Public health: Five keystones on managing pandemics

Precision Medicine at Population Scale

by Luis Lasalvia, MD, MIB and Reto Merges, Siemens Healthineers

Executive summary

There isn’t one single solution to managing COVID-19 or other pandemics. Rather, there are five critical keystones needed for effective pandemic management: 1. testing, 2. tracing, 3. public health infrastructure, 4. global collaboration, and 5. addressing the most vulnerable patients, are key to successfully navigating pandemics. Understanding the factors that place people at risk for infection, morbidity, and mortality and developing tailored precision medicine approaches for each patient is vital to successful management.

COVID-19 pandemic puts health systems to the test

The consequences of COVID-19 have been devastating for the population worldwide: millions have been infected  and hundreds of thousands have died, while massive unemployment and supply chain challenges have pushed social safety nets to the breaking point. The impact has been unprecedented, and the long-term  physical,  psychological, and economic toll of the pandemic is as yet unknown.1

As the pandemic rages on, “infodemics” – outbreaks of false, misleading, or unsafe information on the pandemic – have eroded public trust in global agencies and government institutions in some countries. With the advent of online channels and social media platforms, disinformation can spread rapidly and hamper mitigation efforts.

However, significant progress has also been made on a number of fronts. Control measures such as social distancing have significantly slowed the spread  of the virus where they have been implemented aggressively. Manufacturers have refitted plants to produce personal protective  equipment (PPE), ventilators, and other vital supplies. Vaccine development efforts are proceeding at a record pace.

The principles of precision medicine can  guide our collective response to COVID-19. Precision medicine can help us to understand who is most at risk, and why; and to tailor both individual treatment and community responses to COVID-19, based on high quality data. Rather than increasing expenses, this approach actually directs resources to where they will have the greatest impact.

Precision pandemic response: Five keystones

A global pandemic requires a robust international response. That response should be guided by data, and tailored to the unique circumstances of each patient as well as the national or regional context. We have identified five “keystones” that are vital to a successful pandemic response. In each of these domains, a precision, data-guided approach will maximize the effectiveness of the response.

1. Testing

Extensive testing is a foundational key to controlling the pandemic. Testing identifies ongoing, potentially infectious, cases; and also helps assess total community exposure and identify “hot spots.”

Design of a national testing program can be thought of as an exercise in precision medicine at scale. Which tests are provided  to  whom, and when, depends on an array of factors unique to a given region or country. Access to healthcare facilities, laboratory analyzer and reagent availability, and reliability of tests and equipment are just a few of the key variables that must be taken into account when devising  a testing program.  Designing test programs with these factors in mind enables national health agencies to maximize the impact of finite testing resources.

The two main types of testing for COVID-19 are polymerase chain reaction (PCR) testing for active infection and antibody (or serologic) testing to determine prior exposure to SARS-CoV-2, the virus that causes COVID-19. Together, these two forms of testing can help health agencies get a clear picture of the state of the pandemic, and assess the effectiveness of their response with great precision.

Serologic testing has also been considered a factor in developing “immunity passports,” government-backed certificates that indicate the bearer has immunity to the virus and can therefore return to work and other activities. However, there is currently no evidence that COVID-19 recovery and the presence of antibodies confers prolonged immunity and protection from a second infection.

2. Tracing and surveillance

Contact tracing can help control outbreaks, particularly when  the prevalence  of infection is relatively low. Widespread contact tracing, coupled with quarantine of exposed persons, can reduce transmission by up to 50% , if 90% of new cases are detected and 90% of their contacts are identified.2

Technology, including smartphone apps, can be important tools for contact tracing. Countries like New Zealand and Uruguay have used an integrated approach of  online and offline contact tracing to stem community transmission of COVID-19. South Korea leveraged its experience with previous epidemics and its excellent IT infrastructure to create a sophisticated contact tracing program that draws upon data from a wide range of public and private sources.3

But there are limits to the effectiveness of contact tracing. Regions with a high prevalence, relatively low testing rates, and a general distrust of guidelines by national agencies have difficulty executing ambitious contact tracing programs.2

3. Public health infrastructure

By one estimate, a partial economic shutdown in the US reduces gross domestic product by 5% per month. That quickly adds up to a staggering toll – a loss of $2 trillion and tens of millions of jobs in the first few months of shutdown in the US.4  Meaningful investment in contact tracing infrastructure and widespread molecular and serologic testing can help the US contain the spread of the pandemic for roughly $5 billion USD.4

Modernized and standardized healthcare IT infrastructure can enable real-time data sharing so that health agencies can respond with speed and precision to new outbreaks or hot spots. Precision in early detection and aggressive mitigation can produce powerful results, like those achieved in New Zealand.

Other important investments include systems for rapid production and distribution of personal protective equipment, and development of a trusted communication and education system that provides citizens with data-driven advice and practical assistance to help them stay safe during a pandemic. Such communications should be precisely targeted to promote voluntary compliance and overcome cultural barriers.

