Prof. RNDr. Vanda Boštíková, Ph.D. Prof. RNDr. Aleš Macela, DrSc.
A pandemic is an epidemic of an infectious disease, typically viral, that spreads across a population in large geographic areas. It is usually a new disease of a serious nature that spreads easily and rapidly among humans (1).
Many biological agents can cause epidemics or pandemics (e.g., the Ebola epidemic in 2013, the Spanish flu in 1918, the Russian flu in 1889, and the COVID-19 pandemic in 2019). These phenomena are driven by the existence and evolution of a variety of factors whose effects and interactions remain poorly understood (1, 2).
Recognizing the onset of an epidemic or pandemic spread of biological agents remains a major challenge in the 21st century, despite the availability of modern technologies and scientific knowledge, as well as the successful management of these situations. This is due to the undeniable fact of biodiversity and its laws, which are very difficult for us to predict and are practically uncontrollable (1–4).
It is gradually becoming apparent that the SARS-CoV-2 virus that causes COVID-19 disease exhibits different virological behaviour across populations. Societal factors, particularly socioeconomic factors such as the availability and level of medical care or the quality of public health programmes, also have a specific and unquestionable influence (2–5).
The combination of several influences has led to the reclassification of the SARS-CoV-2 pandemic as a syndemic (11–14). A syndemic occurs when several infectious and non-infectious diseases coexist in the human body, which in turn adversely affects the course of an infectious disease, in this case, COVID-19.
Complicating factors may include associated common infections, but also stress, obesity, diabetes, or high blood pressure. For this reason, the global situation caused by the spread of the new SARS-CoV-2 coronavirus required both detailed study and innovative approaches to managing the situation, with an emphasis on crisis management (11–14).
There are now several newly published studies and analyses that look at, among other things, how the United States and European Union countries managed the spread of COVID-19. These studies highlight both the different ways in which each situation was handled during the pandemic and the points of convergence where approaches and solutions meet, and what both sides can contribute to the management of crises caused by epidemically spreading diseases based on their experiences (7).
Less than three years ago, a pandemic swept every inhabited continent in the world. It started in China in late 2019, only to spread very quickly to more than 180 countries in the first months of the following year. COVID-19 has been a contributing cause of more than 7 million deaths. Over time, more than 675 million people worldwide have been infected, including reinfections (2, 11, 12).
Europe and the United States are now slowly beginning to recover from the pandemic. It is more than evident that they have approached the challenge differently. This is due to the history and evolution of each nation, as well as to different value rankings, different priorities, and different conceptualization and management of public health programmes.
The US federal government did not impose any restrictions on individual states within the union. In the United States, public health is constitutionally divided between the jurisdictions of individual states and the federal level. The US government managed the pandemic from the federal position of Surgeon General through J. Adams, then S. Orsega, and Vivek Murthy. Today, the position of Surgeon General is vacant, but Denise Hinton has already been appointed to the office.
The Surgeon General heads the Federal Health Administration (United States Public Health Service Commissioned Corps), responsible for the public health of the United States population. He is appointed to this position by the President of the United States for a term of 4 years.
This system, including its leaders, has traditionally been highly respected by the American population, and the management and decision-making during a pandemic has increased this respect. The relevant regulations for which this administration is publicly accountable are always based primarily on U.S. studies and data that the office receives from the federal government’s Centers for Disease Control and Prevention (CDC).
The Surgeon General and his administration’s mission is not only to protect, promote, and advance the health and safety of Americans during a pandemic. He is also required to keep the public informed of the development and availability of new evaluated treatments and processes related to the current infectious disease situation. Utilize all available government, business, and community resources to address important public health issues. Increase awareness of health threats for population preparedness and resilience. Implement statewide action through public health promotion and disease prevention programmes. Introduce new strategies to advance public health science (6–8).
The European Union is in a very different position, as it does not have a Surgeon General and has not had and does not have the authority or tools to require any restrictions, actions, or changes in public health for its member states. Europe does have the European Centre for Disease Prevention and Control (ECDC), but this institution has completely failed during the pandemic and has limited itself to retrospective assessments of the situation and not to conceptual visions and recommendations for the member states of the European Union. However, viruses know and respect no man-made borders or political systems in their spread (9, 10).
It is an undeniable fact that some countries within the European Union managed the pandemic better than others. Many European governments have characterized the SARS-CoV-2 pandemic as the greatest European challenge since the end of World War II, with potentially far-reaching political, social, and economic consequences that go beyond the public health impact (10).
In contrast, there has been a surprising lack of trust and transparency among the individual Member States of the European Union, particularly about the enactment of generally applicable health regulations as laid down and required by the World Health Organization. The complex politics negatively affecting the very understanding of the principles of the public health agenda has led to a fundamental lack of conceptualisation of anti-epidemic measures in the European Union.
In its aftermath, the pandemic has highlighted the vulnerability and fragility of both the political and structural systems of the European Union’s public health programme in emergencies. It has become clear that it is the European Union’s limited health mandate that has fundamentally hindered the active implementation of most effective measures in the effort to prevent and contain outbreaks of rapidly spreading infectious disease.
