Is the world ready for the next pandemic threat? Local successes in sporadic outbreaks mask serious gaps in global planning Wim Van Damme professor in public health 1 , Willem van de Put research fellow 1 , Narayanan Devadasan director 2 , Juan Antonio Ricarte health policy intern 1 , Jean-Jacques Muyembe director 3 1 Outbreak Research Team, Institute of Tropical Medicine, Antwerp, Belgium; 2 Institute of Public Health, Bengaluru, India; 3 Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo Growing antimicrobial resistance combined with the risk of infectious diseases transform the global health agenda. New cases of Ebola reported last week in the Democratic Republic of Congo (DRC) after apparently successful control of an outbreak in May 1 2 revive memories of the Ebola epidemic in west Africa n 2014-16. An equally alarming outbreak of Nipah virus occurred in Kerala, India, earlier this year. 3 Although the Nipah outbreak was contained locally and quite rapidly, both recent outbreaks of Ebola in DRC underline the importance of avoiding neglect and complacency after a serious epidemic has been resolved. 4 In a linked article, Leigh and colleagues (doi:10.1136/bmj. k3254) analyse whether the global community has improved its capacity to collectively manage such outbreaks. 5 They describe how, despite various initiatives, we are still far from secure, with gaps in funding, monitoring global capacity, and global leadership. Jonas and colleagues recently called for a global independent mechanism to monitor outbreak preparedness to break the usual cycle of panic and neglect. 4 Such a mechanism should focus on country level preparedness; improving science, technology, and access; identifying and communicating risks; and strengthening global mechanisms. 5 Attention to global preparedness and coordination mechanisms is important. 4 6 The recent Ebola and Nipah outbreaks, however, show that the immediate reaction of frontline health workers and the community where the first cases occur is equally important. 7 Local skilled health workers can recognise cases, organise an appropriate community response, and avoid initial panic. The first cases of Nipah virus were diagnosed by private health facilities, but the Kerala government introduced strong public health measures immediately, including contact tracing and quarantine of all probable cases. 3 Similarly, when the first Ebola outbreak in DRC reached the north western city Mbandaka, rapid control was probably the result of public health measures implemented by Congolese teams with longstanding experience with Ebola. Whether the new heat sensitive Ebola vaccine administered to contacts and health workers was decisive in the initial containment remains uncertain, 8 but its fast and effective deployment may have helped to decrease fear among people at the frontline. Deployment in such a difficult environment was a remarkable achievement by the Congolese Ministry of Health and the World Health Organization led coalition—and we can only hope it remains possible in the conflict affected Beni District in North Kivu, where access and contact tracing of the new cases is a serious challenge. 9 Effective local response Although the preparedness of local community workers and health systems is vital for early containment of outbreaks, it’s far from clear that similar preparedness will be present for future infectious disease alerts. This depends on local context and event specific elements; on local concepts of disease transmission, 7 and on the trust communities have in frontline health workers and local authorities. It also depends on the links between local and higher authorities, the leadership provided by the authorities, and the resources that can be mobilised rapidly to support the local response, including international support and resources. This local trust, preparedness, and reactivity is most doubtful in places affected by conflict. These settings are of greatest concern to the international community because trust in public authorities cannot be assumed, governance on all levels is contested, security is uncertain, and the humanitarian system is already overburdened. 10 Whether better preparedness for such challenging contexts can be obtained through the application of International Health Regulations and WHO led global initiatives remains uncertain. 5 If conflict, lack of accountability, and distrust are uncontrolled, effective engagement of independent and neutral humanitarian organisations will remain challenging, as shown by the recent cholera epidemic in Yemen. 11 Collaborations with groups outside the health sector are increasingly needed, but difficulties remain despite growing Correspondence to W Van Damme wvdamme@itg.be For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe BMJ 2018;362:k3296 doi: 10.1136/bmj.k3296 (Published 9 August 2018) Page 1 of 2 Editorials EDITORIALS on 7 November 2018 by guest. 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