Episode 370: The Global Race to Detect the Next Outbreak: Ebola, Hantavirus, and the Politics of Public Health Response with Professor Meru Sheel
In this episode, we host Professor Meru Sheel to examine whether global health systems are prepared for the next major infectious-disease outbreak. Drawing on her work in infectious-disease epidemiology, vaccine research, emergency preparedness and global health security, Professor Sheel explores the difficult questions now facing governments, public-health agencies and international institutions: how quickly outbreaks can be detected, how effectively information is shared, and how public-health systems can respond before local emergencies become wider international crises. Set against the recent Ebola outbreak in the Democratic Republic of the Congo and Uganda, and the international response to the MV Hondius hantavirus outbreak, this conversation looks at the race between disease spread, surveillance, public trust and political coordination.
We discuss why outbreaks test far more than medicine alone. Professor Sheel explains how public-health responses depend not only on vaccines, diagnostics and contact tracing, but also on logistics, risk communication, community engagement and trust in institutions. We explore the difference between individual severity and population-level risk, why a virus can be highly fatal without necessarily posing a pandemic-style threat, and why public-health messaging must warn people without creating panic. The episode also examines the role of the International Health Regulations, the World Health Organization, national governments and multidisciplinary response teams in managing complex, cross-border outbreaks involving cruise ships, repatriation, quarantine, clinical care and international contact tracing.
Professor Meru Sheel is Professor of Infectious Diseases and Global Health at the University of Sydney. Her work focuses on epidemiology, vaccine research, outbreak preparedness, emergency response and immunisation systems, particularly across Australia and the Asia-Pacific region. She has worked extensively on the relationship between routine vaccination systems and health emergency preparedness, and her research examines how surveillance, community engagement, vaccine delivery, public-health coordination and equity shape the ability of countries to prevent, detect and respond to infectious-disease threats.
The International Risk Podcast brings you conversations with global experts, frontline practitioners, and senior decision-makers who are shaping how we understand and respond to international risk. From geopolitical instability and organised crime to cybersecurity threats and hybrid warfare, each episode explores the forces transforming our world and what smart leaders must do to navigate them. Whether you’re a board member, policymaker, or risk professional, The International Risk Podcast delivers actionable insights, sharp analysis, and real-world stories that matter.
Dominic Bowen is the host of The International Risk Podcast and Europe’s leading expert on international risk and crisis management. As Head of Strategic Advisory and Partner at one of Europe’s leading risk management consulting firms, Dominic advises CEOs, boards, and senior executives across the continent on how to prepare for uncertainty and act with intent. He has spent decades working in war zones, advising multinational companies, and supporting Europe’s business leaders. Dominic is the go-to business advisor for leaders navigating risk, crisis, and strategy; trusted for his clarity, calmness under pressure, and ability to turn volatility into competitive advantage. Dominic equips today’s business leaders with the insight and confidence to lead through disruption and deliver sustained strategic advantage.
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Transcript
[00:00:01] Meru Sheel: You don’t want to dumb it down, you don’t want to hide messages, but you also want to create this assurance. And one of the best ways to manage that risk communication is breaking down how you got to the assessment of it being a low risk. That helps build trust because you’re giving people the information that they need to know, not overloading them with information by sharing why they think it’s a lower risk to the general public than just assuming that telling them that it’s low risk is going to be enough.
[00:00:27] Podcast Intro: Welcome back to the International Risk Podcast, where we discuss the latest world news and significant events that impact businesses and organisations worldwide.
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[00:01:07] Dominic Bowen: Please hit the subscribe or follow button now and let’s jump in to today’s episode. Welcome back to the International Risk Podcast. I’m your host, Dominic Bowen, and today we’re discussing health security, international coordination and crisis management. In recent weeks, the world’s watched the hantavirus outbreak unfold across multiple countries. We’ve had health authorities continue responding to the Ebola outbreak in the Democratic Republic of the Congo.
[00:01:30] Dominic Bowen: And now these are very different public health outbreaks, but they expose the same fundamental question. When infectious diseases emerge, are governments and international systems truly prepared to detect them early, to share information quickly, to communicate and to respond before these local outbreaks become wider international crises? Today we’re joined by Professor Meru Sheel from the University of Sydney, where she’s a professor of infectious diseases and global health, and she focuses on epidemiology and vaccine research, looking at outbreak preparedness and emergency response, not just in Australia, but across the Asia Pacific region. Professor Meru Sheel, welcome to the International Risk Podcast.
