Eleanor Ellie Murray ScD Department of Epidemiology World Bank Chief Economist Office Middle East and North Africa Section Dec 3 2020 Outline Public health epidemic response What has worked for COVID ID: 920528
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Slide1
Time for a family reunion: Economics & epidemiology need to work together to end the COVID pandemic
Eleanor (Ellie) Murray, ScDDepartment of Epidemiology
World Bank Chief Economist Office,
Middle East and North Africa Section
Dec 3, 2020
Slide2Outline
Public health epidemic response
What has worked for COVID
Political and economic dimensions
Areas where economists are sorely needed
Challenges for collaboration
Slide3Public health epidemic response tools have existed for 500+ years
Slide4Field (applied) epidemiology
Epidemiologic investigations initiated in response to urgent public health problems
Timing is unexpected
Timely response is needed
Public health epidemiologists must travel to and work in the field to solve the problem
Time & situational constraints on study design & methods
Slide5Steps in Outbreak Investigation & Response
Prepare for field work
Confirm the diagnosis and outbreak
Identify and count cases (create a case definition and tracking system)
Describe data in terms of time, place, person
Consider whether control measures can be implemented nowFormulate and test hypotheses.Plan for systematic studiesAct—interpret, make recommendations, monitor, etc.Communicate findings
Slide6Emerging zoonotic infections in humans since1976
Infection
Animal linked to transmission
Year
infection first reported
Ebola virus
Bats
1976
HIV-1
Primates?
1981
E.
Coli O157:H7
Cattle
1982
Borrelia
burgdorferi
Rodents
1982
HIV-2
Primates?
1986
Hendra virus
Bats
1994
Bovine
spongiform encephalitis, variant
Cruetzfeltd-Jakob
disease
Cattle
1996
Australian
Lyssavirus
Bats
1996
H5N1 influenza
A
Chickens
1997
Nipah
virus
Bats
1999
SARS
coronavirus
Palm civets
2003
Influenza
H1N1
Swine
2009
Middle
East Respiratory Syndrome (MERS/ MERS-
CoV
)
Camels?
2012
SARS-CoV-2
/ COVID-19
Bats? Pangolins?
2019
Slide7Understanding the outbreak and response level needed
How important is intervention in general?
Imperial College simulation model, Report 9
Worst case scenario estimate of deaths
Where do we prioritize interventions today?
IHME modelShort-term estimate of expected resource needs
Slide8Where these tools have been applied to COVID control, the epidemic is largely under control.
Slide9Strategies for Limiting Spread
Rapid identification of cases
Isolation of suspected, probable, or known cases
Quarantine of potentially exposed individuals
Screening of high risk groups
Limiting contact opportunitiesIncreasing public awareness
Slide10Case study: Mongolia
January 10: government advisory to wear masks
January: began widespread rapid COVID testing; borders closed
February: repatriation of citizens abroad with testing and quarantine
March: first domestic COVID case detected; contact tracing & quarantine of all contacts
March: 24 hour COVID information hotline to combat misinformationGraphic: Reuters
Slide11Case study: New Zealand
Widespread, rapid turnaround testing on population-level and isolation of infected individuals
Infected individuals identified & isolated an average of 2 days
before
symptom onset by late April
Lockdown used to scale up testing and then relaxedGraphic: Reuters
Slide12Case study: Vietnam
Graphic: Reuters
Testing & Contact tracing
Targeted lockdowns; mass gathering & travel restrictions
Clear & creative messaging (
eg TikTok handwashing dance)
Slide13Epidemiology is not the only consideration: politics and concerns for economic activity have outsized impacts on COVID response
Slide14For infectious disease outbreaks there are 3 possible goals
(Effective) Control
Elimination
Eradication
Reduction of prevalence and/or incidence to locally-acceptable level; usually interpreted to indicate “No longer a public health priority”, but intervention is still required.
Eg seasonal fluReduction of incidence to “~Zero” in national or regional context; organism continues to exist somewhere (other regions, host species); intervention remains required. Eg polio in the USPermanent reduction of global incidence to Zero and the organism is not present in nature; no interventions required but may require PH preparedness in case of re-introduction because organism could still be present in lab. Eg smallpox
Slide15What is the goal for COVID?
SARS was eliminated No cases in humans but no proof it doesn’t still exist in natureMERS was controlled
Cases occur sporadically, monitoring is required, but incidence is low
Slide16Politics determines the goal for COVID
In Spring 2020, COVID goal was elimination or eradication
From Summer, USA COVID goal appears to have shifted to control
What level is “acceptable”?
Who gets to decide?
Can we get back to elimination or eradication?
