The national COVID-19 emergency finally came to an end on Thursday, and the virus that caused it seems to be a waning force, but public health leaders are clear on one thing: This is no time to celebrate. It is time to prepare.
This won’t be the last pandemic. Those who have toiled at the heart of the current catastrophe are already looking ahead to the next, seeking to learn from what went wrong and prepare for an unknowable pathogen that could strike tomorrow, or two years from now, or 50 years in the future.
“We’ve learned a lot of humbling lessons over the last three years,” said Dr. Jacob Lemieux, an infectious disease physician at Massachusetts General Hospital.
“Over time the memory of this event will fade. It seems like pandemics happen frequently but also infrequently enough [that] the memory has faded almost completely when it’s time for the next pandemic,” he said.
The challenge is to put in place robust and supple systems that can respond to whatever might come. “We just don’t know what it’s going to look like,” he said.
Here are some of the changes underway, and some of the gaps that health leaders have identified as clear priorities.
Focus on the local level
Dr. Robbie Goldstein, commissioner of the Department of Public Health, said the state’s experience with COVID-19 positions it well to respond to future threats.
The state has stockpiled personal protective equipment, tests, and treatments “not just for COVID-19 but for other respiratory illnesses and other public health emergencies,” Goldstein said at a news conference Tuesday. The stockpile includes 5.9 million N95 face masks, approximately 100,000 doses of COVID-19 antivirals, and 19,000 doses of influenza antivirals.
But there are lessons still to learn. Massachusetts’ public health system, like the nation’s, is decentralized. Every one of the state’s 351 cities and towns has its own public health authority. For some, it’s a well-staffed full-time department; for others, a handful of part-timers. That helped make the response to COVID uneven.
“Your public protections depend on your ZIP code,” said state Senator Joanne M. Comerford of Northampton. Comerford cochaired a legislative commission that last year came out with 16 recommendations, many of them focused on strengthening, and engaging with, public health agencies at the local level.
The report describes how local officials who had been doing vaccine-distribution drills were sidelined — and blindsided — when the state instead hired private agencies to run mass vaccination sites. The state’s vaccination effort proved slow to reach those most in need and local officials protested that the rollout might have gone better if they had been involved.
Next time they more likely will be. Proposed legislation in the House and Senate would provide support for municipal health authorities, evening out disparities in resources, encouraging sharing of services among smaller towns, and setting standards for the services a local health authority should provide. In a pandemic, such systems could prove especially important in gathering and sharing data, and tracing the web of people who had contact with an infected person. Comerford is optimistic about the bill’s passage.
“Let’s have a transformation of local and regional public health,” Comerford said, so that local health authorities can become “the kind of fortified front line that they can be and want to be.”
Surveillance: Detecting the next threat
Responding to any new pathogen requires an ability to detect it early and track it. COVID took the world by surprise, but experts hope better early warnings will help them buy time to develop an effective response and save lives.
Starting long before COVID, the Department of Public Health has collected anonymized data from hospitals and health systems about patients’ respiratory symptoms, counting how many people went to their doctors with such problems as fever, cough, or shortness of breath. This is how the state now reports flu activity, a tally of symptoms called “influenza-like illnesses.” Properly deployed, the system can also serve as an early warning of a plague on the way.
A group at the Harvard Medical School Department of Population Medicine is working on that now, testing a new algorithm that compares symptoms with the results of laboratory tests for various viruses, including flu, COVID-19, and RSV.
“What if we start to see an increase in influenza-like illnesses that wasn’t associated with an increase in identified viruses?” said Dr. Alfred DeMaria, the former medical director of the state’s Bureau of Infectious Disease, who continues to work as a consultant to the state. Such a pattern could be a sign of an infection never before seen.
In the spring of 2020, after the normal flu season had passed, there was a notable spike in influenza-like illnesses, but no corresponding spike in positive flu tests. Those “influenza-like illnesses” clearly were COVID-19. The goal of the new system is to detect such signs ahead of time, DeMaria said.
The system still needs to be proven accurate, but DeMaria sees potential to give all sorts of early warnings, such as a wave of RSV that might prompt nursing home directors to ask everyone to wear masks.
