Health: Preparing for the next global pandemic

Nov 20, 2023

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The ONS led the way informing the UK response to the Coronavirus pandemic. But what lessons can be learned and how can we best prepare not only ourselves, but the rest of the world, for the next pandemic?

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MILES FLETCHER

This is Statistically Speaking, the Office for National Statistics (ONS) Podcast. I'm Miles Fletcher, and as we approach the darkest months of winter, we're revisiting COVID-19.

Now the ONS doesn't do predictions, and we're certainly not forecasting a resurgence of the virus, either here in the UK or anywhere else. But pandemic preparedness has been the driving force behind two important pieces of work that we're going to be talking about this time. Looking beyond our shores, how well equipped now is the world in general to spot and monitor emerging infections? We'll hear from Josie Golding of the Wellcome Trust on that, including how even weather events like El Nino could affect the spread of viruses. We'll also talk to my ONS colleague, Joy Preece about the pandemic preparedness toolkit, a five-year project backed by Wellcome to create and develop resources that will help countries with health surveillance in the event of future pandemics.

But first, and closer to home, a new UK winter surveillance study to gather vital data on COVID-19 is now well underway. Jo Evans is its head of operations. Jo, this is a brand new COVID-19 survey the ONS is running in partnership with the UK Health Security Agency (UKHSA). What is the new survey and what's it going to be monitoring over the winter?

JO EVANS

So this is now the winter COVID infection study. And we're going to be going out to, I think we've got 145,000 people signed up, and we're going to ask them to take a lateral flow test to see if they are testing positive for COVID-19. Then we'll ask them to tell us a little bit about how they're feeling, what symptoms they have and some other household information - what work do they do? Do they have caring responsibilities? And so on.

So we're gonna be getting people to take a test and everyone's familiar of course now with administering their own lateral flow test, that wasn't the case back in the early days of the pandemic, when it was a new thing for the vast majority of us. So they'll take a test that'll tell us whether they are positive or negative for COVID-19. And on top of that, we're going to be gathering data in the form of a questionnaire.

That's right. And then this is a collaboration this time, so we'll be working with the UKHSA. I mean, we've worked with them on the COVID infection study before, but this time what we'll be doing is looking at those responses of how many people are telling us that they have COVID-19 And we'll be trying to understand that by where people live or their age group and so on, but we'll be sharing that information with UKHSA and they will then be looking at what the impact is on hospitals. So what they call the infection hospitalisation rate, how many people are going into hospital because they have COVID, so it'll really help us understand what pressures there are on the NHS over this winter period.

And that will give us some inkling, once again, about how many people are infected but not actually displaying any symptoms?

Absolutely. And we do ask people about their symptoms and if they tell us they test positive, we'll then be sending them a second questionnaire, a follow up, asking them to keep testing until they get two consecutive negative tests so that we can see how long they are testing positive, but we'll also ask them how long did their symptoms last and did they need to go and see a doctor, did they take any medication, so really trying to understand how they're experiencing that period of illness.

So during those critical winter months, that'll give us some insight into what's really going on on-the- ground and in communities.

That's right and we're running this study from November right through to March so that we can understand that, because COVID, unlike flu, it's not a seasonal virus, but we know that the NHS really suffers through the winter with those increased pressures, with more people needing their services. And this is about understanding what's happening out there. In the community, and what impact that is having on our healthcare services.

Another very important aspect of that is we're going to be monitoring for people who say they're suffering the symptoms of what is popularly known as long-COVID, ongoing impacts of the virus, and that will fill a very important evidence gap won't it.

Absolutely. We will in a follow up questionnaire be asking people how long they've had COVID for and whether they have long-COVID. And interestingly, in some research we did when we were designing the questionnaire, long-COVID sufferers told us that they know precisely what date their symptoms started and how long they've had it because of the impact it's been having on their lives. So we are hopeful that this study will provide some really useful information.

So 145,000 people taking part. Has it been difficult to get as many people as that involved?

Do you know what, we got halfway there within the first 48 hours, people were so keen to take part in this study. We've really been surprised about that.

It's probably a reflection of the success of the profile that the original study had.

I think so, people are really keen to do their bit here and get involved in this study. And we've had a lot of participants, particularly in the older age groups, who have signed up so we will have to do something that we call 'weighting of the data' across the different age groups, but we do this all the time and we are also going out to those under 16s, right up to the over 70s.

And as well as taking part in a very important public study, people get a COVID test for free and can see for themselves whether they've been affected.