The European Union and its ECDC have no authority to issue binding decisions in the health sector, nor can they enforce any organizational or management guidelines within the health systems of individual European Union countries (15–17).
Another difference between the United States and the European Union in the approach to COVID-19 is the political view of the syndemic. In Europe, we have not yet witnessed the political divide in the approach to anti-epidemic measures as in the United States. Republicans in the United States are less likely to support restrictions related to pandemic management, including getting vaccinated less often.
In Europe, political parties on the right and centre-right (except for the far right) do not have such a more liberal approach to measures. The measures introduced in the UK, for example, have until recently been relatively strict. The same applies to Germany, and yet both countries are led by centre-right parties. One reason for the described phenomenon may be that Europe does not have such a polarizing media environment (CNN, local TV, Fox News, MSNBC, Yahoo, and Google News) as is the case in the United States (18, 19).
According to analysts, the United States and European Union countries also differed significantly in their approach to the introduction of ‘lockdowns’. Compared with the United States, many European Union member states have implemented much more extensive lockdowns, which were initially effective (marked reductions in the number of infections, deaths, and hospitalizations).
By March 2020, nearly all European governments had implemented national restrictions, including school closures and bans on large gatherings. Except for Sweden, which initially took a different trust-based approach towards its citizens. The Swedish government expected voluntary responsible practice of maintaining recommendations such as social distancing, etc. Therefore, the government introduced very few mandatory restrictions, but many public health experts have questioned this strategy (20–25).
Most European governments have also introduced controls at national borders, and some have restricted internal travel. As the situation improved, a gradual reopening was initiated, but most European countries continued to restrict unimportant international travel, whether private or business, for their citizens.
Subsequent waves of the virus in the autumn of 2020 and in 2021, associated with newly circulating variants of the virus, triggered new rounds of restrictions on social and commercial travel across Europe, although in some countries the restrictions were less severe than during the first wave, and the epidemiological situation also began to vary between countries (23–25).
The nationwide lockdowns in Europe were clearly much stricter than the varying levels of ‘stay-at-home orders’ issued by individual states in the U.S. However, the vigorous European lockdowns were not sustainable in the long term, and further pandemic waves of SARS-CoV-2 spread occurred after their lifting (23–25).
There are also significant differences between Europe and the United States in other areas of the approach to the COVID-19 pandemic. European national bureaucratic systems are built on a tradition of social security to mitigate the health and economic impact of emergencies. The American system is based on free enterprise and individual responsibility for their health, which is a private matter.
The stronger safety nets of the traditional welfare system in Europe showed that, compared to the United States, significantly fewer people with COVID-19 symptoms tended not to interrupt work because they were financially supported by the system. However, it is important not to forget the American ‘furlough’ – that is, a leave of absence or temporary leave that employees can take without economic detriment in the event of health problems. This system has been activated by several employers in the United States during the pandemic, but the amount and duration of support are markedly different from that to which Europe is accustomed (22, 26).
There was also a critical difference in the speed with which antiviral measures were proposed and adopted. Clearly, dealing with such crises requires a rapid response in the form of the design and implementation of transnational measures, which the above-mentioned system in the United States can implement and which the European Union has not yet been able to match. A typical example is the ambitious US vaccination programme.
The European Union has been completely inflexible in dragging out negotiations with the pharmaceutical giants on the supply of newly prepared vaccines (it has negotiated on behalf of all its Member States). By the time the vaccines were available, EU member states still had to wait, and their national vaccination campaigns were ‘unacceptably slow’ from the American perspective. Only 10% of the European population was vaccinated in the first months of vaccine availability, while the United States, meanwhile, had established a smooth, simple, highly effective vaccination programme (26, 27).
U.S. federal authorities allowed Big Pharma to streamline testing and quickly granted preliminary approvals for two vaccines. Subsequently, the Trump administration’s $14 billion program to rapidly produce and distribute vaccines, known as Operation Warp Speed, was set in motion. The result was the vaccination of more than 30% of the population of the United States as one large economy that needed to healthily ‘survive’ the pandemic.
The successful implementation of this program led to a strong confidence of the American people in the recovery of society after the COVID-19 pandemic. Today, 82% of Americans have received at least one dose of the vaccine, and 70% have been fully vaccinated. At the time the United States was implementing its anti-epidemic programme, Europe was devising administrative processes to map the pandemic, import, release, and distribute vaccine doses, and enable people to register for vaccination.
As a result, at that time, the vaccination coverage of the European Union population lagged that of the United States and was not uniform across Europe. Western European countries generally had vaccination rates that were one-third higher than those of Central European and Balkan countries. Attitudes toward revaccination of vaccinees also varied; it was only with the spread of the faster-spreading SARS-CoV-2 variant, Omicron, that most European governments put a revaccination system in place (28, 29).
