THE THREAT FROM PANDEMICS AND EPIDEMICSIn the 21st century, our Intelligence Community has expanded the definition of bio-threats to the US beyond weapons to naturally occurring pandemics. The most pressing infectious disease challenge facing the US is the potential emergence of a new and deadly avian influenza strain, which could cause a worldwide outbreak, or pandemic. International health experts worry that avian influenza could become transmissible among humans, threatening the health and lives of millions of people around the globe. There are many unknowns about avian flu, but even the specter of an outbreak could have significant effects on the international economy, whole societies, military operations, critical infrastructure, and diplomatic relations.
The most direct threat to the US is the spread of infectious pathogens to our shores, or within areas where US personnel are deployed. Disease also indirectly threatens us with its potential impacts upon the international economy, civil society and critical infrastructures. Even a relatively limited outbreak, as happened with SARS in 2003, can have widespread ripple effects. Even if an outbreak does not threaten the US directly, the resulting instability or humanitarian emergency can place additional demands on US military and financial resources.
The most pressing infectious disease challenge for the United States is still the potential emergence of a severe influenza pandemic. Although the avian H5N1 virus has remained primarily a threat to poultry, it continues to expand its geographic coverage, and to evolve—indeed it retains the potential to evolve into a human pandemic strain.
Note: although both the 2002—2003 SARS and the 2012 MERS outbreaks were caused by a corona virus, the intelligence community refers to flu pandemics, but that is not all that relevant. terminology.
Considerable empirical and theoretical studies have demonstrated the links between the health of a population and economic growth and development. Highly publicized virulent infectious diseases—including HIV/AIDS, a potential influenza pandemic, and “mystery” illnesses such as the 2003 outbreak of severe acute respiratory syndrome (SARS)—remain the most direct health-related threats to the United States. The most pressing transnational health challenge for the United States is still the potential for emergence of a severe pandemic, with the primary candidate being a highly lethal influenza virus.
The World Bank estimates that if the next pandemic virus is similar to the one that caused the 1918 pandemic, it could kill 71 million people worldwide and cause a major global recession with global costs exceeding $3 trillion. Other estimates, applying the 2.5 percent fatality rate from the 1918 pandemic to today's population, reach 180 million deaths worldwide. Current threats include H5N1 influenza, a virus that, while primarily a poultry disease, continues to evolve and expand its geographic range. Infectious diseases are not the only health indicators with strategic significance. Chronic, non-communicable diseases; neglected tropical diseases; maternal and child mortality; malnutrition; sanitation and access to clean water; and availability of basic health-care also affect the US national interest through their impacts on the economies, governments, and militaries of key countries and regions.
Strategic Health Challenges and Threats
The current influenza pandemic is the most visible reminder that health issues can suddenly emerge from anywhere in the globe and threaten American lives and US strategic objectives. It also highlights many of the United States's critical dependencies and vulnerabilities in the health arena. But like an iceberg, the visible portion is just a small fraction of the myriad of health issues that will likely challenge the United States in the coming years. Significant gaps remain in disease surveillance and reporting that undermine our ability to confront disease outbreaks overseas or identify contaminated products before they threaten Americans. The policies and actions of foreign government and non-state actors to address health issues, or not address them, also have ripple effects that impair our ability to protect American lives and livelihoods and impair Washington's foreign policy objectives.
In my threat assessment last year, I noted that “the most pressing transnational health challenge for the United States is the potential emergence of a severe influenza pandemic.” Unknown to everyone at the time, the 2009-H1N1 influenza virus had already started spreading by late March. By the time anyone was aware of the new virus, thousands of American travelers had been exposed. Fortunately, the disease has been, thus far, relatively mild; but even a mild flu pandemic can strain health care resources, cause millions of people to become ill, thousands to die prematurely, curtail economic activity, and upset diplomatic relations as countries attempt to limit the spread of the virus.
