Pandemic (from ancient Greek παν pan 'total, comprehensive, everything' and δῆμος dēmos 'people') describes the spread of a disease across countries and continents , in the narrower sense the spread of an infectious disease . In contrast to an epidemic , a pandemic is not locally restricted, but in the case of pandemics there may also be areas that are not affected by the disease. With regard to influenza , the World Health Organization (WHO) stipulated in its guidelines on Pandemic Influenza Risk Management , which was last revised in May 2017 , that the declaration of a pandemic - i.e. the transition from an epidemic to a pandemic - is carried out by the Director General of the WHO .
The word pandemic goes back to the ancient Greek noun πανδημία pandēmía , German 'the whole people' , which also exists as the adjective πανδήμιος pandēmios , German 'in the whole people [spread]' . Both words are made up of πᾶς pās , German 'all, whole, everyone' ( neuter πᾶν pān ) and δῆμος dēmos , German 'people' .
Since the ending -demie refers to people, the terms epidemic and panzootia (from ζῷον zõon , ` ` living being, living being, animal '') instead of pandemic and epizootic (from επί epí ` ` on '') instead of epidemic are also common in veterinary medicine .
Today, flight routes are considered to be the fastest ways of spreading infectious diseases. This is how AIDS , caused by the HI virus , developed among others. a. by air tourism from a local to a global problem. This effect was also understandable during the SARS pandemic of 2002/2003 : While the classic distribution routes for SARS were still assumed in Asia , the increasing number of diseases in Canada showed this travel effect quite clearly. The spread of the Zika virus epidemic in South America in 2015/2016 was also associated with the intensive travel activity during the final round of the 2014 World Cup .
The World Health Organization has pointed out that a pandemic pathogen can overload the health system of a state due to the large number of people affected at the same time.
Major Pandemics (selection)
Major pandemics in history were:
- Antonine Plague , 165-180. Probably a smallpox pandemic that spread to the territory of the Roman Empire; around 5 million dead.
- Justinian plague , from 541. Effects were noticeable until the 8th century. The disease spread throughout the Mediterranean and throughout the world known to the Romans. The number of deaths is controversial. The trigger was probably Yersinia pestis .
- Black Death , 1347-1352. Coming from Central Asia spread over all of Europe; an estimated 25 million deaths, that is: a third of the European population of that time. The trigger was Yersinia pestis .
- Third plague pandemic , since 1896. First occurred in China, spread worldwide, around 12 million deaths. Caused by: Yersinia pestis .
- Spanish flu , 1918–1920, Probable origin is the United States, estimated to have infected 500 million people, of whom around 20 to 50 million died.
- Spread of HIV / AIDS (since the early 1980s); According to UNAIDS, around 75 million infected and 32 million deceased since 1980 (as of the end of 2018)
- COVID-19 pandemic : On March 11, 2020, the World Health Organization declared the spread of the SARS-CoV-2 virus since December 2019 a pandemic, after it had already described the infection as an international health emergency on January 30, 2020 . According to WHO data, there were more than 17 million people infected and around 650,000 deaths worldwide by the end of July 2020.
Endangerment from new pathogens
In 2012, the German federal government hypothetically simulated a pandemic with an imaginary virus called “Modi-SARS”.
Bill Gates warned in 2015 that one was not prepared for a global epidemic.
Carolien van de Sandt, Peter Doherty Institute for Infections and Immunity at the University of Melbourne , and other authors warned of a second Spanish flu in the journal Frontiers in Cellular and Infection Microbiology in October 2018 . Demographic change, antibiotic resistance and climate change could make fighting the disease more difficult, with the result that up to 150 million people could die.
Chinese researchers warned in March 2019 about the problem of the connection between bats and corona.
In August 2019, the US Department of Health and Human Services carried out the Crimson Contagion simulation game, assuming a new flu virus from China, with the result that 500,000 deaths occurred in the US.
In recent times, the influenza pandemics in particular have attracted a lot of media attention. These pandemics were triggered by group A influenza viruses , whose antigenic surface molecules hemagglutinin (HA) and neuraminidase (N) had changed. Such changes can occur at any time and result in the changed surface molecules not being recognized or inadequately combated by the immune system after an infection despite vaccination (or immunity after a previous influenza infection with viruses that also had other surface properties). As a result, the viruses can multiply in the body of the infected person.