[00:02:11] Meru Sheel: Hi Dominic. Thanks for having me. It’s great to be joining you.
[00:02:14] Dominic Bowen: Wonderful. Now, where in the world do we find you today?
[00:02:17] Meru Sheel: I am sitting in Sydney, Australia. As we say, I’m calling from the lands of the Gadigal people of the Eora Nation in Australia. For your listeners, they may have heard from others. We often routinely acknowledge the First Nations or the Indigenous people of Australia and the traditional owners of this land.
[00:02:35] Meru Sheel: So I’m calling from the lands of the Gadigal people of the Eora Nation, which to those who don’t know, is in Sydney, Australia.
[00:02:42] Dominic Bowen: Now, if we look a little bit further afield, if we start talking about what’s been happening with the latest Ebola outbreak now, you know, some of us might remember, you know, I was fortunate enough to be able to respond to the outbreak back in 2014 in Liberia, and that was a huge one that many people remember across several countries, but it hasn’t gone away. There’s been many outbreaks since then of Ebola and right now in DRC and sadly, it’s in North and South Kivu provinces, in Ituri. And I say sadly because these are areas that are very underdeveloped, that are wracked by conflict and, you know, significant morbidities and mortalities from a variety of areas.
[00:03:20] Dominic Bowen: But we’ve also seen the same Ebola outbreak spread to the capital of neighbouring country, Uganda. So I think so far there’s been about 900 suspected cases, over 100 confirmed cases, obviously several deaths, which is tragic. When you hear and when you see outbreaks and news releases about stories like this, Meru, how do you feel? How does it sit with you as a professional who looks at this day in and day out?
[00:03:42] Meru Sheel: You know, there’s no dull moment in this field. Every outbreak is very devastating and sad in that way, because at the end of the day, every outbreak begins and ends in communities. And so there are people at the centre of this outbreak, people, sadly, in the Ebola outbreak, it’s expanding very quickly. You know, as you said, over 900 cases now suspected, large number of deaths. And so these are people.
[00:04:06] Meru Sheel: And I think that’s one of the complexities of outbreaks. Why they catch so much attention and why they get such an acute response. Why epidemiologists and other health practitioners really respond and all resources get channelled into outbreaks is because they present this really acute high level of morbidity and mortality, so a very high proportion of deaths. And we’re already seeing that, you know, and there are people in communities at the centre of it, and then there’s the whole entire health workforce. And there are direct and indirect impact of every outbreak, as Covid has shown us, every day delay, every bit of pace matters.
[00:04:44] Dominic Bowen: And you talked about that race. And I think, you know, these outbreaks, you know, they’re testing much more than just medicine. You know, there’s the trust, and we’ve seen that in DRC with Ebola outbreak after outbreak, about the trust that communities have with public health officials, with government officials, with humanitarian organisations. But it’s also about logistics and about moving the vaccines, if the vaccines are actually available, and moving personnel, the surveillance systems, about tracking the people and where they are. And of course there’s politics involved in the decision making and the allocation of resources.
[00:05:15] Dominic Bowen: And then, not to mention, and, you know, without trying to get too heavy on the international politics of aid and global assistance, there are so many different areas where these outbreaks are influenced by and come from. How have we performed in these areas? If we look at this from a macro perspective, before we start diving into some of them, if we were giving a scorecard on our ability to manage these outbreaks, whether it’s Covid, whether it’s Ebola or whether it’s the hantavirus, how are we performing?
[00:05:42] Meru Sheel: Great question, and I won’t answer it as a scorecard, but I will say I think we’ve learned a lot from Covid. Or have we? Have we not? You could debate it either way. I don’t think we did very well in Covid. I think we did very well in the technical aspects of knowledge sharing, information generation.
[00:06:01] Meru Sheel: But I think where we didn’t do well is the politics of it all. I think the political scientists would have said, oh, we saw this coming, or we’ve always talked about this. Right, because the political scientists knew about this. But health has predominantly always been dealt from a health perspective. They’ve always traditionally, historically been leading the response appropriately.
[00:06:22] Meru Sheel: So because it’s a health problem, you want to put people’s health at the centre of it. But it’s where I think the tension points came in, because you know that when you’re making these large decisions, it’s not just about health, it’s about the social impact, the economic impact, the broader policies impact. And that’s what we saw in Covid. So border closures, we saw for the first time that they were effective at controlling the outbreak, but perhaps sometimes they were inappropriately applied. The border control measures, the vaccine distribution under the COVAX programme, it was a fantastic initiative.