As seen with H1N1-2009 pandemic, travel between countries links our population's health to the health and sanitary conditions of every country, and our knowledge of the potential threats is limited by the inadequacies of international disease surveillance in animals and man. We have warned in the past that surveillance capacity to detect pathogens in humans varies widely between countries. Of equal concern, the lack of consistent surveillance and diagnostic capability for diseases in animals is a formidable gap even in developed countries that undermines the United States' ability to identify, contain, and warn about local outbreaks before they spread. Some 70 percent of human pathogens originated from animals, yet global surveillance of animal diseases remains chronically under funded.[sic]
- The pandemic highlights the need to avoid narrowly targeting surveillance and control measures on only one particular health threat. No one can predict which of the myriad of potential health threats will suddenly emerge, where the threat will come from, or when. For the last several years, the world focused on the emergence of H5N1 avian influenza from Asia. While the possibility of an H5N1 avian flu pandemic helped the US government respond to the actual H1N1 pandemic, the international focus for avian influenza in Eurasia deflected international attention and resources away from the possibility of the emergence of a different virus, from another region, and from a different animal host.
Strategic Health Threats
It is unlikely that any country will be able to detect cases early enough to prevent the spread of another new, highly transmissible virus should one emerge during the next five years, despite pandemic preparedness efforts by the World Health Organization (WHO) and many nations over the past decade. Once such a disease has started to spread, confining it to the immediate region will be very unlikely. Preparedness efforts such as the stockpiling of medical countermeasures will be critical to mitigating the impact from a future pandemic. Governments in much o f Asia, the Americas. and Western Europe perceived pandemics as a serious threat, and their preparedness efforts helped them lessen the impact of the 2009-H1N1 pandemic. These nations are likely to apply the lessons they learned; however, tight budgets over the next few years will limit further improvements in preparedness and may cause some countries to backslide.
Although we can say with near certainty that new outbreaks of disease and catastrophic natural disasters will occur during the next several years, we cannot predict their timing, locations, causes, or severity. We assess [sic] the international community needs to improve surveillance, early warning, and response capabilities for these events, and, by doing so, will enhance its ability to respond to manmade disasters. This can be accomplished in part by member state implementation of the World Health Organization's International Health Regulations (2005). The key challenge is that fiscal austerity measures in many countries might so restrict funding that preparedness declines.
HEALTH and PANDEMIC THREATS
Scientists continue to discover previously unknown pathogens in humans that made the “jump” from animals' oonotic diseases. Examples are: a prion disease in cattle that jumped in the 1980s to cause variant Creutzeldt-Jacob disease; a bat henipavirus that in 1999 became known as the human Nipah Virus; a bat corona virus that jumped to humans in 2002 to cause Severe Acute Respiratory Syndrome (SARS); and another SARS-like corona virus recently identified in individuals who have been in Saudi Arabia, which might also have bat origins. Human and livestock population growth and encroachment into jungles increase human exposure to crossovers. No one can predict which pathogen will be the next to spread to humans, or when or where such a development will occur, but humans will continue to be vulnerable to pandemics, most of which will probably originate in animals.
An easily transmissible, novel respiratory pathogen that kills or incapacitates more than one percent of its victims is among the most disruptive events possible. Such an outbreak would result in a global pandemic that causes suffering and death in every corner of the world, probably in fewer than six months. This is not a hypothetical threat. History is replete with examples of pathogens sweeping populations that lack immunity, causing political and economic upheaval, and influencing the outcomes of wars—for example, the 1918 Spanish flu pandemic affected military operations during World War I and caused global economic disruptions.
The World Health Organization has described one influenza pandemic as “the epidemiological equivalent of a flash flood.” However, slow-spreading pathogens, such as HIV/AIDS, have been just as deadly, if not more so. Such a pathogen with pandemic potential may have already jumped to humans somewhere; HIV/AIDS entered the human population more than 50 years before it was recognized and identified. In addition, targeted therapeutics and vaccines might be inadequate to keep up with the size and speed of the threat, and drug-resistant forms of diseases, such as tuberculosis, gonorrhea, and Staphylococcus aureus, have already emerged.
