A Wake-up Call on Community Pneumonia

Severe Acute Respiratory Syndrome (SARS), which presents as pneumonia, was first discovered in Asia in February 2003. The outbreak lasted approximately six months as the disease spread to more than two dozen countries in North America, South America, Europe, and Asia before it was stopped in July 2003. Public health plays an important role. The goal of situation monitoring and assessment is to collect, interpret, and disseminate information on the risk of a pandemic before it occurs and, once under way, to monitor pandemic activity and characteristics. To assess if the risk of a pandemic is increasing, it is important to monitor the infectious agent, its capacity to cause disease in humans, and the patterns of disease spread in communities. It is important to collect data on (influenza) viruses, the genetic changes taking place and consequent changes in biological characteristics, and to rapidly investigate and evaluate outbreaks. SARS was a wake-up call for how we think about global health.

Doctors once had little choice but to be fatalistic about deaths from pneumonia. Sir William Osler, sometimes called the father of modern medicine, famously called it “friend of the aged” (often rendered as “the old man’s friend”) because it was seen as a swift, relatively painless way to die.  Pneumonia is more of a pathogenic team sport. The pneumococcal vaccine (PPV23) targets 23 variants of Streptococcus pneumoniae (also known as pneumococcus), the bacterium responsible for a quarter of community-acquired pneumonia cases. Even so, the vaccine doesn’t provide protection against all the pneumococcus variants, nor against other types of bacterial infections or the viral and fungal causes of pneumonia. People sometimes make the mistake of viewing the pneumococcal vaccine as the pneumonia vaccine, but it’s not. Moreover, novel causes of community pneumonia keep appearing.

The influenza virus is the one we are most familiar with. It lives longer indoors in winter, because the air is less humid than outside. While it’s alive and in the air, it’s easy for people to inhale it, or for it to land on the eyes, nose, or mouth. We spend more time indoors and have closer contact with each other, which makes it easier for the virus to spread. The influenza A virus does not lie dormant during summer but migrates globally and mixes with other viral strains before returning to the Northern Hemisphere as a genetically different virus. These viruses spread seasonally each year because of a phenomenon known as antigenic drift: They evolve just enough to evade human immune systems, but not enough to develop into completely new versions of the virus. Accordingly, public health promotes a vaccine each year to reduce the morbidity and mortality in the community.

When the flu virus causes pneumonia directly, it’s really the immune response that causes much of the damage, bringing fluid and cells into the alveoli of the lungs. Both the 1918 virus and the more recent H5N1 bird flu virus cause a dramatic immune response that is exponentially larger than the response to the typical flu virus. It’s probably this strong immune response that makes the death rate from infection by those two viruses so much higher than the rate for normal flu. While other types of pneumonia rapidly infect large regions of the lungs, COVID-19 (much like pandemic flu strains) begins in numerous small areas of the lungs. It then uses the lungs’ own immune cells to spread across the lungs over many days or even weeks. This is similar to how multiple wildfires spread through a forest. The long duration of COVID-19 pneumonia, rather than greater severity, may be why it causes more serious complications than other types of pneumonia.

Research has repeatedly shown that women have stronger immune systems than men – they’re less likely to become seriously ill from infections, less susceptible to cancer, and significantly more prone to overreactions such as autoimmune diseases and allergies. Women also tend to mount more powerful immune responses to vaccinations. “The female immune system has to be very different for the obvious reason that they have to be able to become pregnant and not reject the foetus. Therefore you have to have an immune system which has a more intricate feedback mechanism. And that is true from birth,” says Aaby. Previous research has found that the severity of COVID-19 tends to be higher for men compared to women. A study of 17 million adults found that men could face nearly twice the risk of death from the disease than their female counterparts.

Influenza mutates up to three times more often than coronaviruses do, a pace that enables it to evolve quickly and sidestep vaccines. But coronaviruses have a special trick that gives them a deadly dynamism: they frequently recombine, swapping chunks of their RNA with other coronaviruses. Typically, this is a meaningless trading of like parts between like viruses. But when two distant coronavirus relatives end up in the same cell, recombination can lead to mutations on their spike proteins that confer an advantage, creating so-called variants. A subset of these variants spread more easily and quickly than other variants, which may lead to more cases of COVID-19. This leads to an increase in the number of cases that puts more strain on health care resources, leads to more hospitalizations, and more deaths in younger persons. The response has been increased lock-downs, regrettably associated with push back from groups opposing government trampling on individual freedom. The answer is to have everyone vaccinated.

 Once a pandemic virus begins to circulate, it is vital to assess the effectiveness of the response measures. Reducing the spread of disease will depend significantly upon increasing the “social distance” between people. Measures such as individual/household level measures, societal-level measures and international travel measures, and the use of antivirals, other pharmaceuticals, and vaccines will be important. During a pandemic, health systems will need to provide health-care services while attending to the influx of patients with influenza illness. Planning for surge capacity in health-care facilities will help determine the extent to which the existing health system can expand to manage the additional patient load. Health-care facilities need to maintain adequate triage and infection control measures to protect health-care workers, patients, and visitors. A core element in management is to maintain and build public trust in public health authorities before, during and after a pandemic.

The goal of communications before and during a pandemic is to provide and exchange relevant information with the public, partners, and stakeholders to allow them to make well informed decisions and take appropriate actions to protect health and safety and response. This is a fundamental part of effective risk management! Public health professionals in Canada and the US are not single-handedly responsible for communication failures during COVD-19 – politicians found it necessary to elbow their way to the front of the communication queue. Thus, initially the people with the least knowledge and experience in pandemic response were impacting the public health message. Government officials were concerned about public panic, so they validated the public’s complacency, leaving us incredibly unprepared. In a February 25th media briefing a CDC official said bluntly that “disruption to everyday life may be severe.” The stock market plummeted, President Trump was angered, and the CDC was rebuked.

The World Health Organization (WHO) sounded its highest alarm on January 30, 2020 – a declaration called a ‘public health emergency of international concern’, or PHEIC, signalling that a pandemic might be imminent. Few countries heeded the WHO’s call for testing, tracing and social distancing to curb the coronavirus. By mid-March, it had spread around the world. The Trudeau government dismantled a world class Global Public Health Intelligence Network in Canada the year before the pandemic. An expert’s panel’s report found that prior to the pandemic, the replacement alert system lacked standard operating procedures. Senior managers also didn’t fully understand the rationale and the intended audience for alerts. In the US, President Donald Trump and his administration silenced scientists, meddled in their reports and ignored their advice. A coronavirus-crisis sub-committee within the US House of Representatives report notes that the frequency of meddling (such as recommendations altered) increased in the lead-up to the US election.

If something that happens is a wake-up call, it should make you realize that you need to take action to change a situation. In particular, what happened in both the US and Canada is politicians did not understand the basic functions of public health monitoring systems in protecting citizens from the ravages of pandemics. In general, the global pandemic alert system is not fit for purpose; critical elements of the system are slow, cumbersome and indecisive. There has been a wholesale failure to take seriously the existential risk posed by pandemic threat to humanity and its place in the future of the planet. The World Health Organization has been underpowered to do the job expected of it, and the incentives for cooperation are too weak to ensure the effective engagement of States (countries) with the international system in a disciplined, transparent, accountable and timely manner. This situation cries out for change.

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