[00:06:55] Meru Sheel: I, as somebody who’d worked on vaccine development, you know, I did my PhD on this topic of vaccine development for a new vaccine 20 years ago, and I remember my supervisor in 2005 saying, we’ll have the vaccine this year and we still don’t have a vaccine for that disease, for rheumatic heart disease. There’s a lot of work happening. It’s a disease of poverty. And I was quite surprised, I was pleasantly surprised and shocked that we got a Covid vaccine that quickly. And the reason was the resources, the coordination that went into it was truly amazing and remarkable. But then we failed at the distribution of the vaccines.
[00:07:29] Meru Sheel: I still remember this stat and I’m pretty sure it was Ghana was the first country to receive the vaccine under COVAX and there was like a 66 days or 60 days, more than two months delay from when the first person in the UK got a Covid vaccine to when the first low and middle income country received the first shipment of the vaccine. I could be wrong in the days, I may have mixed up the countries, but I remember that lag very clearly and that was not a small amount of time. Two months in Covid at the pace at which, if we recall, the outbreaks were spreading in 2021, that’s a huge amount of time. And I think right now that’s where the conversations have led to the revision of the IHR and the pandemic agreement. But things have slowed down and gotten stuck.
[00:08:12] Meru Sheel: But then now we’re seeing the Ebola outbreak and the hantavirus outbreak and I think some things are working better. There’s more awareness, there’s more coordination, desire, but there’s still things that we will wait to see how these things pan out.
[00:08:26] Dominic Bowen: You raised a lot of great points there and I’d love to dive into several of them. So let’s start with. You talked about people, you talked about behaviour and social changes. And I think, you know, I worked with Médecins Sans Frontières, Red Cross, Save the Children in many public health responses over the years. And one of the things I’ve always found so fascinating is behaviour change.
[00:08:46] Dominic Bowen: I mean, public health responses can look really exciting and dramatic. You know, there’s quarantines, there’s repatriations, there’s monitoring, there’s personal protective equipment, there’s contact tracing. These things can be all quite technical and exciting. But so much of it is about behaviour change and the amount of time that it takes to achieve behaviour change. Now obviously there was the Ebola outbreak that we spoke about earlier in 2013, 14 and there’s been many, many since.
[00:09:10] Dominic Bowen: Why is behaviour change so, so slow? I mean, we see sadly in some of the conflict affected areas in DRC that again, some of the hospitals that have been temporary hospitals have been set up to treat Ebola patients have been again burned down. We see that there was one of the victims of Ebola recently was an imam. And as part of the tradition, they washed the body.
[00:09:31] Dominic Bowen: And despite the fact he died of Ebola, some of his students thought that it was still a good idea to drink the water that had been used to wash his body. I say this not to be sensational, but I say this to understand and for our listeners to understand. And we’ve all seen it with Covid how many times. We’re all taught as adults and children how to cough properly and how to sneeze and how to wash our hands. And yet we only have to catch the tube in London or Stockholm to see that people still aren’t practising good behaviour.
[00:09:53] Dominic Bowen: And people with colds and flus are still coming into the office. Talk to us about behaviour change. You know, we have this and we’ll talk about these global responses and the World Health Organisation, but at a very basic level, why are we so, so slow to learn basic lessons?
[00:10:06] Meru Sheel: It’s a great question. And, you know, I’m an epidemiologist, vaccine researcher. I thrive on the things that you’ve been talking about, you know, surveillance and contact tracing and disease burden. But at the end of the day, vaccine uptake, so people actually getting shots in their arms is all reliant on behaviour. Right?
[00:10:23] Meru Sheel: People coming to get vaccinated, all the narratives and the stories you’re talking about and from a general public health perspective, and there will be anthropologists and social scientists who will have much more deeper insight and view to the world. But I think one of the places where, and this was one of the key lessons that we learned from the 2014 Ebola outbreak, but also for decades from the HIV outbreak lessons or HIV stories. The community has taught us that really, community engagement and understanding the social norms, the cultural norms, are really important to outbreak preparedness and response. And I think that’s core and central. One of my greatest inspirations to take on this career was many years ago, Professor Michael Alpers, who passed away last year, and he was an Australian doctor researcher who was really involved in the understanding of what caused Kuru disease in Papua New Guinea.
[00:11:20] Meru Sheel: And it really is related to prions. There’s a beautiful documentary and he talks about this entire understanding of how they discovered prions. Many people wouldn’t have even heard of it, and it was all related to this transmission of disease that really caused neurological symptoms like mad cow disease. They initially thought it’s mad cow disease. There’s a really nice documentary on it about Kuru disease.