Yeah, think that's one of the things people are keen to do, particularly over the winter periods when we're going to be mingling and visiting family, that reassurance really that you're going to test every month and find out whether or not you have COVID, I think we all want to make sure that we are virus free before we go and see our loved ones over Christmas, for example.

Well, we're meeting to discuss this in mid-November. The first results are still a few weeks away but how are things going, we've got enough people? Are the tests out in the field yet?

The tests are out in the field. I think we're looking to get two publications in before Christmas, so testing windows start next week. We're expecting around 25,000 people a week to take their tests and answer their questionnaire.

And over the course of a month then, all 145 we hope will have been covered?

Yes, I mean 145 is a fantastic number, and if we get all of them taking their test kits each month, then yes, that number will be higher. But even if we were looking at a 50 or 60% response rate, that is excellent for a social survey.

Yes, and all the time, what we've heard in other contexts, is that it is difficult to get people to take part in surveys, but certainly in this case people can see the need for it and have come forward in their thousands. It's possibly worth pointing out though that you do have to be selected to take part, that's very important isn't it, that we've never looked for volunteers. We've selected households randomly and that approach, that's very important to make this a really, really reliable survey isn't it?

Yes, and as soon as there was information about the study in the newspapers earlier this year, we had people ringing up and asking to take part and we've had to explain to them that we want a nice random sample so that we can have a fully representative study.

So ONS will be producing the figures then it's over to our colleagues in the UK Health Security Agency to interpret what that means from a public health point of view, and what response might be necessary. Absolutely.

Absolutely. And they'll be producing some statistics as well. Looking particularly, as I said, at that infection hospitalisation rate.

So are we expecting the virus to take off again, or is it just a just a precaution to be monitoring things in this way?

When we started this, it was more about understanding if there would be that impact on the NHS over the winter. But then we did see back in September, a new variant, particularly in the US, and as you know, from looking at COVID over the past few years, when you see a new variant coming, sort of appearing in one country, you know that it will come here eventually. So, it's about keeping track of that really, although because we are doing lateral flow tests, we won't actually have information about what kind of variant people have, but it will just be to look to see whether we're seeing an increase in positivity in the community.

Okay, so all eyes on the first result, and we wish you, and the team getting the survey together once again, every success on what is a highly valuable and important exercise.

So we've heard how the new winter surveillance study is helping us track ongoing COVID infection here at home. But we're also using the experience the ONS gained during the last pandemic to prepare not only ourselves, but other countries around the world for another one, Josie, with that global perspective in mind, my first question to you just to get us started is what have been the biggest learnings, the biggest take homes if you like, for Wellcome from the pandemic. And what's your priority now as an organisation considering how best to respond to others?

JOSIE GOLDING

Thank you for having me today, I think this is good to be reflecting on COVID in the future. So the biggest take home message is, probably I can look at the positives and the negatives, so I'll go on the negatives first.

So I think we had a lot of the tools for responding to outbreaks and bigger events but I think we weren't prepared to deal with such a massive pandemic that we saw at SARS-CoV-2, we had expected to prepare for something like influenza and of course we probably didn't use our imagination of how the impact would be so great, affecting people in so many different ways. I think we need to really use that imagination going forward, it's about thinking through the variety of different impacts we could see across different populations. I think we've learned a lot on how we communicate with the public, with the key people who are involved, and take those lessons because I think we did struggle. I think globally, not just Wellcome as one of the actors on communicating the importance, and the push to be better prepared to respond to these pandemics.

One of the successes, and I'll put this up from a Wellcome point of view, really was the true integration of research into the response. And you know, this has been building up for many years from the Ebola West Africa outbreak in 2014. And tested again, and tested and tested and refined, on how we do this across the small research community who are engaged in those relatively smaller outbreaks to now a complete game change on how people expect research to be integrated into outbreak responses through pandemics.

So I think that's now set the new status quo, and before I had to convince people of the importance, I think the importance now speaks for itself.

Yes, it was notable in the early stages of the pandemic, those countries, notably in East Asia that have had experience of major respiratory viruses, and dealing with those on a public health point of view, didn't seem to be much better prepared than us in the West, who perhaps have underestimated the risks?

It is absolutely true. You know, it is testing the system over and over and over again. So you know who your stakeholders were, you knew how to get things done quickly and at speed. And I think that's the one piece we have to keep remembering that we can keep preparing, but you still need to keep testing the system to ensure that it works in practice. But through it all I would say, you know, one of the things that Wellcome is taken away from SARS-CoV-2 is really the belief that we can't predict exactly what's going to come next when it comes to emerging infectious diseases. We have to keep that in mind, but actually the way to test the system time and time again, is dealing with the health priorities right now. So things like antimicrobial resistance. We know this has been a growing threat for many years. It's had some setbacks through SARS-CoV-2 and the pandemic, you know, we need to really re-energise the community to really take this seriously and to finance and to conduct the research that's required. But there are other threats that are, you know, common health issues, common infectious diseases that countries are dealing with, and we should be integrating the readiness, haemorrhagic fevers, viral fevers, other viruses, whatever it may be, into how we deal with those everyday infectious diseases.

