In an incisive article authored by Dr. Michael S. Sinha and colleagues, published in the New England Journal of Medicine*, he and his co-authors raised the question of whether the U.S. has learned the lessons of COVID and is capable of responding to the emergence of a novel epidemic. The most immediate risk involves additional possible mutation of the H5N1 avian influenza virus that has become adapted to mammalian hosts and has infected a limited number of humans in direct contact with infected flocks and dairy herds. Despite emergence as a zoonotic infection in Hong Kong in 1997, the H5N1 virus has not become a pathogen of significance but is most certainly on the radar of the World Health Organization and public health authorities in many nations, including the U.S.

Dr. Sinha and colleagues question whether the U.S. is in a more favorable position to respond to an epidemic than it was prior to the introduction of COVID. The U.S. was unprepared in 2020 despite recommendations by the Institute of Medicine and the National Academies of Sciences, Engineering and Medicine over 25 years ago.  The federal and state agencies responsible for public health did not responded appropriately and efficiently as evidenced by events during early 2020.  The early months of the COVID outbreak were characterized by institutional denial, a search for ‘quick fixes’, a lack of personal protective equipment and imperfect coordination among federal agencies.  These inadequacies should have been corrected in intervening years but it is evident that little has changed. In some respects, the legal environment is less conducive to a coordinated and scientifically appropriate response.

During the early weeks of acceptance that the H5N1 B3.13 mammalian-adapted strain was transmissible to humans, operators of dairy herds were disinclined to cooperate with either state or federal agencies to initiate appropriate surveillance.  In the state of Texas, the Commissioner of Agriculture was on record as characterizing the efforts by the Centers for Disease Control to determine the extent of exposure of workers as “overreach”.

Dr. Sinha correctly characterizes the response to H5N1 as uncoordinated with ill-defined areas of jurisdiction among the Department of Health and Human Services subsidiary agencies comprising the Centers for Disease Control and Prevention, the Food and Drug Administration, and the National Institutes of Health and the Departments of Defense, Agriculture and Homeland Security. In addition individual state governors created self-serving policies with their departments of health and of agriculture involved at the case and plant levels. Initially the White House designated the Secretary of the Department of Health and Human Services as the coordinator but this rapidly degenerated into a free-for-all with no indication of “who was in charge”. 

With the emergence of bovine influenza-H5N1 cooperation between state departments of agriculture and their public health counterparts expedited programs of surveillance. This involved both herds and workers and state agencies that undertook to educate owners of farms and their workers on protection.  Michigan and Colorado were preeminent in actively addressing the problem with Colorado introducing a mandatory testing program involving milk samples from all herds to detect the presence of virus and to impose quarantine measures.

In the event, it appears that H5N1 does not represent an immediate concern for public health.  Notwithstanding this fortunate circumstance, the threat of an emerging epidemic reveals obvious restraints to addressing what might occur in the future.  An outbreak involving a human-adapted pathogen that is also contagious has the potential to spread rapidly and extensively.  If a severe form of human influenza emerges it would probably affect children disproportionately. State and local authorities applying experience from COVID would be disinclined to close schools or to mandate masking, supported by state regulations and court decisions.  The initial response of state officials in traditionally conservative regions would be to place personal freedoms above sound principles of disease prevention especially in the early stage of an epidemic when control measures would have the potential for the most favorable outcome. 

A rising wave of science-skepticism and an unjustified lack of confidence in public health agencies including the Centers for Disease Control and Prevention would impair the development, coordination and implementation of containment measures following the emergence of an infection with epidemic potential.

Proposed changes affecting the tenure of federal employees together with traditional pressure to conform to institutional norms is likely to inhibit open discussion of alternative modalities and would stifle the development of appropriate policy. Attempts to impose censorship on scientists and public health specialists as occurred during the COVID period will become more intense and absolute in the event of a subsequent epidemic.  The recent overturn of the Chevron Doctrine eliminated deference to scientists and medical professionals and would impede their efforts to introduce emergency measures intended to reduce the incidence rate of an infection. Directives based on scientific principles would be subject to interdiction by courts and result in prolonged litigation as rulings are appealed. 

Expenditure on vaccine development as evidenced by the “warp speed” production of mRNA vaccines that effectively provided protection from COVID among those receiving vaccines will probably be politically unpopular.  Even if mRNA technology can be applied to developing a vaccine against a new virus, prevailing vaccine hesitancy supported by misinformation on social media would limit administration allowing an infection to spread among the susceptible proportion of the population.

It is hoped that the incoming administration, irrespective of political persuasion, will recognize the inevitability of a future epidemic and will respond to the obvious deficiencies that occurred during the early COVID period. Those responsible for our Government should take heed from the emergence of H5N1 among dairy herds albeit with only a few workers affected who were involved in depletion of infected egg-production flocks. Events since March suggest acceptance of the One Health principle with regard to the emergence of a zoonotic infection. Bovine influenza H5N1 was a warning—the next pathogen to emerge or a mutation of an existing benign human or animal virus currently circulating may not be as forgiving going forward.

There will be no simple and inexpensive solution to contain a future epidemic.  The economic implications of an outbreak in a susceptible population will inevitably lead to disruption in food and industrial production, will curtail everyday activities and represent the potential for extensive mortality. The consequences of a contagious infection of zoonotic origin can be ameliorated by preemptive planning and the application of proven epidemiologic practices. This will involve embracing science and selecting hard choices that may, in the short term, be politically unpopular. The U.S. and the World could face a 1918 “Spanish flu” situation at some time in the future.  We are woefully unprepared with respect to political and public acceptance of control measures. We are faced with a hostile legal environment to implement meaningful protection coupled with a fractured system of jurisdiction over public health.  We need to use whatever time is available before the next outbreak to develop action plans that are cohesive and epidemiologically valid.

*Sinha, M.S. et al. (2024) Déjà vu all over Again-Refusing to learn the lessons. New England J. Medicine 391:481-483.                         DOI 10.1056/NEJMp2406427.