Other early detection efforts are also underway. The Broad Institute of MIT and Harvard, in partnership with the African Center of Excellence for Genomics of Infectious Diseases — a consortium of African academic and medical institutions — launched a pandemic surveillance system called Sentinel just as COVID began to circulate. Using genomic tools, the program seeks to detect known and unknown pathogens and quickly share data about them so that tests and vaccines can be developed rapidly.
Technology developed for the Sentinel program helped the Broad track COVID variants in Massachusetts, and the system is currently being piloted in several African countries, which have been home to some of the biggest and deadliest pandemics.
“We’re trying to reduce that time, from identification of a new threat to [development of] counter measures,” said Pardis Sabeti, an institute member at the Broad and a professor at Harvard University.
Although federal funding for COVID-19 response and pandemic preparedness in general has declined, state health officials point to one bright spot. Last year, the state DPH received a $25 million federal grant to boost genomic research. The department will lead the New England Pathogen Genomics Center of Excellence, which encompasses the Broad and several universities and biotechs, to monitor and combat all kinds of microbial threats, from emerging infections to food-borne illnesses.
Fortifying the front line: hospitals
Emergencies and infectious disease threats are nothing new to hospitals, but COVID hit them with uncommon fury, overwhelming existing systems and exhausting staff. That memory of those desperate days has invigorated efforts to improve the response to future onslaughts.
At Mass General Brigham, for example, the electronic medical record system asks about travel history, and has pop-up alerts for the highest risk outbreaks around the world. There is also a continuously updated electronic document nurses can refer to that has links to protocols, including specific isolation protocols.
“We don’t want to do it only when there is an outbreak. We made it part of medical care,” said Dr. Paul Biddinger, chief preparedness and continuity officer at Mass General Brigham.
Tufts Medicine has implemented a similar system, which already proved useful last year guiding the response to the Mpox outbreak, an infectious disease characterized by a painful rash. “We did that quickly with lessons learned from COVID,” said Nick Duncan, director of operations and emergency management at Tufts Medical Center.
Health systems have also stepped up collaboration with state epidemiologists, Boston EMS, and Logan Airport to tighten protocols and create a checklist of procedures in case a patient who may pose an infectious disease threat is identified.
Other concerns: data, funding, equity
There also needs to be a better way to track emergency room and inpatient capacity — both stretched to the brink by COVID. While health systems are now capable of sharing such data, many must input the numbers manually.
“I’ve been using the analogy of a thermostat. No one can tell you the temperature of health care capacity right now,” Biddinger said. “We need that on a constant basis. . . . It would be great to know — here is the average strain on emergency department capacity. When you saw it ticking up, it would be another way to know something is going on.”
Some needs will require additional federal money to address, particularly now that some pandemic response funding has dried up. During the Ebola outbreak in 2015, the federal government created a three-tiered system of hospital response, including assessment hospitals equipped to identify infected patients and treatment hospitals able to care for them. Originally, the system involved 56 hospitals across the nation, but today there is only funding for 13, including Mass. General.
“We need more than 13 hospitals in the country capable of caring for patients with special pathogens, and we need hospitals in every community to at least start the assessment,” Biddinger said.
Another question for hospitals and health systems is how to support their staff through a prolonged crisis, said Diana Richardson, president of Tufts Medical Center who worked as chief operations officer of the hospital during much of COVID. Hospitals tend to think of emergencies as short-lived events, but COVID taught the country that such stressors can last years.
“If we had a new pandemic start all over again, we have to think about how we support those teams, so it’s not just — everyone work longer hours or harder,” Richardson said.
Additionally the nation’s public health system needs strong and consistent financial support, Lemieux said. When the public health emergency was extended last year, Congress failed to provide the funding to cover the ongoing response. “There’s a legacy of underfunding of public health at the national, state, and local level that makes this an uphill battle,” he said.
Carlene Pavlos, executive director of the Massachusetts Public Health Association, sees pandemic planning as an opportunity to improve public health broadly, shoring up the morale and the ranks of those who work at everything from restaurant inspections to contact tracing.
”We have to have mechanisms in place, not just for times of crisis, but in the day-in and day-out working of public health — to build trusting relationships,” she said.
The state also needs to address longstanding inequities that led low-income people and people of color to suffer higher rates of illness and death.
”It’s so important that the end of the public health emergency does not translate into a return to normal,” Pavlos said, because “normal” meant stark inequities that could have been prevented and an underfunded public health system.
”We cannot return to normal,” she said.