An influenza epidemic, or 'flu epidemic,' infects 10–20% of the population, but outbreaks remain local. In a pandemic, on the other hand, the viruses spread rapidly and with infection rates of up to 50% across the entire globe. The trigger is always a new subtype of the influenza A virus, which can also result from an antigen shift (a mixing of human and avian, i.e. gene segments from poultry). Such a mixing of “ bird flu ” and human influenza viruses can take place in pigs (“ swine influenza ”), for example , if these animals are carriers of both viruses.
Even in "flu" years without a pandemic, a large number of people die every year from this disease or its consequences, especially from the consequences of pneumonia as a result of bacterial superinfection . For example, around 334,000 laboratory-diagnosed influenza diseases were reported to the Robert Koch Institute in the winter of 2017/18; 60,000 sick people were admitted to hospitals and 1,674 sick people verifiably died of an influenza infection.
Recent examples of pandemic influenza include:
- Pandemic influenza from 1889 to 1895 , one million deaths, subtype A / H2N2 or A / H3N8
- Spanish flu (1918–1920), 20–50 million deaths, subtype A / H1N1
- Asian flu (1957/58), 1–4 million deaths, subtype A / H2N2
- Hong Kong flu (1968), 1-4 million deaths, subtype A / H3N2
- Russian flu (1977/78), 700,000 deaths, subtype A / H1N1 (case numbers and classification as a pandemic are controversial, as children and adolescents in particular fell ill)
- Swine flu (2009/10), 100,000–400,000 deaths, subtype A / California / 7/2009 (H1N1) (number of cases and classification as a pandemic disputed due to the relatively low pathogenicity )
World Health Organization definitions of pandemic influenza phases
- Phase 1: No new virus subtype was discovered in humans, but a subtype circulating in humans was also detected in animals. The risk of transition from animals to humans is rated as low.
- Phase 2: No new virus subtype was discovered in humans, but a subtype circulating in animals creates a significant risk of disease in humans.
- Phase 3, start of the alarm phase: Occasionally people are infected by a new subtype who, for example, had independent contact with infected animals. Transmission from person to person is very rare and only occurs when there is close contact with an infected person.
- Phase 4: Locally limited accumulation (s) of infections (e.g. 25 diseases within two weeks) and limited person-to-person transmission are documented, which suggests, however, that the subtype is not adequately adapted to humans.
- Phase 5, significant pandemic risk: Larger accumulation (s) of infections (e.g. 50 illnesses within two to four weeks) are documented, but human-to-human transmissions are still localized (e.g. to remote locations or islands or community facilities such as universities and barracks), which suggests that the subtype is increasingly better adapted to people, but is still only partially transferable from person to person.
- Phase 6, Pandemic: Growing and persistent human-to-human transmissions across the population.
The definition of phase 6 established by the World Health Organization from 2009 as a response to the spread of the H5N1 avian flu , that a pandemic is an "epidemic outbreak in at least two of the six WHO regions", is valid since 2013 and revised in 2017 WHO guidelines for pandemic influenza risk management no longer included; The aforementioned regions are: Africa, North and South America, Southeast Asia, Europe, Eastern Mediterranean and Western Pacific. The trigger for the further changes was a critical review of the experience gained in coping with the “swine flu” pandemic (2009/10). As a result of this critical retrospection since 2013 less formal criteria and more make "risk-based approaches" ( a risk-based approach the fundamentals of phase definition) is by the World Health Organization.
At the same time, the division into six separable phases was replaced by a cyclical continuum in 2017, i.e. by a smooth transition from phase 1 to phase 4 and then again to phase 1:
- Interpandemic phase: This is the phase between two influenza pandemics, during which preparations can be made for a possible pandemic.
- Alert phase: A new influenza subtype has been identified in humans. This phase is characterized by increased vigilance and careful assessment of possible risks at local, national and global level. If the assessment of the risks shows that no global spread is to be expected , the measures taken can be de- escalated.
