Thinking beyond pathogen surveillance: building resilient biotech ecosystems to combat the next pandemic

Abstract

The lead article by Struelens et al. (1) offers a comprehensive look at the evolution of pathogen surveillance during the SARS-CoV-2 pandemic and maps out how further investment, the development of global standards and a renewed focus on One Health policies and initiatives can play an important role in the monitoring and control of infectious diseases and antimicrobial resistance.We view pathogen surveillance initiatives as the important first step of any public health intervention as the information garnered can be used to tailor subsequent containment strategies. However, any subsequent interventions rely heavily on supporting healthcare and biomanufacturing infrastructure to investigate the cause of syndromic clusters (such as acute flaccid paralysis, hemorrhagic fever or pneumonia of unknown etiology) and develop diagnostic tests and countermeasures to contain them before they evolve into epidemics and pandemics.In this viewpoint we first discuss some of the limitations of surveillance strategies and then share how our experiences during the SARS-CoV-2 pandemic advocate for our view that pandemic preparedness and healthcare systems resilience will benefit substantially from the development of multiple local "biotech" ecosystems with both expertise and equipment that can be repurposed at a moment's notice.In late December 2019, a cluster of pneumonia cases of unknown etiology was reported in Wuhan, People's Republic of China (2) and within 2 weeks the causal pathogen's genomic sequence was made publicly available, enabling the rapid development of diagnostic assays (3). This case contrasts with that of the Ebola outbreak in 2013 in West Africa where poor diagnostic preparedness (4) led to a 3-month delay in identifying the outbreak, and, despite the low reproductive number (5), the delayed implementation of diagnostics infrastructure meant that the outbreak was only contained in 2016.The rapid identification of the pathogen responsible for the COVID-19 pandemic represents close to the ideal case when it comes to hospital surveillance systems linking closely with public health authorities to investigate disease clusters. This was potentially because the virus first emerged in a country which scores highly on the Global Health Security Index specifically for Laboratory Systems Strength and Quality (6), which clearly played a role in the rapid investigation. However, many of the places where emerging zoonotic diseases are likely to first present do not have resilient surveillance and diagnostics infrastructure (7). Some efforts to strengthen surveillance infrastructure have focused on implementing sequencing capacity building efforts in low-and middle-income countries (LMICs) (8) and exploring more cost-effective forms of surveillance such as wastewater testing. Wastewater surveillance, a promising modality in highly populated areas, still largely relies on wastewater treatment plants or formal sewerage systems. This is a significant limitation of this approach as in many parts of the world there is little correlation between population density and the presence of wastewater treatment plants (Figure 1), making it of limited utility to replace current case notification-based surveillance. As a part of the Millenium Development Goals (MDGs), there are efforts to invest in WASH (access to sanitation, hygiene and clean drinking water) initiatives, but many of these projects have decades long time frames and have seen little progress in the last 24 years (Figure 1). Companies such as Ginkgo Bioworks are also focusing on building biosecurity "radar" systems by performing aircraft wastewater testing through collaborations with governments around the world. These efforts can serve as valuable proxies to traditional surveillance, providing insight into community transmission levels (9) in countries without adequate surveillance infrastructure.An early understanding of the epidemiology can then allow for interventions to be planned and