let’s explore.

Infectious diseases have ravaged the world throughout recorded history. The word pandemic stems from Ancient Greek, as Hellenistic society sought a word to encapsulate a plague that affected all people. Yet, for most of human history, the idea of a pandemic was hardly possible. That’s because the world has never been as connected as it is today. 

The Black Death bubonic plague is the most deadly pandemic in history, killing anywhere from 75 to 200 million people. The disease arrived in Southern Italy in 1347, and it took three years for the plague to reach Scandinavia. In contrast, COVID took just 4 months to travel from Wuhan to Seattle.

In other words, diseases used to travel at the speed of a horse. Now, they move with the velocity of a Boeing jet. 

Our increasingly globalized world is perhaps the first important reason we’re still susceptible to pandemics despite advances in medical technology. Our cities are more crowded than ever. International travel is more accessible today than at any other time in history. With that comes endless opportunities to transmit diseases.

But, as the world has learned over the past year, most diseases don’t originate within humans—they come from animals.

The US Centers for Disease Control (CDC) estimates that up to 75% of new viruses come from animals. That’s where we get names like swine flu or bird flu. Just as globalization increases the chances of human-to-human transmission, it also indirectly raises the likelihood of animal-to-human transmission. 

That’s because, as urban areas have expanded and natural habitats have been destroyed, the distance between humankind and disease-carrying creatures has decreased. These creatures could be mosquitoes, rats, bats, monkeys, birds, pigs, or almost anything else. 

The amount of contact required to pass disease from an animal to a human is tiny. Humans don’t have to eat bats to get infections from them; they don’t have to get bitten by rats. Someone touring a cave filled with bats could simply touch a surface that a bat has defecated on, then rub their eye. A speck of rat feces could get into a bag of rice or corn. 

As deforestation and habitat destruction continue, animal-human interactions will increase, perhaps to dangerous levels. Researchers say animals carry over 500,000 different diseases that could potentially be passed over to humans. Thankfully, most of them never will. 

We don’t have a perfect understanding of how viruses evolve so they can be transmitted to humans. Modern theories suggest that this evolution happens gradually, with the initial jump sometimes happening years before the first confirmed outbreak occurs. 

This theory is exemplified by one of the viruses that public health experts believe could lead to the next pandemic: Ebola. 

Ebola Virus by NIAID is licensed under CC-BY

The first deadly outbreak of Ebola was reported in 1976. Since then, the disease has popped up several times, mainly in West Africa and the Democratic Republic of the Congo. It was passed to humans via bats, porcupines, and monkeys.

Thankfully, Ebola isn’t transmitted as easily as many other viruses, including Coronavirus. It requires close human contact with the sick person’s bodily fluids, such as blood, feces, or vomit. Yet, what Ebola lacks in transmissibility, it makes up for with astronomical mortality rates. In the DRC, out of about 3,500 cases, more than 2,250 have died. At its most extreme, the mortality rate has reached 90% in some areas. 

This high likelihood of fatality is one of the reasons that public health experts fear Ebola. Yet, for some, it’s actually a sinister silver lining. That’s because the disease often kills people before it can be passed on to others.

For years, this has assuaged fears of a global Ebola outbreak. Still, some scientists warn that, before long, Ebola will be airborne, making it easily transmissible between humans. That possibility is the most crucial reason that Ebola could lead to the next pandemic. 

Despite all of that, there is reason to believe that we could withstand an Ebola pandemic. Recent outbreaks in Africa led to increased funding for vaccines and other forms of Ebola prevention. Also, retrospective tests have shown that Ebola spread to humans years before anyone showed any symptoms. With increased monitoring and coordinated public health responses, this could give scientists the time to develop vaccines for new forms of Ebola, those resistant to current vaccines, before they reach pandemic levels. But, it would require severe changes in how we observe potential outbreaks.

The current system for detecting threatening outbursts of novel diseases was established by the World Health Organization in 1947. As you may have guessed, it’s tragically outdated.

The process relies on something called syndromic surveillance—sentinel hospitals check patients against a list of standardized symptoms for potential pandemics. In the best-case scenario, the first person to catch a new disease shows up at a sentinel hospital; their symptoms are immediately attributed to a novel outbreak; then, officials at that hospital convince the rest of the world that they’ve discovered a new viral outbreak. But, it has never happened like that.

Even if it did, it wouldn’t matter. Public health officials say that when someone shows up at the hospital with a new disease, it’s already too late. The outbreak has occurred. 

More modern strategies call for real-time surveillance of areas where animal-to-human transmission is likely to occur. That’s because, like with Ebola, scientists believe that viruses can jump from animals to humans years before that virus becomes dangerous and transmissible between humans. Again, this would allow scientists to develop new vaccines, and it provides crucial data for predictive modeling to predict the next global outbreak.

These predictive modeling tools monitor viruses and rank them according to risk factors that determine their likelihood of becoming a pandemic. These risk factors include things like how many animal species the virus infects, how often humans interact with wild animals in the areas where the virus has been detected, and human-to-human transmissibility. Ebola consistently ranks near the top of these lists.

Other high-ranking viruses include Lassa Fever, Marburg virus, and one that we’re all familiar with: influenza.