[00:11:43] Meru Sheel: And up in the highlands of Papua New Guinea. And, you know, for a long time, one of my lessons learned from talking to him through long stories over a dinner table and lectures he gave when I was living in Perth and watching this documentary is for a long time they were really looking at the medical side of the biomedical causes of this particular disease. And then they tried to take an anthropological lens to it, applied an anthropological lens and what they figured out was the transmission pattern of the women and the children were always the ones getting the disease because it was the way the burial activities were happening and when somebody passed away and how it was getting in the prions and that’s how prions were discovered. And essentially by addressing those behavioural, cultural understanding that cultural norms in the community and working with the communities to prevent, you know, people eating and watching, like how they were dealing with post cremation rituals is what essentially eliminated the disease.
[00:12:36] Meru Sheel: It wasn’t so much that there was a sudden medical treatment, of course, the early detection, the management, all of those things helped, but it was anthropological lens that really made them understand those pathways to disease transmission. And it’s one of the most beautiful stories that it’s always stayed with me. And I’d be happy to share the link to the documentary. I’m a huge fan of his work. And this is back in the 40s or 50s, like decades ago, and we see this time and time again.
[00:13:02] Meru Sheel: This has obviously been a big challenge globally and I think it’s because we often think, you know, as I started, outbreaks begin and end in communities. So then we’ve got to think about what’s important in different communities or what are the social norms or what are the behavioural practices. You know, it’s one thing to say wash your hands in an outbreak, but if people don’t generally have running water and they don’t do that all the time, how can we suddenly expect people to do it? It seems simple to us, but perhaps it’s not that simple or to children.
[00:13:32] Meru Sheel: You know, we’re all creatures of habit and we do things that we’re used to and to do things differently, we have to be aware and we’ve got to remember it. And sometimes public health is not even rocket science. Another colleague of mine used to say, public health is sometimes repetitive and you keep reminding people the same simple message and that leads to great things, right? Like boiling water or drinking pasteurised milk. These are all simple interventions that now feel simple to us, but back then were great inventions. Right.
[00:14:00] Meru Sheel: Boiling milk or pasteurising milk has been one of the greatest successes till day. And in many parts of the world, that’s the usual habit. I grew up in India and most people boil milk at home before drinking it. Like that’s just culturally what I grew up with, only to realise much later in life as an older kid that that’s actually scientific, it’s cultural, it gets passed down for, you know, generation to generation. So I think we often need to think about those things before we sort of design that.
[00:14:25] Meru Sheel: And I think Covid, Ebola and Covid have really taught us that we’ve got to start putting social sciences into our preparedness plans and thinking about behaviour change early on and not at a later stage. And when it comes to some of the responses from the burning down of health centres and conflict settings, very sad, should not be happening. But again, what is leading to that? Is it the trust in the government? Is it the trust in the response?
[00:14:50] Meru Sheel: Because most people don’t want to harm the health system or health workers, they’ve not done anything to people. So there’s something deeper than that that we need to be working towards understanding and preventing and designing those side of things early on.
[00:15:03] Dominic Bowen: Oh, definitely. I think we still have the ratios wrong when it comes to how much we speak versus how much we listen, think in the workplace, with our, in our romantic relationships. But certainly when designing public health strategies and development programmes, I think we still have the ratio wrong how much we speak or lecture versus how much we’re actually listening. And you talked about the impact of messaging. I mean, some of the things that we’re hearing come out of, whether it’s the CDC or the World Health Organisation, is things that, you know, on an international level, there’s a low public health risk, but, you know, for those that have been impacted, there’s a serious, serious risk for those that have been exposed.
[00:15:37] Dominic Bowen: How important is that messaging and how important is that language? How difficult is it to get that right? You know, when we hear Ebola and the impacts of Ebola, it’s very scary when we hear that it’s now, you know, in capital city, at least one capital city in East Africa, that can raise alarm. And I guess that’s the balance, isn’t it, that the CDC and WHO, they want to raise a level of alarm but not a level of panic. You know, how do we get that right when we’re looking at diseases like this?
[00:16:04] Meru Sheel: Yeah, I think it’s again, a very tricky balance and I think that’s why you again, have communication experts to guide you on some of those messaging. It’s a complex process to even make those decisions. It’s not something people say lightly when they say the risk is high, the risk is moderate or the risk is low. These are systematic risk assessments based on the frameworks that are laid out by the International Health Regulations of 2005 and the Emergency Response Framework. So these are two documents that guide that globally.