- Pandemic phase: Based on the observation of virological, epidemiological and clinical findings, it is certain that the new subtype is spreading worldwide and that measures must be taken. The change from the inter-pandemic phase to the standby phase and the pandemic phase can be rapid or gradual.
- Transition phase: As soon as the infection rate weakens, i.e. the situation improves , measures initiated can be de-escalated worldwide or initiated by individual countries .
- Interpandemic Phase: This is the next phase between two influenza pandemics.
The World Health Organization installed a worldwide monitoring system in 1948 which, with the help of numerous reference laboratories, constantly checks the circulating virus strains for new variants. These field studies form the basis for the annually renewed recommendations regarding vaccine composition for the next winter season, whereby ten to twelve months can elapse between the recommendation and the provision of the vaccine in sufficient quantities by its manufacturer. In 1999, the World Health Organization also required all countries to draw up national pandemic plans. These measures are intended, on the one hand, to ensure that safe vaccines can be produced quickly in the event of a pandemic; For Europe, the Vaccine Expert Group of the European Medicines Agency has developed appropriate guidelines. On the other hand, a tried and tested catalog of measures is intended to help prevent chains of infection and the like. a. interrupting by social distance and ensuring health care. Between 2006 and 2015, vaccine production increased worldwide from an estimated 0.5 to 1.5 billion doses per year to nearly 6 billion doses.
An infection with influenza viruses can colonize the airways with pneumococci and lead to pneumonia caused by these bacteria, which can be life-threatening, especially in patients with chronic diseases and in the elderly. A pneumococcal vaccination lowers the risk of pneumococcal pneumonia and fatal courses and is therefore recommended by the German Standing Vaccination Commission for infants from the age of two months, for all people from the age of 60 and especially for patients with chronic diseases of the lungs or the heart or a diabetes requiring treatment. Similar recommendations can be found in the vaccination plan for Austria . According to the Swiss Vaccination Plan 2020, there are vaccination recommendations for people in certain risk groups.
The WHO regards the following eight infectious diseases as possible pathogens of a pandemic and as prioritized for research and development (as of May 2020):
- Crimean Congo fever
- Ebola and Marburg fever
- Lassa fever
- MERS-CoV and SARS
- Nipah virus and Hendra virus
- Rift Valley Fever
- Zika fever
- " Disease X " - a previously unknown disease or a disease not known to be a disease of the human species with currently unknown properties.
Pandemic scenario using the example of Influenza A / H5N1
From 2005/06 onwards, the so-called H5N1 bird flu , caused by the influenza A virus H5N1 , was particularly explosive . Its viruses are spread by migratory birds without any human intervention . The World Health Organization has assigned it to pandemic phase 3 for several years (as of February 2020.)
Should the A / H5N1 viruses mutate so that they can be transmitted from person to person, some experts expect a scenario that will take place in two phases:
- In an initial phase of up to six months, no vaccine would be available, as today's manufacturing processes require this period of time before the first ampoules are delivered. In this phase, antiviral drugs and drugs against opportunistic bacterial infections as well as non-drug protective measures (e.g. face masks, school closings) and quarantine would probably be the only possible measures to ward off the viruses and their consequences. It is therefore recommended that such drugs be kept in stock for 20-25% of the population.
- In a second phase, vaccination protection would be developed, but the production capacities would very likely not be sufficient for the large demand. Therefore, the official emergency plans for the pandemic u. a. also suggest that, for example, hospital, police and fire service personnel should be given priority. Many experts are therefore calling for state-subsidized overcapacities to be built up at drug manufacturers. In addition, because vaccinations cannot be expected to offer complete protection, the other protective measures must also be used in the second phase.
Preparations must also be made so that sufficient hospital beds can be made available. For example, the German Society for Internal Medicine wrote in a press release at the end of April 2006: "Should there be a global outbreak one day, 360,000 people in Germany would probably need a place in hospital."