And what's the legacy been from an analytical point of view of the first few years for the period that is now known as peak COVID? Have we got that to draw on now because we're seeing the virus continuing to emerge? We're seeing potential threats from new variants and possibly other viruses.

I don't think it's evenly applied across the globe on taking advantage of the systems. The approaches that were built up during SARS-CoV-2, some countries are able to maintain some of the resources that have been built or pivot into other health priorities. But that is a bit of a gap that we are seeing. I'll give an example of what I think is a great statistic, you know, for pathogen genomic sequencing and how that was used to track variants and making that as close to real time as you could find through the accelerator and diagnostics working group that mapped out the capacity in countries to be able to conduct pathogen genetic sequencing. And I think at the time, this is going back to 2022, that 77% of the world's countries were able to conduct sequencing when that's a massive game change for a tool that really wasn't a, partly an add on, into how you would do some of the epidemiological research at the beginning of outbreaks. So I think being able to pivot that tool and make sure that these types of facilities and the training and the expertise that people have built up over time can be sustained, working with those communities to be able to identify what are the real use cases for pathogens. And so I think, yes, some of it has probably not been evenly distributed, but we could always be doing more to be able to ensure we can better understand the variants as they come about, but also, what does it mean for a variant you know, how, what changes will that make, what impact will that have on our health?

Hearing the UK with our partners, the UK health security agency, we are preparing, as you well know I'm sure, to run a further study going into the winter. What is the role of studies all like that? Are they uniform now across the world or this is not as similar surveillance programmes going on? Or do we remain a bit of a one off in doing this in the UK?

I don't believe that this is evenly spread around the world. We ourselves at Wellcome had made a decision to continue funding our SARS-CoV-2 work on the genomics as well as the characterization of these variants as they come out. And what difference does it make in people who've been vaccinated or with other health conditions? We know when we've engaged with the research community across a variety of countries around the world, it ends up being very novel that this research has continued to happen. So I do think there is a gap, and it is becoming more challenging for public health institutes, WHO and others, to gather this information to understand are the vaccines still effective when we have these new variants, are they more transmissible, and other impacts that we would assess for those new variants. So I do think it's becoming more limited, and so of course, we need to make sure that the data we do generate is of high quality.

The focus has been very much on COVID, but of course as we've seen historically and in other countries, other viruses have emerged and have serious public health consequences in those countries globally. What other emerging diseases do we need to have our eye on at the moment?

Since SARS-CoV-2 really picked up we've had a global impacts event that affected you know, very select communities around the world, and is still ongoing, but not to the same level. We have the ongoing threat of avian influenza, we have El Nino upon us, which is likely to further impact the rates of cholera that we're going to see as well as impacting temperatures, so mosquito borne viruses and other types of arboviruses, potentially broader than that, so it is happening right now. I don't think we even need to sit back and think what it could be. And there are many events that we need to be preparing for. And particularly with something like El Nino as a particular weather event but thinking about the climate crisis. This is only going to grow we need to really collect the evidence now to understand what difference will it make what risks will it pose by experience, and geographical distribution further afield.

Yes, can you unpack that a bit for us, because most people will be aware of El Nino as a meteorological phenomenon. How does that translate into public health impacts?

The whole background and where we've been watching and waiting for more certainty and whether this was actually going to happen this year, but it's a very high, I think it's now greater than 90% certainty it's going to happen from this part of the year onwards, and and it will vary depending on where in the region it will impact you for droughts or flooding. And of course we need to better understand well, what impact would that have on cholera? Cholera is a prime example. While it's not directly linked to El Nino as it stands right now, we have seen such a change in the cholera distribution in Malawi being a great example where it's seeing rises in cases outside of the expected weather event. So you'd expect it in flooding season but you're seeing it more in dry seasons. So El Nino will make this worse potentially. It's being able to track it and understand the issue we have with events like El Nino is that we don't have enough information on it. We need to be better from a researcher's perspective, we need to just understand the researchers in those countries that are likely to be affected, their opportunity to gather as much evidence about the impact of El Nino so that when it comes around again, we'll be better able to apply what we've learned now.