[00:16:37] Meru Sheel: But then every country will have their own frameworks or public health acts to do what we call are these risk assessments. And risk assessments are typically based on things like is this disease going to spread quickly, in simple words, or is it confined to one area? Will it spread somewhere else? What’s the severity of the disease? Is our hospital system going to get impacted?
[00:16:58] Meru Sheel: What might be some of the other things that might get impacted? So that’s how they look at it. And I know we’re going to get more into the hantavirus conversation, but even with Ebola, that’s what’s happening now. How do we communicate? That becomes really important without being dismissive about it and understanding community’s views.
[00:17:16] Meru Sheel: And again, a Covid example that comes to my mind was the New Zealand Prime Minister back then, Jacinda Ardern. She became so popular because she was really good at communicating effectively with empathy, but yet providing that information that people really needed. Obviously she didn’t do it all by herself. She had a team behind her who was supporting her to do this. And I think again working communication, having communication experts, which if I again think about how incident management teams, as we typically call them, the structure of an emergency response framework, and that might be within organisations, so a government might have their incident management team, WHO will have their incident management team.
[00:17:59] Meru Sheel: But also multiple agencies might have a multi-agency incident management team or a cluster coordination framework, as you would call them, and all of those we know have a communication arm to it for exactly this reason. And communication is within agencies, within technical departments, but also communication with the communities in a way that you genuinely convey. You don’t want to dumb it down, you don’t want to hide messages, but you also want to create this assurance. And one of the best ways, I think personally, to manage that risk communication is breaking down how you got to the assessment of it being a low risk, because that helps build trust, because you’re giving people the information that they need to know. Of course, not overloading them with information, but I think sharing why they think it’s a lower risk to the general public would make more sense than just assuming that telling them that it’s low risk is going to be enough.
[00:18:55] Dominic Bowen: And you mentioned the hantavirus and of course, when a cruise ship has passengers and crews from so many different countries, I’m wondering about who’s actually responsible for the response and how countries actually coordinate, especially once people disperse internationally. I mean, the hantavirus is certainly a case study of international health responses at its best and maybe its worst. I’m keen to hear your thoughts on it. So can you tell us a little bit about the relevant regulations that apply internationally? What do they require of our governments and then the countries?
[00:19:24] Dominic Bowen: What’s the role of the World Health Organisation in this? And who ultimately is responsible for, I guess ideally preventing, but if not preventing, at least detecting, assessing and reporting and responding to these public health risks.
[00:19:36] Meru Sheel: It’s a great question and you know, like, I’ve personally been really hooked to the hantavirus outbreak because it was just fascinating to follow both because we don’t see as many hantavirus outbreaks, we haven’t detected and reported one. So epidemiologically really interesting, of course, human to human transmission has been limited so far, so lots of novel scientific lessons, but also just this idea of who coordinates and how the International Health Regulations come into play has just been super interesting to watch and see it unfold. I think it’s been a really fantastic response actually, to see how it’s all come together and we can talk about it. But to your first question about who is responsible for managing the cruise ship? I guess some of it depends on where the port is and where the ship is and which maritime water.
[00:20:24] Meru Sheel: And I think again, somebody who sort of understands the governance of maritime waters would be able to explain that a little bit better than I would. But my understanding from a public health risk perspective is whose waters are on and, you know, where is the ship originating and ending. So if we think about the hantavirus outbreak, one of the first alerts that went in was from the UK, so I think UK put in International Health Regulations alert on the 2nd of May is, as I understand, and that was because the first patient who died, who at the time we didn’t know that they had hantavirus. On 27 April they disembarked on Ascension Island, which is a UK’s overseas territory. And I think that’s one of the reasons why UK was involved very early on, of course the ship was a Netherlands or Dutch company and so the Netherlands was involved and then some of the patients were disembarked and went to Johannesburg and so South Africa was involved in that process and that’s essentially where the coordination started happening.
[00:21:29] Meru Sheel: And the UK, as I understand. And there was a really nice article that was published in the New England Journal of Medicine last week by the Andes hantavirus Working Group, which I thought was a really nice brief review of what had happened with the cluster. Again, a recommended reading of those who are really interested in how it all unfolded. You know, it describes some of these activities of what happened in 2nd of May. They had a virtual consultation, which is essentially where they tried to piece together the linkages on these deaths that had happened to alert, like a severe outbreak, respiratory infection, we call it SARI outbreak, cluster of unknown disease that triggered that, the hantavirus, testing, et cetera.