No one can predict which pathogen will be the next to spread to humans or when or where this will occur. However, humans remain vulnerable, especially when a pathogen with the potential to cause a pandemic emerges. For example, we judge that the H7N9 influenza in China that emerged from birds in early 2013 is not yet easily transmissible from person to person. However, it bears watching for its extreme severity, high death rates, and potential to mutate and become more transmissible. Between late March 2013, when the virus was first recognized, and the following May, when it was brought under control, H7N9 influenza killed over 20 percent of those infected and caused severe disease with long- term hospitalization in nearly all other cases. If H7N9 influenza or any other novel respiratory pathogen that kills or incapacitates more than 1 percent of its victims were to become easily transmissible, the outcome would be among the most disruptive events possible. Uncontrolled, such an outbreak would result in a global pandemic with suffering and death spreading globally in fewer than six months and would persist for approximately two years.
Critical Trends Converging
Several trends are converging that will probably increase the frequency of shocks to human security in 2015. Emerging infectious diseases and deficiencies in international state preparedness to address them remain a threat, exemplified by the epidemic spread of the Ebola virus in West Africa.
Infectious Disease Continues To Threaten Human Security Worldwide
Infectious diseases are among the foremost health security threats. A more crowded and interconnected world is increasing the opportunities for human and animal diseases to emerge and spread globally. This has been demonstrated by the emergence of Ebola in West Africa on an unprecedented scale. In addition, military conflicts and displacement of populations with loss of basic infrastructure can lead to spread of disease. Climate change can also lead to changes in the distribution of vectors for diseases.
- The Ebola outbreak, which began in late 2013 in a remote area of Guinea, quickly spread into neighboring Liberia and Sierra Leone and then into dense urban transportation hubs, where it began spreading out of control. Gaps in disease surveillance and reporting, limited health care resources, and other factors contributed to the outpacing of the international community's response in West Africa. Isolated Ebola cases appeared outside of the most affected countries—notably in Spain and the United States—and the disease will almost certainly continue in 2015 to threaten regional economic stability, security, and governance.
- Antimicrobial drug resistance is increasingly threatening global health security. Seventy percent of known bacteria have acquired resistance to at least one antibiotic that is used to treat infections, threatening a return to the pre-antibiotic era. Multidrug-resistant tuberculosis has emerged in China, India, Russia, and elsewhere. During the next twenty years, antimicrobial drug-resistant pathogens will probably continue to increase in number and geographic scope, worsening health outcomes, straining public health budgets, and harming US interests throughout the world.
- MERS, a novel virus from the same family as SARS, emerged in 2012 in Saudi Arabia. Isolated cases migrated to Southeast Asia, Europe, and the United States. Cases of highly pathogenic influenza are also continuing to appear in different regions of the world. HIV/AIDS and malaria, although trending downward, remain global health priorities. In 2013, 2.1 million people were newly infected with HIV and 584,000 were killed by malaria, according to the World Health Organization. Diarrheal diseases like cholera continue to take the lives of 800,000 children annually.
- The world's population remains vulnerable to infectious diseases because anticipating which pathogen might spread from animals to humans or if a human virus will take a more virulent form is nearly impossible. For example, if a highly pathogenic avian influenza virus like H7N9 were to become easily transmissible among humans, the outcome could be far more disruptive than the great influenza pandemic of 1918. It could lead to global economic losses, the unseating of governments, and disturbance of geopolitical alliances.
Statement for the Record Worldwide Threat Assessment of the US Intelligence Community Senate Select Committee on Intelligence, February 9, 2016
Infectious diseases and vulnerabilities in the global supply chain for medical countermeasures will continue to pose a danger to US national security in 2016. Land-use changes will increase animal-to- human interactions and globalization will raise the potential for rapid cross-regional spread of disease, while the international community remains ill prepared to collectively coordinate and respond to disease threats. Influenza viruses, coronaviruses such as the one causing Middle Eastern Respiratory Syndrome (MERS), and hemorrhagic fever viruses such as Ebola are examples of infectious disease agents that are passed from animals to humans and can quickly pose regional or global threats. Zika virus, an emerging infectious disease threat first detected in the Western Hemisphere in 2014, is projected to cause up to 4 million cases in 2016; it will probably spread to virtually every country in the hemisphere. Although the virus is predominantly a mild illness, and no vaccine or treatment is available, the Zika virus might be linked to devastating birth defects in children whose mothers were infected during pregnancy. Many developed and developing nations remain unable to implement coordinated plans of action to prevent infectious disease outbreaks, strengthen global disease surveillance and response, rapidly share information, develop diagnostic tools and countermeasures, or maintain the safe transit of personnel and materials.