Without wishing to sensationalise, what do you think the risks are of another big global pandemic of the sought we saw with COVID-19?

I'm a virologist by training so I'm always thinking that viruses hold the opportunity for some of the greatest opportunity for change. I'm always hopeful that you know these risks like the SARS-CoV-2 are actually quite rare events, to see something take off and to be able to transmit that successfully to humans. We see there are many events where we have what people refer to as spillover events between animals to humans, but it takes quite a change and we don't fully understand what the change might be or why it adapts for people to be more susceptible. So I think it is a risk, it's a known risk even for SARS-CoV-2 which could change drastically. It's a very early stage in understanding this virus and how it operates. So I think we just have to be prepared, to be continually preparing, for the event that it could happen. I think influenza is the greatest one that it would be surprising if we didn't have a global event for influenza of some kind in the next few years. We've been preparing for this for quite some time.

Is that the one that was anticipated then? Because if you look back historically, and this was the big comparison of course that was made with the COVID pandemic, it was so called Spanish flu wasn't it after the First World War, which was a huge global pandemic.

Yes, it has been the one that we've always focused on. And if we look at the way that we've managed to monitor the change in the evolution of the virus, and to build the infrastructure globally, to be able to do the research and track that within laboratories and share information on that to help inform the vaccine production, which is very seasonal, influenza has changed every year. This is decades in the making. It's been ongoing for decades, and still, you know, we still have problems with making sure we have enough vaccine at the right time in the right supply to be accessible to all. So even for something that we know is likely to come we still struggle to get to that level of preparedness and it takes a lot of effort and time and it will continue, hopefully SARS-CoV-2 will help evolve those structures and I know a lot of the interest has been to combine, where we can, with coronaviruses respiratory like illnesses in the future to make it more efficient, but it's a big undertaking to really map out what you can do for a single pathogen. So, we have to work to see where we can build in those efficiencies across multi pathogen approaches.

So one response and this is a project that you're working on with ONS and we're going to talk about now, and bring Joy in to explain to us, and that's the pandemic preparedness toolkit. The ONS is developing alongside Wellcome as I say, Joy, you're part of the team at ONS creating the toolkit just to take you from the very beginning, how did the ONS get involved in this and why is ONS well placed to facilitate this work?

JOY PREECE

Well, this was a proposal that we put together for Wellcome in the aftermath of, I think some of the early years of the pandemic response, and the of course well-known Coronavirus Infection Study (CIS) which I was part of, and I think what we really learned during COVID, the during big years, 2020 and 2021 in the UK, was how important really active data monitoring was when a disease is multiplying exponentially. That's really frightening stuff. You can't afford to just sit back and wait and see. So the key to any successful response has to be figuring things out like the reproduction number really, really quickly. You know, you needed to know how many people were affected, how fast infections were increasing, how the numbers of infections related to numbers of deaths, and we saw during COVID that it wasn't enough to just wait until people were already so ill that they were turning up in a healthcare setting in a hospital or you know, even worse kept to have systems that could be producing those kinds of statistical insights early from a community setting. And so that's the unique approach that ONS really took here. Linking up our statistical offices with the public health agencies and the decision makers. They're using our experience with surveys, with administrative data, with data modelling and data science, drawing on connections that we had with academics, with expert epidemiologists to try and get answers to those important questions as quickly as we could. And I think the unique thing that the ONS and other statistical offices around the world can bring to this is the very fact that we aren't part of the public health systems. So we bring here in ONS that expertise in a social research settings or community settings here, and you know, even apart from numbers of infections, there's topics like employment patterns, travel and tourism opinions and lifestyle habits, which tells you really important things about how people are interacting and behaving which gives you the ability to do some really, really clever modelling or things like disease communicability as that's kind of the background ONS brought to this from our experience during COVID. But, of course, we have experience as well supporting capacity building with overseas national statistical institutes.

Now regular listeners to these podcasts will know we recently spoke to our colleagues in Ghana, about everything they're doing in partnership with our own, so there's countries like Ghana, who are very much part of this pandemic preparedness project as well.

That's right. So what we are looking to do from the back of everything we learned in the UK is to go out and work with, initially we've identified that we want to be working with three different partner countries to co-create a toolkit that can be generalizable, and that can be accessed globally. And what's really important here is that it isn't about, oh, well here's a model that the UK used and therefore it's applicable to everybody because yes, we just heard from Josie that's not the case. Different countries have different contexts, different experiences of different diseases and have built different infrastructures and skills as a result. So what we really want to do is generate that pool of knowledge internationally and co-create a toolkit that allows countries, based on their unique context, to draw from it and we're talking here of practical guidance. Statistical Methods, knowledge products, case studies, training materials, really this is about capacity building to support that kind of infectious disease surveillance, but in a way that may look very different depending on the country's context. So it's about an international community of practice here.