[00:22:10] Meru Sheel: So I think it’s a really fascinating way in how people coordinate it, and that is the purpose of the International Health Regulations. And that’s why I think it’s been a really nice test case of how IHR comes into action. And I do think Covid has made us better at utilising it, demonstrating that it’s a valuable tool because people were reporting through the IHR and using that channel of reporting to communicate and coordinate the response.
[00:22:36] Dominic Bowen: Yeah, that’s really interesting. And I remember I sat on the Global Health Cluster back in — was it 2016 or 17? And you know, some brilliant minds, a lot more brilliant than me, very well educated, very committed to global health.
[00:22:48] Dominic Bowen: But sometimes it was a bit frustrating. You just go, how are we still having to discuss the same issues and the same responses time and time again? But certainly a lot of very smart people working on this and I’d love to explore that with you. But I’ll just take a moment, Meru, to remind our listeners that if you prefer to watch your podcasts, the International Risk Podcast is always available on YouTube. So please do go to YouTube and search for the International Risk Podcast and if you like our content, please do subscribe and maybe even share it with a friend.
[00:23:15] Dominic Bowen: It has a huge impact on our success. But, Meru, in an outbreak response, can you explain to our listeners who are these public health teams? Because, of course, some countries have more capabilities than others to respond and assess a public health outbreak. So who does it and how do they actually assess what is high risk and what needs monitoring and who needs quarantining and who can safely continue on with their journeys?
[00:23:37] Meru Sheel: Great question and big question. So let me start with the first one. I think typically, a public health response team is multidisciplinary and I think, again, it’s something that we have become better at after learning from Covid, Ebola, that, you know, we need. Everyone would be familiar with the One Health conversation. We need animal experts and veterinarians and environmental experts.
[00:24:00] Meru Sheel: So that’s all really come to the forefront. But typically you would have what we call the pillars in an incident management team and those could be epidemiology and health information management team. There will be a clinical team which essentially manages your patients and your contacts of the case management, providing clinical guidance. They’ll be around infection prevention and control and that team will typically look at, you know, how do we provide good sanitation practices in a hospital setting and what is the key messages we need to give to people in preventing infection spread within a household setting. So during Covid, you know, how do we.
[00:24:36] Meru Sheel: If your family member is quarantining at home, how do we prevent infection from spreading within the same household? You’ll have logisticians in the team who are very critical. We don’t often think of them, but logisticians are really important for public health response because ultimately somebody’s got to move the people around, somebody’s got to move all the medical equipment around and the reagents around and the personal protective gear around and all of those things. Really important job of logisticians. There is the communication experts.
[00:25:03] Meru Sheel: Increasingly in the last 10 years or so I’ve started seeing a greater focus and emphasis on a pillar or a support system around mental health awareness, both of your responders, but also for the community. We definitely saw it in the Rohingya crisis in Cox’s Bazar. That was critical and it has huge value both from providing support to your response teams, but also to the community. Because in some of these situations mental health impact can be really huge. So social support structures outside of the health sector and other departments, you might have things like providing.
[00:25:39] Meru Sheel: UNICEF will often look at programmes to provide emergency relief support or nutrition support and World Food Programme. So depending on what the context is. So there are different expertise that come in the health space. Often that is led by the World Health Organisation. That cluster or that team is often led by them jointly with the national government.
[00:26:00] Meru Sheel: Where the response is happening, they are the technical lead and the over purview is always of the national government. They always lead the health response with the, I guess joint response from the WHO in settings where they might be now in Australia you often won’t have the World Health Organisation support. Their remit is mostly with the low and middle income countries to provide that extra support and that’s in their mandate. But essentially that’s how it would work and come together. And then in terms of making, I guess, an assessment of risk, as I said, this is all based on key criteria.
[00:26:34] Meru Sheel: One of the core annexes that manages this in the International Health Regulations is Annex 2, we typically say, and that gives you three areas of priority of disease that need to get notified under the International Health Regulations. These could be, I guess, some high priority pathogens that we know often lead to epidemics and pandemics of things like smallpox, polio, human influenza, the SARS or severe acute respiratory syndrome. And now Covid, which was, you know, SARS-CoV-2. But also then there’s a group of pathogens that we know have high epidemic potential. Things like cholera, yellow fever, plague, viral haemorrhagic fever, Ebola etc.
