Exclusive Research: Is Asia prepared for the next big epidemic?

By Tinesh Indrarajah

Three month research project into nations’ readiness by GovInsider Fellow.

All it takes is a passport. An epidemic can start with just a single plane journey, silently ushering an unwelcome guest into an unsuspecting continent.

Our interconnected world makes epidemics increasingly likely. Over the last 15 years, the world has been beset by SARS, H1N1, H9N1, Ebola, Zika, Yellow Fever and MERS Cov. According to Professor Leo Yee Sin, Head of the Institute of Infectious Diseases and Epidemiology (IIDE) of Tan Tock Seng Hospital, it is no longer “if infectious diseases are going to happen, now it’s when.”

In Southeast Asia, the change in thinking about infectious diseases began with the unexpected, yet deadly, 2003 SARS outbreak. The timeline below highlights the main events that took place during the SARS epidemic:

The disease caused Asian governments to radically reform, but are those changes enough? GovInsider has spoken to officials and researchers across Asia to find out about the latest threats, and what governments must do to prepare for them.

Why are epidemics increasing?

First, some context. This topic is increasingly important for officials across government, not just in healthcare, but also public safety, communications, and even city management and urban planning.

Rapid urbanization is one reason for the increasing epidemic rates, says Professor Ooi Eng Eong, the Deputy Director of the Emerging Infectious Diseases Programme at Duke-NUS Medical School in Singapore. “A lot more people now are living in big cities, and the chance of pathogens spreading from human to human, even if through a mosquito, increases,” he says. This is particularly true for Aedes mosquitoes which thrive in an urban environment.

The increasing flow of people into cramped cities increases the proximity between people. Good sanitation and refuse collection is vital, as conditions such as stagnant water are convenient breeding grounds for Aedes mosquitoes, notes Tan Tock Seng’s Leo.

Further, the very creation of cities encroaches upon animal boundaries. “We destroy the forest and animals start coming out to us, bringing along the pathogens,” he adds,” says Dr. Chong Chee Kheong, Director of the Disease Control Division of the Malaysian Ministry of Health.

Aside from rapid urbanization, increasing globalization has spread diseases at a much faster rate. Cheap air travel has shrunk the world so that diseases that previously were endemic to a particular area can now infect people globally. For example, Ooi points out that China has recorded 12 confirmed cases of yellow fever due to close business ties with Angola.

“China is being more involved in the development of some of the African countries, so there are a lot of people moving in and out between these two regions,” Leo says. “The world is so connected today that anything that happens in other parts of the world may potentially end up with us,” reflecting the dangers of greater human population movement.
“The world today is so connected today that anything that happens [elsewhere]... may end up with us.”

This connectivity also affects disease incubation periods. In the past, people with diseases “would either display the symptoms or die from the disease,” Professor Lam Sai Kit, Emeritus Professor at Universiti Malaya and a virology expert. Now, they can fly to a different continent without the problem being spotted.

How well do governments react?

Empty Changi Airport

The 2003 SARS outbreak was a wake-up call for the region because it embodied the severe damage an epidemic could cause. “It surprised us out of the left field,” says Mr. Peter Ho, former Head of the Civil Service. Singapore, arguably the most-advanced nation in Southeast Asia, had her back to the wall trying to figure out how to contain this deadly disease.

There are a six systemic reasons why governments are slow to respond to epidemics. First is the desire to prevent public panic. As The Economist reported, China misreported the severity of the SARS outbreak in late 2002. The Chinese government’s alleged underreporting of the number of SARS cases belied the severity of the problem, and did not provide adequate warning to other nations to prepare for a similar outbreak.

The second systemic issue is government funding, which tends to focus on local priorities rather than international collaboration. For example, Prof Ooi states how funding from the Singaporean Government is primarily given for research based in Singapore. This makes it hard to develop close collaborative partnerships with scientists from other countries in the region.