- Human encroachment into animal habitats, including clearing land for farm use and urbanization, is recognized as a contributing factor in the emergence of new infectious diseases. The populations of Asia and Africa are urbanizing and growing faster than those of any other region, according to the UN. Emerging diseases against which humans have no preexisting immunity or effective therapies pose significant risks of becoming pandemics.
Statement for the Record Worldwide Threat Assessment of the US Intelligence Community Senate Select Committee on Intelligence, May 11, 2017The emergence of a severe global public health emergency is possible in any given year and can have negative impacts on the security and stability of a nation or region. A novel or reemerging microbe that is easily transmissible between humans and is highly pathogenic remains a major threat because such an organism has the potential to spread rapidly and kill millions. Threats such as avian influenza and Middle East Respiratory Syndrome Coronavirus (MERS-CoV) have pandemic potential. The World Bank has estimated that a severe global influenza pandemic could cost the equivalent of 4.8 percent of global GDP, or more than $3 trillion, during the course of an outbreak.
STATEMENT FOR THE RECORD WORLDWIDE THREAT ASSESSMENT of the US INTELLIGENCE COMMUNITY February 13, 2018
HealthThe increase in frequency and diversity of reported disease outbreaks—such as dengue and Zika—probably will continue through 2018, including the potential for a severe global health emergency that could lead to major economic and societal disruptions, strain governmental and international resources, and increase calls on the United States for support. A novel strain of a virulent microbe that is easily transmissible between humans continues to be a major threat, with pathogens such as H5N1 and H7N9 influenza and Middle East Respiratory Syndrome Coronavirus having pandemic potential if they were to acquire efficient human-to-human transmissibility.
- Increasing antimicrobial resistance, the ability of pathogens—including viruses, fungi, and bacteria—to resist drug treatment, is likely to outpace the development of new antimicrobial drugs, leading to infections that are no longer treatable.
- The World Bank has estimated that a severe global influenza pandemic could cost the equivalent of 4.8 percent of global GDP—more than $3 trillion—and cause more than 100 million deaths.
STATEMENT FOR THE RECORD WORLDWIDE THREAT ASSESSMENT of the US INTELLIGENCE COMMUNITY, 29 January 2019
We assess that the United States and the world will remain vulnerable to the next flu pandemic or large- scale outbreak of a contagious disease that could lead to massive rates of death and disability, severely affect the world economy, strain international resources, and increase calls on the United States for support.
Although the international community has made tenuous improvements to global health security, these gains may be inadequate to address the challenge of what we anticipate will be more frequent outbreaks of infectious diseases because of rapid unplanned urbanization, prolonged humanitarian crises, human incursion into previously unsettled land, expansion of international travel and trade, and regional climate change.
- The ongoing crisis in Venezuela has reversed gains in controlling infectious diseases, such as diphtheria, malaria, measles, and tuberculosis, increasing the risk that these diseases could spread to neighboring countries, particularly Brazil, Colombia, and Trinidad and Tobago. Similarly, the ongoing Ebola outbreak in the Democratic Republic of the Congo—the country’s largest ever—underscores the risks posed by the nexus of infectious disease outbreaks, violent conflict, and high population density, including large numbers of internally displaced person (IDPs).
- In the past two years, progress against malaria has halted after more than 15 years of steady reductions, in part because mosquitos and the pathogen have developed a resistance to insecticides and to antimalarial drugs, respectively, while global funding to combat the disease has plateaued.
- The growing proximity of humans and animals has increased the risk of disease transmission. The number of outbreaks has increased in part because pathogens originally found in animals have spread to human populations.