[00:27:17] Meru Sheel: All of those. And then there’s a third category of unknown diseases or diseases that can spread, or something unusual, or a chemical spill or any of those. Those three categories, once these are notified, but also within a country, even without getting notified, you often. At the moment, in Australia, we’re having a large diphtheria outbreak that’s impacting Northern Territory and multiple states and territories. So Northern Territory is where the vast majority of cases are, but also Western Australia and Queensland and few cases in South Australia.
[00:27:46] Meru Sheel: It’s been declared as a communicable disease of national importance. And that again allows for this coordinated response across state and territories and based on the risk that exists to the community at the centre of the outbreak, but also of risk of spread. And that’s often how you decide the risk to the general public, whether it’s locally, at a state level or jurisdiction level or a national level, or even internationally. And that’s often based on disease transmission patterns, health system burden, like the number of people who could die from it, hospitalisation, death. So, you know, when you think about hantavirus, yes, the case fatality ratio is high, people die about 30 to 40%, but the person to person transmission is limited.
[00:28:29] Meru Sheel: So the scope or the scale at which it’s going to spread is limited. And which is why the general assessment was the risk of spread globally was low because the person to person transmission, from what we were observing, was much lower. In contrast, Ebola, we can see, spreads really fast. Measles spreads really fast, but measles, compared to Ebola, doesn’t have the same case fatality ratio. It’s not going to lead to the same number of deaths because it’s vaccine preventable.
[00:28:55] Meru Sheel: Those different dynamics of how disease spreads and the health system, some of the key factors that contribute towards that risk assessment.
[00:29:04] Dominic Bowen: And if we look at the immunisation systems and the public health systems, I mean these are clearly essential for health emergency preparedness, especially diseases like hantavirus and Covid and, you know, a variety of other diseases that some of them you mentioned. Now your work is focused really heavily on vaccines and immunisation systems. We’ve seen some really interesting articles and commentary over the last couple of weeks about vaccines and treatments and their ability to combat dangerous viruses which may actually never reach the market, not because the science is impossible, but because developing them is simply not commercially attractive enough for pharmaceutical companies. So where there’s no vaccines for diseases like hantavirus, why are strong immunisation systems such important parts of our public health and our health emergency preparedness?
[00:29:51] Meru Sheel: Yeah, that’s a great question, but also something that I’m really passionate about because I think typically, historically we’ve always thought about vaccines very different to emergencies. We’ve always sort of worked in silos, again, you know, routine immunisation programmes, that’s all we need to focus on and then we’ve got our emergency preparedness and response. But I guess there’s a lot to be learned from both systems and the way we work. Covid is a classic example. A disease, a new pathogen became vaccine preventable vaccines.
[00:30:22] Meru Sheel: If you also look at public health emergencies of international concern until now, this particular Ebola virus disease, all of them except this particular Ebola outbreak and Zika are all vaccine preventable diseases now, if we look back historically. And so there’s an interlinking between health security and vaccines, which I think historically we haven’t always acknowledged them, but I think there’s a lot to be learned from that and that connection and the intersection of those two. And Covid, of course we knew and there are new commitments globally around a hundred day mission for new emerging pathogens. So we know that vaccines and countermeasures are going to become the new norm for tackling outbreaks. Now there are lots of ways in which outbreaks should be tackled and vaccines are never going to be all complete control of it, as we’re seeing with the Ebola outbreak or hantavirus outbreak.
[00:31:14] Meru Sheel: These are things that need a traditional typical shoe leather approach to a public health response. Being in the field, contact tracing, isolation, contact management, infection prevention, control, community engagement, all of those classic public health responses. But at the same time there are agencies like the Coalition for Epidemic Preparedness and Innovation that are working towards this hundred day mission to get vaccines out really quickly. You know, we know that in like the Zaire strain of the Ebola outbreaks, vaccines have had a huge role in how quickly since then we’ve been able to deploy a vaccine. And the Global Vaccine Alliance supports that deployment, maintains a stockpile of that Ebola vaccine and you know, that has the ring vaccination.
[00:31:56] Meru Sheel: We’ve seen it, it works, it can help control the outbreak really quickly. But there’s a lot to be learned from routine systems. One of my recently completed PhD student, she did a really nice study looking at, you know, what were the key factors that supported the rollout of Covid-19 vaccines in small island development states. So those are like the Pacific island countries, the Caribbean countries. And what she found, and there are other studies that have found similar patterns is countries that had really good health experience of rolling out the HPV vaccine.
