“Those who cannot remember the past are condemned to repeat it.” —Jorge Agustín Nicolás Ruiz de Santayana y Borrás, known in English as George Santayana (1863–1952), Spanish-American philosopher, essayist, poet, and novelist
In early January 2020, a new strain of human coronavirus was definitively identified in a cluster of patients in Wuhan, Hubei, Central China, presenting with a similar appearing, severe viral pneumonia.1,2 On February 11, 2020, the International Committee on Taxonomy of Viruses (ICTV) officially named this novel virion the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), and the World Health Organization (WHO) announced it to be the cause of the rapidly spreading, newly crowned coronavirus disease 2019 (COVID-19). Worldwide COVID-19 public health surveillance and containment efforts failed, and on March 11, 2020, the WHO declared a pandemic (global epidemic) status for this highly contagious and pathogenic viral disease.2 An epic human chain reaction was set in motion.
In this issue of Anesthesia & Analgesia, Tung et al,3 members of the Society of Critical Care Anesthesiologists (SOCCA), and each actively involved in the frontline responses to COVID-19 in their own institutions, describe what they encountered and learned during this pandemic. These authors thoughtfully imagine how their experiences with COVID-19 could inform the critical care response among anesthesiologist-intensivists to the next pandemic.
WHAT MIGHT BE THIS FUTURE, NEXT PANDEMIC?
An emerging infectious disease (EID) is defined as a disease that either (1) has newly appeared in a population or (2) previously existed but is now rapidly increasing in incidence or geographic distribution.4,5 COVID-19 is the most recent of a myriad of EIDs that have opportunistically infected humans for centuries and likely for millennia.4,5 As witnessed by COVID-19, an EID with worldwide pandemic potential is a major threat to global health as well as social and economic stability. Most new viral infectious disease outbreaks with pandemic potential, including possibly COVID-19, have been zoonotic in origin.4
Zoonotic diseases result from a bacterium, virus, fungus, protozoan, parasite, or prion being transmitted from a vertebrate animal to a human. There are over 150 known zoonotic diseases worldwide—causing substantial annual human morbidity and mortality.6 Zoonotic diseases are transmitted to humans from either wild or domesticated animal species. Livestock, live animal markets, petting zoos, and family pets are the most common sources of zoonotic disease. Some zoonotic diseases require a blood-feeding arthropod such as a mosquito, tick, louse, flea, or biting fly to transmit the infection to humans.6
Unrelenting globalization and urbanization have radically transformed how and where humans live and work. Expansive integration of the world economy has also accelerated global interconnectedness. Earth has become a small and crowded planet. As human society, along with the natural and built environment change, new pathogens can arise or existing pathogens can find new niches in which to thrive and to cause disease.7
The novel H1N1 influenza strain and pandemic of 1918 to 1919, the deadliest of the 20th century, ultimately infected one-third of the world’s population. This so-called “Spanish flu” was a politically motivated misnomer, given that it likely first appeared in March 1918 in the United States, among congregant young Army recruits at Camp Funston in Fort Riley, Kansas. This novel H1N1 influenza virus then traveled with “American Doughboys” across the Atlantic into the disease-filled trenches of World War I.8–11 In August 1918, a more virulent variant of H1N1 reentered the United States via a ship arriving in Boston from England and unleashed a more lethal form of influenza on the country.8,10 The H1N1 influenza disproportionately killed its younger, previously robust victims, typically within hours, by unleashing a cytokine storm with a sea of inflammatory fluid in their lungs, and drowning them from within.8–11
The 1918 H1N1 influenza pandemic took months to spread throughout the United States, Europe, Africa, Asia, and Australia, as ship-borne international travel took time and had less capacity. Modern airline travel allows passengers to crisscross continents in less than a day.8,12 Present-day international travel and trade patterns are thus even stronger determinants and facilitators—force multipliers—of transmission of a contemporary EID like COVID-19.