Volunteer nurses from The American red cross during flu epidemic (1918)
Volunteer nurses from The American red cross during flu epidemic (1918)

The Spanish Flu pandemic of the early 20th-century affected 500-million people, killing up to 100-million. Thankfully, the mortality rate is much lower today. But, what the flu lacks in fatality, it makes up for with high transmissibility. It can quickly be passed between humans through contact with respiratory droplets from sneezing or coughing. Wild birds and poultry carry many different strains, and human proximity to these carriers is closer than ever.

To the general public, a flu outbreak may not seem too high a risk. That’s because new flu vaccines are available each year. Plus, the flu disproportionately affects the elderly and infants.

Unfortunately, neither of those statements is entirely accurate. 

For one, vaccines are only effective when much of the population receives them. COVID has demonstrated that we can’t take widespread vaccine use for granted. Furthermore, the most dangerous flu strains have proven unpredictable in their drug resistance and who they affect. Also, the most threatening of these variants has proven to affect all age demographics with equal intensity.

The two strains that most worry public health officials are H5N1 and H7N9, and these strains have higher mortality rates than the typical seasonal variety.

Between 1997 and 2019, there were 861 confirmed cases of H5N1. Of that number, 455 were fatal, placing the mortality rate above 50 percent. Of those affected, more than half were below 40 years old. For H7N9, the mortality rate is closer to 40 percent, and two-thirds of deaths were in people over 50. Still, for both of these strains, mortality rates are unusually high.

In recent years, researchers have discovered that H5N1 has acquired resistance to many therapeutics. Typically, these therapeutics are just 10-60 percent effective, and they aren’t available in many developing countries. Altogether, this makes another influenza pandemic a grave possibility.

Choosing between all of these viral infections can feel a bit like a guessing game. Yet, the next pandemic may not stem from a viral outbreak. Ultimately, it may look less like COVID or the Spanish Flu and a bit more like the Black Plague.

Plagues stem from bacterial infections rather than viruses. The Black Death was a bubonic plague, but we could be facing a pneumonic plague. 

These lung infections break out across the world almost every year. They’re carried by rats and often passed to humans via fleas that live on those rats. A recent outbreak in Madagascar affected 2000 people and killed 200. 

But, it isn’t the mortality rate that worries public health officials. It’s the bacterial nature of the disease and the problems with treating that kind of infection. 

There is no plague vaccine available in the United States and most developed countries. That’s because bacterial infections are typically treated with antibiotics. 

Sir Alexander Fleming discovered the first antibiotic, penicillin, in 1928. The discovery was groundbreaking and would go on to shape the next 100 years of medicine. 

But, it also had unintended consequences. Antibiotics rely on living organisms to produce compounds that fight other living organisms—the bacteria. However, by harnessing these organisms, humankind set off an evolutionary battle for survival between antibiotics and the bacteria they fight. 

As a bacterium is exposed to an antibiotic, it evolves to develop resistance. As such, it’s absolutely critical that doctors refrain from overprescribing antibiotics. Unfortunately, that hasn’t happened.

In the US alone, almost 260 million antibiotics are prescribed each year. The CDC estimates that at least 30% of those are totally unnecessary. At COVID-19’s onset, there was an uptick in this number of prescriptions. Altogether, this means that many bacterial infections have developed extreme resistance. 

One of the most common bacterial diseases, urinary tract infection, has developed resistance of 90% of various antibiotics. That number is closer to 30% for pneumonia, but it’s on the rise, and it may be impossible to overcome.

That’s because funding for new antibiotics has dried up. Profit-seeking biopharmaceutical firms have moved away from developing new antibiotics in response to the warnings against overprescribing them. Changing that reality would require vast influxes of money from governments.

The dark reality is that it may already be too late.

A 2014 study by the British government estimated that up to 700,000 deaths each year can be attributed to the antibiotic resistance of bacterial infections. The same study estimated that, by 2050, that number could be as high as 10 million. 

That figure is derived from a whole host of bacterial infections rather than a single disease. But, if a highly contagious and resistant strain of pneumonic plague were to sprout up, there’s no guessing where it would stop. Doctors in Europe recently discovered a pneumonic bacteria that resisted almost all of their antibiotics. 

A pneumonic plague would be entirely different from pandemics like COVID, and there’s little modern historical precedent to forecast just how bad it could become. 

Yet, hope is not lost. Over the past 18 months, the world has learned so much about how to deal with a dangerous outbreak. We’ve discovered our strengths—like timely vaccine development—and our weaknesses—like coordinating between public health agencies and separate governments.

Stemming the tide of the next pandemic will require increased coordination between those entities. It will also require improved surveillance and proactive funding of new vaccines and antibiotics. 

Despite the painful consequences of living with COVID-19, the world has been lucky this time. If not for COVID’s relatively low mortality rate, there could have been tens of millions of deaths already.

For the next pandemic, that may not be the case.

Of course, we can’t know with perfect accuracy what the next pandemic will be. But, we have a good idea of what it might look like, whether it’s Ebola, Influenza, Pneumonic Plague, or something else, like Lassa Fever or the Marburg Virus. 

There’s no hope of stopping the next pandemic, but with the right changes, we may be able to delay it and dampen its impact.

But what do you think? Which potential outbreak would be most catastrophic? Which seems most likely to happen? Have we learned enough from the COVID pandemic to change our systems to prevent the next global pandemic? Or does the increasingly globalized and antibiotic-resistant world mean that it’s just a matter of time until the next deadly disease affects so many lives? Let us know what you think in the comments, and, as always, thanks for watching.

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