Evolving and Emerging Challenges in Biopreparedness

ContagionContagion, April 2023 (Vol. 08, No. 2)
Volume 8
Issue 2

The complexity of dealing with emerging infectious diseases makes preparedness difficult.

Let’s be honest, this started long before COVID-19. Perhaps it’s because we’re in the fourth year of a pandemic during which there’s also been an unprecedented outbreak of monkeypox (mpox) as well as outbreaks of Ebola, Marburg, and H5N1. Perhaps it’s because this phase of the pandemic has us discussing how we failed and thinking about the transition from acute to sustained response. Either way, more recent conversations about vulnerabilities and opportunities for improving preparedness feel very Groundhog Day-esque. We’ve been here before. Yes, COVID-19 challenged us on a global scale, but previous incidents have led to the same conversations: What are we doing for health care infrastructure to ensure emergency preparedness and response? Although these discussions and findings are not new, we have been talking in circles instead of doing anything differently. Emerging infectious diseases are not a novel concept in health care or biopreparedness, but we’re not equipped to manage the complexity of the present reality.

SARS-CoV-1 often seems like the first emerging infectious disease we had to face in the United States and the one that triggered the discussion about the growing risk of spillover events. The HIV/AIDS epidemic of the 1980s/1990s revealed a deeply inadequate health care and public health system and should have been the catalyst not only for better responses to emerging and novel infectious diseases, but also for discussions about the social dynamics that make response difficult. Nevertheless, stigma and marginalization of already vulnerable groups is something we’re still struggling with, as demonstrated by mpox.

In 2002/2003, Toronto’s health care system quickly learned about the challenges of responding to a novel infectious disease. SARS-CoV-1 hit the province hard and health care transmission played a considerable part in the outbreak. I wrote about this in October 2022, and the most frustrating aspects of the problem continue to be the lack of communication and the changing guidance. As I said back then, “overall, the challenges and failures that occurred during the outbreak in 2003 are representative not only of the systemic infection control failures within health care, but of the operational challenges of biothreat response at an administrative level. Beyond the challenges of operationalizing a response to the outbreak, substantial financial strain also was associated with the novel disease.”1

Then in 2012 came MERS-CoV. Health care–associated cases strained both outbreak response and readiness across Saudi Arabia, South Korea, and the United Arab Emirates, which were hit hardest by the disease. As was true of SARS-CoV-1, the higher rates of nosocomial MERS transmission shed light on how health care facilities can amplify disease during such challenging situations.2

Although exposure to SARS-CoV-1 and MERS in the United States was limited, Ebola changed the game in 2014. The interesting thing about the attitude of our health care system that year was that Ebola seemed far away. We had yet to learn the lessons of an increased incidence of infectious and emerging diseases. The single case of Ebola in a US health care worker seemed to bring us to our knees. Response was chaotic at best, despite Ebola’s discovery dating back to 1976. The truth is that unless we encounter emerging infectious diseases frequently, we assume they won’t affect us. Moreover, we fail to establish readiness plans that acknowledge their highly invasive capacity and how that can increase the risk to health care workers.3

Ebola virus disease wasn’t new in 2014, but its ability to show up in American emergency departments despite being an emerging disease halfway around the world proved that we weren’t ready, even with our financially resourceful health infrastructure. One thing I like to emphasize is that when we talk about the evolving nature and needs of health care biopreparedness, the dialogue often focuses on novel or emerging infectious diseases such as Ebola or a new respiratory pathogen like COVID-19. The truth, however, is that the highly resistant infections we’re starting to see and our inability to manage health care–associated infections (HAIs) are actually the canary in the coal mine.4 We should see antimicrobial resistance and the utter failure of HAI control in the US as an indication of gaps in biopreparedness. We haven’t been ready, and we continue to focus on the past rather than adapting to the present and preparing for the future.