The origin of SARS-CoV-2 has yet to be definitively determined,13 and the origin of the virus, thus, remains controversial.14,15 Nevertheless, sustained human-to-human transmission of SARS-CoV-2, including superspreading events, may have occurred between November 2019 and January 2020 at large public venues in Wuhan, including the sprawling Huanan Seafood Wholesale Market.12,16
The Hunan Seafood Market is conveniently situated adjacent to Line 2 of the ultramodern Wuhan Metro System. In late 2019, a single, plum-trimmed Wuhan Metro Line 2 train held up to 2030 passengers, and the Metro Line 2 transported an average of 1 million passengers daily.17 Metro Line 2 directly connects to all 8 other lines of the extensive Wuhan Metro System—providing an infectious disease access to all of Wuhan and the rest of Hubei Province. Line 2 conveniently links up with the high-speed Hankou Railway Station—enabling swift spread of an infectious disease throughout China. The westernmost station of Line 2 is the Wuhan Tianhe International Airport, with its regular nonstop flights to New York City, San Francisco, London, Tokyo, Rome, Istanbul, Dubai, Paris, Sydney, Bali, Bangkok, Moscow, Osaka, Seoul, and Singapore18—promoting prompt propagation of such a disease to Asia, Europe, and the United States.
However, before further castigating the Wuhan, Hubei, and Chinese governments and public health authorities, a similar, very porous, high-capacity, tightly interwoven local, regional, national, and international transportation infrastructure exists in places such as New York City, Chicago, London, Paris, San Francisco, Seoul, and Tokyo. Are any of these other metropolitan locations capable of more robust public health surveillance and earlier detection of an EID?
It also bears worth noting that the current coronavirus pandemic came as no surprise to many scientists, clinicians, public health officials, and policy experts. As presciently described in 3 articles in the July/August 2005 issue of the journal Foreign Affairs, the recent emergence of a novel viral strain such as SARS-CoV-2 and the ensuing COVID-19 pandemic were by all accounts biologically, historically, culturally, and politically inevitable.19–21
The presence and human effects of SARS-CoV-2 remain unabated due to its Greek alphabet soup of successive, successful variants.22 Similar to the 4 other, much older, seasonal strains of still circulating coronavirus (types 229E, NL63, OC43, and HKU1),23 SARS-CoV-2 may become more indolent and endemic—and then just another cause of the common cold.
Before anyone breathes a sigh of relief—a completely new strain of the influenza virus and a resulting influenza pandemic will still occur: it is not a question of if but when and how.24 Yet, if lessons can be learned, and new public health and clinical expertise applied, it is not inevitable that this next viral pandemic will wreak comparable global havoc on humanity.24
The phenomenon of “spillover” or “evolutionary jump” refers to the transmission of a pathogen from a natural animal host to a novel host—including a human host—leading to infection in the new host. This phenomenon may transpire by chance, novel exposure, repeated exposure, or key genomic change enabling the pathogen to infect the new host.25
Recent globalization and urbanization, and attendant seismic social and socioeconomic shifts have promoted this phenomenon of spillover or evolutionary jump of pathogens, accelerated the spread of novel viruses, and enhanced the threat from a viral EID. By the same token, globalization can potentially facilitate international cooperation, promoting advances in public health practices and clinical care. Collectively, embracing these global environmental changes and fostering international cooperation can alter the way that pandemics originate and are recognized, understood, experienced, and controlled.9
With this goal in mind, in this issue of Anesthesia & Analgesia, Tung et al3 share some of their lessons learned and knowledge gained from the contemporary coronavirus pandemic. They focus on health services delivery and clinical care, with a futuristic perspective on how this information can be proactively applied when we are faced with the next, inevitable viral pandemic. These members of SOCCA are to be commended for sharing their firsthand, real-life experiences as anesthesiologist-intensivists in such a transparent way, so that our readers can walk alongside them on their bedside rounds.
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