The third problem is a lack of specificity in research focus. According to Ooi, “targeted research on specific topics are done rarely.” Universities allow a free reign on researching diseases, and governments do not sufficiently direct research to ensure preparation for the next epidemic.
Fourth, governments are slow to ensure that drugs are ready to release into the market, stalling on safety testing of promising drugs. The clearest example to illustrate this scenario was during the Ebola outbreak. “It was not like the whole world had no vaccine; they did have. Just that it never went to clinical trial because there were no Ebola cases,” Ooi says.

Fifth, even after the production of an effective vaccine, market forces play a limiting role. For example, yellow fever has an established vaccine made in the 1930s. However, market demand for yellow fever vaccines is low because it is only needed at specific times. Yet, when it is required, it is needed very urgently, Ooi notes.

We witness this dynamic playing out in Congo today. The capital city of Luanda has 12 million people who require vaccination for yellow fever but the global supply of yellow fever vaccines is only at 6 million. Due to its 6-month long production time, the yellow fever epidemic in Congo will not be stopped anytime soon, with mid of 2017 as the most likely date.

The sixth problem is that of distribution. For instance, Indonesia just uncovered a syndicate that distributed fake vaccines for the last 10 years. The lack of proper enforcement has now jeopardized the accuracy of vaccine records. Individuals who have previously been vaccinated have to redo the process to ensure that they are properly vaccinated. Not to mention, the added cost of re-vaccinating everyone is money that could have been better spent in other areas.
The diseases on the horizon
When asked to predict the next possible outbreak in Southeast Asia, Prof Lam and Dr. Chong suggested it would primarily be influenza-based. With new strains developing that circumvents the efficacy of existing antibiotics, our low immunity to influenza-related diseases could result in a serious outbreak - the first since the 1918 flu pandemic.

On the other hand, Ooi believes that yellow fever could be the next major epidemic. It has already arrived in Asia and has the potential to inflict serious casualties in the region. The region's low immunity to yellow fever coupled with the huge Aedes population here greatly increases the possibility of a yellow fever epidemic in Southeast Asia.

However, Professor Tikki Pang, Visiting Professor at the Lee Kuan Yew School of Public Policy, National University of Singapore and former Director of Research Policy & Cooperation at the World Health Organization, named a familiar foe as the region’s greatest epidemic threat- dengue. He notes that despite all the years of effort and study that has gone into dengue research and prevention, Aedes mosquitoes have caused an average of 2.9 million cases in the region annually from 2001-2010. From that amount, 5906 cases have been fatal.

Prevention is better than cure

To combat these possible outbreaks, Southeast Asian governments need to ensure that they learn from previous outbreaks. The list of suggested solutions below should serve as a checklist of what is required to properly manage a future outbreak.

According to Prof Leo, SARS taught officials to increase surveillance of possible disease outbreaks in the region. It was no longer sufficient to focus on the internal safety of a nation; a collaborative outlook is required, she adds. For instance, Singapore’s recent successful isolation of a Zika patient effectively stopped the spread of that disease to the Singaporean public, notes Leo.

On the ground, it is the responsibility of environmental agencies to ensure proper safety standards are maintained. Pang highlights this when he talks about the “dengue Warriors” in Singapore who assist the National Environmental Agency (NEA) in “regularly monitoring construction sites, housing sites, wherever there is a chance of mosquito breeding.”

And Pang stresses that these surveillance measures need to be aided by strong legislation. Governmental policies. The threat of punishment incentivises agencies to actually comply with safety measures, he further explains - for example tackling mosquito breeding grounds through fines.

Information is vital


Governments must also ensure that their citizens are properly educated about the dangers of infectious diseases. In particular, strategies to prevent infection need to be emphasised. For instance, foreign ministries should ensure that information is available so that the appropriate traveller vaccines are taken prior to departure from their own nations, says Leo.