At a specialist influenza congress in Vienna in October 2006, it was reported that more than 95% of all vaccines were produced in just nine countries, which means that 86% of all people lived in countries that did not have any production capacities themselves. If all capacities for the normal flu vaccine had been switched to pandemic vaccine in 2007, a maximum of 300 million people could have been supplied. By 2011, eleven developing countries had started setting up or commissioning corresponding production facilities. Despite the significant expansion of production capacities that has now taken place, it is still considered an illusion that global protection against an influenza pandemic through vaccinations is possible in view of the size of the world's population.
If, however, the authors of a report published in Nature in July 2006 were right, then all plans for mass vaccinations - at least for the first wave of the disease - would prove to be obsolete: They predicted that the peak of the first wave of disease would be two to three months after the start of the Pandemic reached and the acute pandemic phase would end after just four months.
For Germany, the Robert Koch Institute - as the national reference center for influenza - has developed several scenarios that are intended to serve as a basis for assessing the consequences of a pandemic. The worst variant assumes 21 million additional doctor visits and up to 160,000 deaths. However, a medium-sized variant is considered more realistic, but is also assumed to have around 100,000 additional deaths. The Federal Foreign Office has also drawn up its own pandemic plan to ensure the protection of its employees in missions abroad.
Emergency planning in German-speaking countries
In the national pandemic plan for Germany published at the beginning of 2005, a minimum measure was stipulated in the event of an outbreak of an influenza pandemic that the therapy of all sick people should be ensured with antiviral drugs. The federal states then began planning to stock up on the appropriate drugs. The national pandemic plan was supplemented by more detailed local planning by the districts and municipalities. The National Pandemic Plan was revised in 2016 and also updated thereafter. Funded with 10 million euros each, the companies Novartis and GlaxoSmithKline were contractually obliged to expand their production capacities so that the entire population could be supplied with a pandemic vaccine - that would be 80 million doses twice.
The first Swiss influenza pandemic plan was drawn up in 2004 under the leadership of the Federal Commission for Pandemic Preparation and Management (EKP). This was updated in the following years - most recently in 2018. There is also a compulsory stock of antiviral drugs in Switzerland. In addition, the Federal Office of Public Health recommends purchasing a protective mask as a precaution.
Since health care is a matter of the state in Austria , the federal government can only offer recommendations and coordination. Nevertheless, a current influenza pandemic plan was published in 2006 (status: February 2020). An example of the regional pandemic plans is the influenza pandemic planning for Vienna . The Austrian Civil Protection Association has also published a guide with rules of conduct in the event of a pandemic.
Contingency planning in the USA
As part of emergency planning, the US National Vaccine Advisory Committee (NVAC) submitted a proposal back in March 2006 to determine which groups of people should be given priority in the event of a pandemic influenza if vaccines are not available for the entire population. This group, which must be protected as a matter of priority, includes those involved in the manufacture and distribution of the vaccine, doctors and nurses, senior government officials, pregnant women and the critically ill who are at increased risk of developing pneumonia. In addition, priority should be given to vaccinating those who care for immunocompromised people or a child under six months at home. The second priority was proposed for the following groups: people over the age of 65, children under two years of age, as well as employees of the police and fire brigade, energy supply and transport companies, telephone systems and IT companies. In a slightly modified version, these criteria have been incorporated into the multiple updated version of the guidelines of the US health authorities on vaccination measures during a pandemic (as of February 2020).
The United States has also given significant funding since 2005 to develop a new generation of technology to produce enough vaccine for all US citizens within six months of an epidemic.
Since 2005, the US health authorities have also launched a website with a code of conduct in the event of a pandemic.
Alleged influence of the pharmaceutical industry on the WHO to change the pandemic criteria
According to a criticism published in 2015 by the German doctor Wolfgang Wodarg, the WHO pandemic plan was drawn up in 1999 by industry-sponsored experts and made an international health regulation (IHR 2) in 2007. Wodarg initiated an investigation by the Council of Europe. In 2015, Thomas Gebauer , spokesman for Medico international , expressed similar criticism , and the scientific services of the German Bundestag also wrote in a status report on the WHO in March 2019: “In the past, the WHO has faced increasing criticism that external non-state actors such as companies or foundations exerted influence on the operational and normative business of the WHO and instrumentalized them for their own purposes. "
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