Slide17Other known political aspects of outbreaks:
International trust and collaboration
Re H5N1:
“We
must
have assurance that the viruses we send will be used solely for noncommercial public health purposes in an equitable manner, not only for the benefit of company profits or rich people in rich nations. We must have
trust that when we
entrust
our
viruses
to the multilateral system,
it would
not be at the
expense
of our
sovereign rights
and at the
expense
of our peoples’
health.
For
that to happen,
we
need to formulate a
new system.”
Slide18Social
Context:
Concepts
of
DiseaseHow much of the COVID morbidity and mortality in the US can be attributed to people not believing that COVID is really happening?
Slide19Social context: race, ethnicity, and discrimination
Slide20The efforts of economists in tackling the
economic sequelae of this pandemic are vitally needed.
Slide21Infectious disease outbreaks have always had huge economic costs
In
McLeod
A,
Morgan
N, Prakash A, Hinrichs J. Economic and Social Impacts of Avian Influenza. FAO Emergency Centre of Transboundary Animal Diseases Operations (ECTAD). Geneva:Food and Agriculture Organization .
H5N1
Slide22http://www.healthcare.philips.com/main/shared/assets/documents/bioshield/
ecoandsocialimpactofemerginginfectiousdisease_111208.pdf
Infectious disease outbreaks have always had huge economic costs
Slide23(Some) Economic impacts of COVID
Unemployment
Decreased trade, commerce, tourism
Population shifts
Health care, response, & preparedness costs
Research costs (funding new research / disruptions to previously funded research)Impacts on other diseasesImpacts on other public health programs23
Slide24Some COVID questions that need economic solutions
Economic impacts of the pandemic versus economic impacts of
response
to the pandemic?
Sustainability of public health response:
Mandatory sick leave and/or quarantine leave?Penalize businesses for exposures or transmissions onsite to encourage safe practices?Eviction freezes, utility shut-off freezes?National coordination and distribution of resources:Creation & access to personal protective equipment? Distribution of excess crops?Vaccines & therapeutics?
Slide25The efforts of economists in development of tools for
tracking, predicting, or preventing future pandemics are vitally needed.
Slide26What we know about pandemic drivers
Globaliza
ti
on
Global
travel: people, animals, vectorsGlobal trade: animals and their productsAmplificationUrbanizationPopula
tion
density
Agricultural
Intensifica
ti
on
Technology
and
Industry
Vector
distribu
ti
on
and
densi
ti
es
Transmission
in health
care
centers
Successful
A2H
&
H2H
transmission
Emergence
Human
encroachment
Exploita
ti
on
Transloca
ti
on
Climate
variability
Vector
density
and
distribu
ti
on
Ecological
Pressure
Slide27Epidemiologists have long used these drivers to predict emerging diseases…
Ref: Jones, K.E., Patel, N.G., Levy, M.A., Storeygard, A., Balk, D., Gittleman, J.L. and Daszak, P. 2008. Global trends in emerging infectious diseases. Nature
451
:990-994.
27
Wildlife Source
Slide28Case study: Lombardy
Among the earliest, worst hit regions outside of China was Lombardy, Italy.
A number of theories have been proposed for why COVID spread so rapidly in Lombardy, but another important question is
why
COVID arrived so early in Lombardy versus other regions.
A hypothesis: Lombardy is home to a key worldwide supplier of nasopharyngeal swabs, and demand for these swabs to diagnose COVID may have led to high degree of contact between Lombardy & Wuhan.A question: Could economic trade networks be used to predict early spread, or detect early signals, of future pandemics?
Slide29Collaboration between epidemiologists and economists will be crucial for surviving COVID and building a safer, less vulnerable, world going forward.
Public health & economics need to collaborate!
Slide30Research on COVID has exploded rapidly
Nearly 75,000 articles indexed on PubMed which include “COVID”, as of 11/30/2020COVID first reported 12/31/2019
Clinical reports published as early as January 2020
Slide31… but a large proportion of COVID papers suffer from known problems …
Slide32… and other COVID “research” isn’t even research at all …
Slide33… even for experts, COVID research is challenging
Most COVID research is observational
Observational data requires deep understanding of the data collection methods, population, and decision-making processes
Once these are known, observational data requires careful analytic methods that account for these features
Contagion is a form of
endogeneity and requires special methods and special estimands
Slide34Epidemiology and economics need to work together
We are sister fields – both use primarily observational data to understand population processes
Since John Snow developed difference-in-difference methods for understanding cholera spread, our fields have diverged
Biggest challenge: We speak different languages and need to learn to translate between our fields
Slide35Thank you
Read more:Murray EJ. Epidemiology’s time of need: COVID-19 calls for epidemic-related economics. Journal of Economic Perspectives
. 2020; 34(4): 1-17.
Contact me:
ejmurray@bu.edu