In particular, regional governments need to address the suspicion of vaccines among citizens. The Straits Times reported on two cases of child death from diphtheria in Malaysia because parents did not believe vaccines worked. They were also worried about the potential side effects of vaccines. Government’s need to address this misconception to ensure their vaccination measures are effective.

Comprehensive educational policies need to be supplemented by sustained surveillance, Chong says. The large population movement in the region makes this measure particularly important in Southeast Asia. One crucial way is through the formation of regional partnerships that allows information to be shared quickly.

The ASEAN Emergency Operation Centre network (pictured above) is one such platform that facilitates regional collaboration, adds Chong. It links countries on a monthly basis across ASEAN to discuss the latest threats, and provide alert states about impending outbreaks.

Changes to funding structures can also improve these partnerships, Ooi notes. Regional scientific collaborations are currently limited because countries usually only fund their own internal research, says Ooi. Therefore, if three scientists from Singapore, Malaysia and Vietnam want to work together on a project, they may need to acquire three separate grants, which is a cumbersome process, he notes.

It is necessary to streamline this process by creating a regional fund for collaborative work. “If you can control the disease before it hits Singapore, then you have basically protected all 5.5 million people here,” Ooi notes. As infectious diseases recognise no boundaries, it is imperative that countries work together to curtail the spread of such diseases.

Tackling silos

Cross-government coordination is essential, because many agencies are involved in tackling disease outbreaks. Environmental agencies need to ensure safety standards are followed; information ministries must promote vaccinations and ensure calm; finance ministries must fund regional partnerships need to be established and funded; and health ministries should promote cooperation between researchers and clinicians to create better treatment plans.

How can governments coordinate all these responsibilities? Peter Ho acknowledges that it is “natural for organisations to operate within their own silos.” However, large-scale problems like health epidemics require a cooperative response, which necessitates overcoming organizational silos, he adds.
“It is ‘natural for organisations to operate within their own silos’”
To that end, governments not only need to ensure that individual ministries are carrying out their respective tasks properly, he believes. They must to also create cross-government platforms that allow these agencies to communicate effectively. During an epidemic, the presence of such a platform will be pivotal. These platforms must have the ability to ensure that trade-offs are made, and decision-making is coordinated.

International and regional organizations like WHO and ASEAN can also assist governments in effectively managing epidemics by “increasing awareness of such issues at the global level”, says Professor Thisyakorn, Professor of Pediatrics at Chulalongkorn University and a consultant at the Faculty of Tropical Medicine at the Mahidol University, Thailand. In particular, these organizations need to share best practices with local governments to improve their capacity to manage outbreaks, she adds.

Research funding is critical in improving a nation or even region’s ability to handle an epidemic. Philanthropic organizations like the Gates Foundation can help by providing research funding for “targeted diseases affecting the region”, says Ooi. This alleviates the financial burden of governments, while still allowing scientists to solve important issues threatening regional health.

Aside from direct funding, governments can also help improve Southeast Asia’s preparedness by conducting sharing sessions with medical professionals. For instance, Leo revealed that Tan Tock Seng Hospital has partnered with the US Department of Defense and ASEAN.

It’s cross-government coordination that will prove most effective. Dr. Thisyakorn emphasizes, the purpose of all these potential solutions is to “work together to safeguard all peoples.” Governments need to take the lead in putting these strategies in place, but they cannot do it alone. Important global and regional organizations need to lend a hand in sharing best practices and providing financial support. And citizens need to develop ownership over their surroundings and educate themselves about the dangers of infectious diseases.

Improved funding systems; citizen communication; predictive methods; data sharing and cross-government coordination are all necessary to prevent the next big epidemic.

But it is only when we’re all working together that we can effectively safeguard the peoples of ASEAN from a future epidemic.

Tinesh Indrarajah was GovInsider’s first Fellow, on a placement from Yale-NUS College. The scheme allowed a promising researcher to spend three months investigating service delivery across Asia Pacific.

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