Two decades of alerts for infectious diseases reveal the disparity of criteria and the weight of the human factor

Until now, an official pandemic model had not prospered to record the health alerts that are reported around the world on a daily basis, sometimes tens of thousands a day. The covid pandemic accelerated a unifying process that had already been underway for years, but still needed to be developed. Today, a group of scientists publishes an unprecedented record of official alerts from the World Health Organization (WHO), which allows any doctor to report potential health threats from around the world. And, in addition, it offers a detailed review of what the epidemic outbreaks of the last two decades were like, just until months before the covid pandemic broke out.

The authors point out that their work with the historical record allows us to observe recurring global threats, such as influenza or cholera, and persistent epidemics, such as Ebola virus disease in Africa or MERS-CoV in the Middle East. Another piece of information is the persistent inequality between countries, not just North-South, when it comes to reporting diseases. “Egypt, with 115 health alerts, is the fifth country in number of notifications and with strong monitoring of yellow fever, while the neighboring country Libya has never reported anything, reflecting the collapse of its health system, once very effective. after two civil wars”, laments rebecca katzdirector of the Center for Global Health Sciences and Security at Georgetown University Medical Center (Washington, United States), and leader of this review covering 1996 to 2019.

Among the information collected, China stands out with the highest number of health alerts (262), in its case the majority related to different types of flu. Katz celebrates the coincidence between the information collected and the accuracy with which epidemics have been recorded, since despite “the lost protocols”, the redundant information or the problems when the categories do not coincide, there has not been any phantom pandemic “no reported”.

“The WHO page is the main source of information on health,” says Katz, “so we believe that the official record must be approved.” The researcher details how specialists must “monitor tens of thousands of signs every day that may represent a serious global health problem, and all the time they must elucidate what is relevant and what is not.” Hence, the main author considers it vital to design a model like hers that unifies criteria throughout history on health alerts. The synthesis presented by the Georgetown team is intended to make it possible to consult in network all over the world.

The criteria of the experts

the epidemiologist Susana Monge Corella, who has not participated in this research, highlights another key that draws attention after analyzing the work: the human role when deciding the severity of an outbreak. In those moments the experience is a degree for the expert: “You filter thanks to the accumulated knowledge, but there is no committee of experts where health alerts are decided in which there has been no discussion, despite the decades of knowledge.” “Due to the complexity of decision-making, the human factor is difficult to replace,” concludes the person who was part of the Health Alerts and Emergencies Coordination Center of the Ministry of Health during the covid crisis.

Monge, from the National Epidemiology Center of the Carlos III Health Institute, points out that there are other infections with which the decision to report is made based on the unexpected or virulent nature of the event. “A family intoxicated with botulism from a homemade preserve is a concrete problem; but if a child is poisoned with botulism by a commercial milk formula that has been sold throughout Spain, then the same disease has a completely different risk, another dimension, and if the milk brand is foreign it is already an international problem ”, summarizes the epidemiologist.

A case of bird flu is “priority one, every event is notifiable” and is subject to “vigilant surveillance over the years, hence its prevalence in the study,” Monge points out. Hence the alarm generated by the outbreak among minks that emerged in Galicia and that has put virologists around the world on alert, although it has not reached humans.

Dangerous flu outbreaks are the main disease reported in these 26 years with 776 notifications. For example, the last recorded outbreak, on January 18, 2023, is one of Avian flu in a 9-year-old girl in Ecuador. Due to its prevalence for decades and severity, in the new work the Georgetown scientists highlight that they have unified the different subtypes of influenza, considering that the WHO obliges to report the new variants in accordance with the International Health Regulations. In an attached comment, they describe that the number of flu cases has increased globally, but that due to its pandemic, fewer are reported, and that distorts certain parameters. The authors are aware of the thousands of people infected with influenza A in Iran and India, or other minor cases in Canada or the Netherlands, during the last decade, but that only China has reported them.

The Georgetown researchers reviewed 2,789 reports of WHO disease outbreak news, which span from 1996 to December 2019, shortly before the current covid crisis. These online documents contain the relevant information on unexpected epidemic outbreaks, such as the Ebola virus from 2014 to 2016 in West Africa or the cholera virus from 2011 in the Democratic Republic of the Congo, and in them you can read the “decision making level that governs the exchange of information during a public health emergency,” the researchers explain in the paper. That is why Katz concludes that more information transparency and “the adoption of standardized formats to share epidemiological data” would help its dissemination and the usefulness of the reports for other specialists. Despite this, the author admits a tangible improvement in the WHO health alerts registry due to the new normality imposed by the pandemic.

Monge considers that the role of the WHO is “delicate, because it must be very careful when alerting about outbreaks”, since it must “coordinate communications” and mediate between different organizations and countries. For the researcher, it does need to be better added to search engines or have more precise labels, but she believes that “asking for the same type of writing does not make sense, because it influences who writes that report over decades.”

There is no committee of experts where health alerts are decided in which there has been no discussion, despite decades of knowledge, due to the complexity of decision-making, the human factor is difficult to replace

Susana Monge Corella, from the National Epidemiology Center of the Carlos III Health Institute

All healthcare professionals must report a possible infectious outbreak and report it urgently on the mere suspicion of a case. An alert about an epidemic outbreak is anything that could “pose a risk to public health,” sums up the specialist in Preventive Medicine and Public Health Jose Maria Arteagoitia Axpe. The speed in the transmission of information is “essential”, affirms the expert, given that the objective of the epidemiological surveillance system is “the detection and control of communicable diseases”.

The professional points out that to support the surveillance of infectious diseases there are “protocols for more than 60 notifiable diseases” such as “whooping cough, hepatitis A, tuberculosis or meningococcal disease, others less frequent in our environment such as measles and other emerging such as the West Nile virus or Ebola”, as detailed in the Department of Health of Euskadi. Arteagoitia, emeritus head of the Service in the Department of Health of the Basque Government, points out that the surveillance procedure for diseases, outbreaks and health alerts “is legally protocolized and regulated”, although he admits that “it is true that it is currently not completely automated, Steps are being taken in this direction, such as the data going directly from the health system to Public Health ”, he points out.

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