Well, that's why it's a toolkit. Not a template for how to deal with a pandemic.

That's absolutely right. So we're thinking about this under I think, three headings. So data collection on one hand, statistics and modelling on another but crucially, also the relationship building between statistical producers and public health professionals, and that's really essential, because you want to help toolkit users build those relationships of trust between analysts and the public health decision makers that needs to be already there. It needs to be there as a fundamental before a crisis hits because otherwise the opportunities for that kind of productive collaboration that ONS was able to do during the COVID pandemic, just become so so limited.

And it's about sharing of learnings as well, sharing of intelligence...

No, absolutely, absolutely right. This is why I talk about it as a co-created toolkit. This is something that will be kind of jointly delivered in collaboration between ourselves and the three countries that we end up working with. We're going through a process right now to kind of identify volunteers and select countries that we'll work with, but also our first stage of that we are launching with a couple of kind of lessons learned workshops are where we're inviting statistical Institute's from around the world and a number of large international NGOs and experts in the field to come and talk about their experience of you know, disease surveillance of COVID and pandemic response and of other disease response. I start drawing out you know, what is there that we can find in common, what are there that are common challenges that have been common enablers to make your situation better, what is there that collectively we identify as the key criteria for a toolkit that will have the most value to the most countries.

And Josie, from Wellcomes point of view, what are what are Wellcome's ambitions for this piece of work?

We're very keen to understand how that toolkit can be of value to others, but also think through what is that epidemic preparedness model? So how would you apply it in the future to whatever that disease may be? So we never know maybe during the lifespan of this project, there will be opportunities for the countries to be able to test it out to see what works for them in in real time. I mean, I hope there's not another pandemic, but we have to just work on that assumption that as we go along, during this particular project, there could be something that might have to test it. But we'll see.

There was of course much soul searching about the effectiveness of particularly early response to COVID in certainly this country, in the UK and in other Western countries. But, of course, looking back, and now we have the data, it was the global south that was disproportionately affected.

It's fair to say, and I think there's still an unanswered question why some countries were affected more and some were less, and I think Joy has be very clear about the different contexts that countries operate in, but that includes also the populations as well and the other diseases they might have seen, what other health issues. I know, there's been less cases observed on the African continent and of course, that is down to the ability to test, but to a degree it is a different population structure that we're seeing. So yes, we want to make sure that these types of tools are equitably shared, and applied to whatever the health requirements are for their systems. And I think this is the exciting part of this project. And I guess my main kind of message that I repeat to everybody is the only way to prepare for a future pandemic or a future epidemic is simply to deal with the health issues that we have right now. So make sure that we're thinking about things like MMR, and thinking about the impact of climate and understanding better how it's changing the dynamics of infectious diseases such as mosquito borne, or other viruses or malaria, you know, the common issues that many countries are facing and just act now rather than just planning for something. I want to see some real tangible research and systems being built. I think that's why the ONS approach for this is important because it's about just getting on with it. And not just, you know, coming up with a theoretical model, it is actually working with the countries to see how you're going to apply it now. So we have to just keep focusing on that it could be tomorrow. So just get going.

Well, and I would just say aye because I completely agree Josie because it's very easy to get caught up in talking about a pandemic response. But of course, a pandemic response, you can only draw on the resources that are already there. There is no time in a crisis situation to be developing things that are substantially new. So what we're really talking about when we talk about a pandemic preparation is about supporting improved health statistics for all sorts of purposes. You know, data and modelling and communicating and understanding the statistical insight and actually having that really good disease, that has a multiplier benefit for a whole range of health outcomes. Whether or not we see a pandemic tomorrow, we should be planning, even if it doesn't happen tomorrow. And I think that's the critical thing in this, this isn't a once in 100 years. This is an event that is happening on a daily basis, when people are catching diseases and communicating diseases on a daily basis, and providing improved tools to support that has a benefit even in the absence of a large-scale event.

And that's it for this episode of Statistically Speaking, next time, as the end of the year approaches, we'll be joined once again by the UK's National Statistician. If you've got a question for us then please ask us via @ONSfocus on the 'X' social media platform, or Twitter for us traditionalists.

Thanks to all of our guests today and our producer Julia Short. You can of course subscribe to new episodes of Statistically Speaking on Spotify, Apple podcasts and all other major platforms.

ENDS