As we enter the fourth year of a pandemic, we’re forced to address the transition from acute response to sustained management. How do we reiterate prevention efforts while moving away from COVID-19 wards and the testing of all patients on admission? COVID-19 stressed our health care systems beyond anything previously seen. Now, we must decide whether we will learn the lessons of COVID-19 and rectify the failures in all aspects of health care biopreparedness. Although we had ample warning that something like this would happen, most of our response was chaotic and inconsistent, often using the lessons learned of old events to guide future initiatives.

Today we face a new reality: emerging, reemerging, and novel diseases are not going away. In fact, their frequency is rising. In 2022, the world saw an unprecedent outbreak of mpox and a massive surge in RSV. Instead of viewing them as one-off events, we must start increasing our investment in health care biopreparedness. A highly worrisome H5N1 outbreak is occurring on a global scale, underscoring the risk posed by zoonotic diseases.5 In addition, late 2022 saw yet another outbreak of the Ebola virus in Uganda and just last month Equatorial Guinea began working to manage its first Marburg outbreak.6 All these events point to the fact that the world is increasingly experiencing infectious disease events and that we must invest in One Health efforts and a proactive response.7

Efforts to improve health care response require continued conversations, community engagement, diversity and inclusion efforts, and ingenuity. There are a few things, however, that we must acknowledge about the increasingly complex work of health care and public health. Funding for biopreparedness and pandemic prevention ebbs and flows, but a sustainable investment must be established. We have to find a hospital- or facility-level approach to building biopreparedness programs,8 and this need will become more acute once the emergency declaration for COVID-19 expires on May 11. The Johns Hopkins University COVID-19 tracker is also being retired as is the emphasis on control mechanisms from public health agencies.9 Lastly, science and public health have become more and more politicized. From the origins of the virus to vaccines and PPE, the response to the pandemic has been increasingly partisan. Although public health is inherently political, at the hospital level our goal must be to bolster a sustained response that benefits all. It’s up to us to determine how ready we are for the next disease. We must be cognizant of our strengths and weaknesses and not allow hubris—rather than past performance— to determine our preparedness.


1. Popescu S. Historical perspective: lessons from SARS-CoV-1. Contagion. October 18, 2022. Accessed February 22, 2023. https://www.contagionlive.com/view/historical-perspective-lessons-from-sars-cov-1
2. Assiri A, McGeer A, Perl TM, et al. Hospital outbreak of Middle East respiratory syndrome coronavirus. N England J Med. 2013;369(5):407-416. doi:10.1056/NEJMoa1306742
3. Sun LH. Cost to treat Ebola in the US: $1.16 million for 2 patients. The Washington Post. November 18, 2014. Accessed February 22, 2023. https://www.washingtonpost.com/news/post-nation/wp/2014/11/18/cost-to-treat-ebola-in-the-u-s-1-16-million-for-2-patients/

4. McKenna M. The antibiotic resistance crisis has a troubling twist. WIRED. February 7, 2023. Accessed February 22, 2023. https://www.wired.com/story/the-antibiotic-resistance-crisis-has-a-troubling-twist/

5. McKenna M. The bird flu outbreak has taken an ominous turn. WIRED. February 16, 2023. Accessed February 22, 2023. https://www.wired.com/story/the-bird-flu-outbreak-has-taken-an-ominous-turn/

6. World Health Organization. Equatorial Guinea confirms first-ever Marburg virus disease outbreak. February 13, 2023. https://www.afro.who.int/countries/equatorial-guinea/news/equatorial-guinea-confirms-first-ever-marburg-virus-disease-outbreak. Accessed February 17, 2023.

7. World Health Organization. One Health. September 21, 2017. Accessed February 22,2023 https://www.who.int/news-room/questions-and-answers/item/one-health

8. Popescu S, Leach R. Identifying gaps in frontline healthcare facility high-consequence infectious disease preparedness. Health Secur. 2019;17(2): 117-123. doi:10.1089/hs.2018.0098

9. Roubein R. Goodbye, Johns Hopkins covid tracker. The Washington Post. February 14, 2023. Accessed February 22, 2023. https://www.washingtonpost.com/politics/2023/02/14/goodbye-johns-hopkins-covid-tracker/

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