4. Global collaboration/coordination

Because viruses do not respect national borders, a disease outbreak anywhere in the world can quickly become a pandemic everywhere in the world. Effective coordination at a global level, in addition to robust, precise, data-guided national and regional efforts, is vital to successfully overcoming a a pandemic.

A global infectious disease surveillance system could provide early warning of regional outbreaks so that authorities could act to prevent further transmission.

East Asian nations have developed considerable experience in managing infectious epidemics. A variety of robust responses to COVID-19 in countries including Japan and South Korea led to lower caseloads than those seen in many Western nations that were slower to take meaningful action. This expertise should be shared in a collaborative manner, along with information on the equipment and technology these nations used to enact rapid testing, tracing, and quarantine protocols. And naturally, any information on the disease and the virus itself should be made available to the research community worldwide, to accelerate progress and avoid duplication of effort.

Finally, it is in the best interest of wealthy nations to assist lower-income countries in managing local infectious disease outbreaks, which can quickly jump national borders if not contained.

“Identifying groups that are at higher risk to exposure and disease-related mortality, and applying precision medicine to disease prevention and treatment, is critical to successful pandemic management”

5. Addressing the most vulnerable patient populations and high-risk groups

Identifying people that are most vulnerable to an infectious disease outbreak like COVID-19 is vital to providing a precision approach that addresses subpopulations’ specific needs.

Essential workers, like healthcare providers and people who work in food industries, perform life-sustaining work and must be given the equipment and knowledge to do their jobs with minimal risk. They should be prioritized for receiving PPE, testing and other resources.

Other key risk factors include limited access to healthcare and socioeconomic factors. For example, African-Americans are less likely to have insurance coverage and also face an increased risk of hospitalization and death from COVID-19.5  Other populations, like undocumented immigrants and LGBTQ people, often face similar barriers to care and may suffer disproportionately from infectious disease outbreaks.

A data-driven precision medicine approach can help identify vulnerable populations and give them the support they need. Mitigating community transmission in these populations is vital to containing pandemics.

Conclusion

During a pandemic, widespread testing is a must. Rapid contact tracing and quarantine/ isolation can decrease community transmission. Meaningful investments in health infrastructure are necessary for management of the current pandemic, and can prepare countries and regions for future outbreaks. International cooperation is vital for early identification of outbreaks, as well as sharing best practices and scientific research.

And finally, identifying groups that are at higher risk to exposure and disease-related mortality, and applying precision medicine to disease prevention and treatment, is critical to successful pandemic management. By addressing these 5 keystones of pandemic management now, we will be better equipped to manage not just COVID-19, but also subsequent pandemics.

Luis Lasalvia, MD, MIB
Vice President, Global Medical Officer, Siemens Healthineers

Dr. Luis Lasalvia leads by driving high financial and clinical value across organizations. Keynote guest speaker, panelist, and moderator at about 500 events and conferences around theworld, Luis has authored close to 50 peer reviewed papers and articles in prestigious publications; while submitting multiple patents in Europe and the US. He’s been leading numerous teams, participating in advisory boards, developing new ventures, and innovating in multiple fields in more than 30 large programs in the US and across multiple countries in Europe and Latin America, and is international advisory board member. Dr. Lasalvia lives in New York, and is Medical Doctor from the Republic University in Montevideo, holds a Master in International Business from Pompeu Fabra University in Barcelona, postgraduate degree in Business Administration and Executive education at The Wharton School of Business, New York University, and Harvard Business School.

Reto Merges
Global Head of Expanding Precision Medicine Siemens Healthineers

With more than ten years’ leadership experience in healthcare marketing, Reto Merges has a strong track record in building effective teams for clinical and innovation marketing.In addition, he has four years of work experience in China, ramping up efforts for research collaborations in China and South Korea. Reto Merges holds a degree in electrical engineering and information technology from the Karlsruhe Institute of Technology, Germany, and  has studied at the Nanjing Normal University, China. His scientific background is in the field of medical imaging where he has authored many publications and holds multiple patents.

References

  1. Duke-Margolis-Duke Center for Health Policy, White Paper, “Advancing a comprehensive response to COVID-19.” June 12, 2020. https://healthpolicy.duke.edu/publications/advancing-comprehensive-covid-19-response-one-pager-june-12-2020; “Immunity passports” in the context of COVID-19. WHO Report, April 24, 2020, https://www.who.int/news-room/commentaries/detail/immunity-passports-in-the-context-of-covid-19
  2. James Temple, Why contact tracing may be a mess in America. MIT Technology Review. May 2020.
  3. Park S, Choi GJ, Ko Information technology-based tracing strategy in response to COVID-19 in South Korea – privacy controversies. JAMA. 2020;323(21):2129-2130.
  4. Walensky RP, Carlos del Rio From mitigation to containment of the COVID-19 pandemic:  Putting the SARS-CoV-2 genie back in the bottle, JAMA. 2020;323(19):1889-1890.
  5. Owen Dyer, Covid-19: Black people and other minorities are hardest hit in US. BMJ 2020; 369:m1483.