[00:32:24] Meru Sheel: So the human papillomavirus vaccine that prevents cervical cancer and had been running the programmes for about more than five years. So their system was used to deploying vaccines essentially for adolescents. Because that vaccine is given at school age, we’re better at rolling out the Covid-19 vaccine. So the speed at which we’ve seen similar patterns with influenza vaccine, the relationship with influenza vaccine rollout and the Covid-19 vaccine, because as you can imagine, it’s a different age group and a platform approach of how we can roll out. So I think again thinking about, you know, how routine immunisation systems can really leverage and support that emergency preparedness and response.
[00:33:04] Meru Sheel: I mean, your health workforce is the same, right? Like who’s going to vaccinate for routine childhood vaccines or routine HPV or influenza. It’s essentially going to be the same. You don’t sit in an emergency response and say, sorry, I only do measles and rubella vaccination or only diphtheria vaccination and I’m not going to vaccinate for Covid-19. That’s not how health systems and health workers work.
[00:33:24] Meru Sheel: So even from their personal training and skills and their ability to communicate about vaccines and knowledge, all of those things directly go across and your cold chain supplies and all of those. And I guess for us personally, we do a lot of work on how we improve data systems both from measuring coverage. So like electronic immunisation registers, many high income countries have historically had in Australia we have the Australian Immunisation Register, but also surveillance systems. So all of these are connected and I think historically we’ve siloed them a little bit, but I think we need to start thinking about the health system as a whole, rather than just for vaccines or just for emerging diseases and new viruses and pathogens.
[00:34:03] Dominic Bowen: Yeah, very interesting. You brought up a lot of great points around data surveillance around island communities and how they respond to public health emergencies, but also the different risks that different communities might be facing. But I think we’re at the end of the episode, but one question that we ask all of our guests that come on the International Risk Podcast is when you look around the world, what are the risks that concern you the most?
[00:34:25] Meru Sheel: Oh, my God. That’s a big question. Look, I think the statement that we are seeing more outbreaks than before is true. I think we need to get better at detecting the outbreaks and how we overcome the lag, both in the case of hantavirus and Ebola outbreaks, there is a bit of lag now.
[00:34:42] Meru Sheel: You know, some of it is inevitable because when somebody dies on a cruise ship, they’re elderly, they’re an older person, it’s not uncommon. But there was still this delay in detection of a couple of weeks before we could, you know, figure out that it was hantavirus. You look at the Ebola virus outbreak from when the initial detection happened and they went to the first case, the testing, you know, they were testing for the other Ebola strain and other febrile illnesses. Febrile illness is a very common symptom that presents so strengthening our ability to detect. That, I think is really important.
[00:35:12] Meru Sheel: And I think historically surveillance is underfunded, under-recognised as being important. I think the political determinants and coordination, you know, the pandemic agreement, the PABS, pathogen access and benefit sharing aspect of the pandemic agreement did not go through the World Health Assembly this year. It’s been pushed forward. But there’s a commitment all of these things are still highlighting. There’s an equity gap around how things would be shared across member states.
[00:35:36] Meru Sheel: And I think, finally, I guess I would say, is that we really shouldn’t be lifting our eyes from routine childhood preventable diseases leading to large outbreaks that are leading to hospitalisation, deaths that are children dying from measles all over the world and we’re not paying enough attention to it. And I think sometimes the larger outbreaks, these new pathogens, because of that point about high morbidity and mortality that I was talking about, we give a lot of attention to those, as we should, but I think we equally need to think about your routine vaccine preventable diseases, because there’s so much interconnected and no child should be dying from these preventable diseases.
[00:36:13] Dominic Bowen: Thanks very much for coming on the International Risk Podcast today.
[00:36:16] Meru Sheel: Thank you for having me, Dominic. It’s been great.
[00:36:18] Dominic Bowen: Well, that was a great conversation with Professor Meru Sheel. She’s a professor of infectious diseases and global health at the University of Sydney. And I really appreciated hearing her thoughts on the current Ebola outbreaks, the hantavirus, international health coordination, International Health Regulations, surveillance, immunisation systems, and of course, emergency response. Today’s episode was produced and coordinated by Edward Penrose. I’m Dominic Bowen, your host.
[00:36:40] Dominic Bowen: Thanks very much for listening. We’ll speak again in the next couple of days.
[00:36:44] Podcast Outro: Thank you for listening to this episode of the International Risk Podcast. For more episodes and articles, visit theinternationalriskpodcast.com. Follow us on LinkedIn, Bluesky and Instagram for the latest updates and to ask your questions to our host, Dominic Bowen. See you next time.