Throughout the pandemic, European leaders have struggled with the challenge of balancing measures to limit the spread of the virus and to manage the growing ‘pandemic fatigue’.
While the pace of economic recovery has been faster than expected in the European Union, it varies widely across Member States. National measures to mitigate the negative effects of the pandemic on the economy have been set up to include credit programmes, guarantee schemes for businesses, subsidies for the disabled and the socially vulnerable, or tax deferrals and debt rescheduling.
The measures implemented were thus directed more towards the economy than the health sector, even though the European Union has declared support for research into the treatment of COVID-19, support for the development of new diagnostic methods, vaccines, and medicines. The above measures have been inconsistent across EU countries and, although partially effective, have been very costly, which will mean that Europe will need to develop a less costly and more effective pandemic response programme, preferably without a large bureaucratic burden (28–30).
In comparison, the White House has already launched an action in January 2022 to increase the availability of COVID-19 disease detection with a very simple but more effective measure. The federal government has purchased rapid antigen tests and is distributing them by mail to its citizens in their places of residence (each household is entitled to 4 free tests per month). It also provides these tests free of charge to government entities, health centres and clinics, and community organizations.
In addition, in an effort to limit the economic and social impact of the pandemic, the US federal government focused on providing information and financial support for testing, vaccination, and education of its population during the last federal administration. This open approach by the US administration also had one very positive effect in that it reduced the spread of false or misleading information, disinformation, untruths, and hoaxes, and thus the risk of an infodemic (20–30). However, this trend changed fundamentally with the arrival of President Donald Trump’s administration.
The experience to date in implementing counter-epidemic measures in the context of the COVID-19 pandemic approach has led the European Union to develop an overarching plan, which can be summarised as follows:
- unification of legislation for pandemic crisis management in the European Union at the supranational level,
- defining coordinating unifying mechanisms as tools to improve cooperation between public health agencies, nationally, but also at the European and international level,
- the establishment of a European Union regime for laboratory biosafety and biosecurity within European reference laboratories as important pillars for the rapid management of pandemic outcomes,
- the introduction of a European Union early warning function,
- the development of multisectoral pandemic emergency preparedness and response plans at the national as well as local level,
- a coordination plan for the European Union response to health emergencies and linking emergency management systems with national emergency operations centres at the national and local level,
- improving the mechanism for sending and/or receiving international aid,
- expanding emergency and risk communication capacities so that pandemic communication mechanisms are fully operational at the national and local level and can proactively communicate with affected communities in local languages and integrate their feedback into the emergency response system,
- integrate all European Union airports, ports, and land crossings into national emergency response plans (30–32, 36, 37).
On the U.S. side, then, in the aftermath of a pandemic caused by a new coronavirus, new systemic measures include, first and foremost, the introduction of a pandemic severity index in which the fatality ratio (proportion of deaths among clinically ill persons) serves as the determining factor for categorizing the severity of a pandemic. The severity index is designed to better predict the impact of a pandemic and to provide local decision makers with recommendations that are appropriate to the severity of the situation.
The starting point for the entire system is the awareness of the high unlikelihood that the most effective tool for pandemic mitigation (i.e., a well-matched vaccine against the pandemic biological agent) will be available at the time of pandemic onset. This means that the U.S. population must be prepared to face the first wave of the next pandemic without a vaccine and possibly without sufficient drugs.
During a pandemic, then, all decisions about how to protect the public must be prepared and announced before an effective vaccine is available, based on sound scientific data, ethical considerations, and consideration of the public’s perspective on protective measures and their impact on society. An appeal to the application of common sense is also considered.
The retrospective data from past pandemics and the conclusions drawn from them must be seen in the context of modern society and analysed from this perspective, and appropriate conclusions drawn. Few of these conclusions can be fully generalisable, but they can serve as a basis for the use of current mathematical models. The results from these studies can then be incorporated into the design of new systems of anti-epidemic measures.
The proposed US framework for pandemic mitigation is based on the early, targeted, and multifactorial application of a combination of several non-pharmaceutical measures, even if partially effective when applied individually. It is the combination of these that leads to greater effectiveness.
To be effective, such combined measures must be initiated early, before the explosive development of an epidemic or pandemic. In the case of severe pandemics, they must be consistently maintained throughout all waves of an epidemic or pandemic in each community. These are essentially the measures already in use today, but folded into a single operating system. These are:
- isolation and treatment of all persons with confirmed or probable pandemic disease; isolation may take place at home or in a health care facility, depending on the severity of the individual’s illness and/or the current capacity of the health care infrastructure,
- voluntary home quarantine of household members with confirmed or probable disease and consideration of combining this measure with prophylactic use of drugs, provided that enough effective drugs are available and a feasible method of distribution is available,
- the release of students from schools (including public and private schools as well as colleges and universities) and the restriction of school activities requiring the physical presence of students,
- the closure of childcare programmes, along with the protection of children and adolescents through social separation in the community, to achieve a reduction in social contact outside of school, and to prevent community mixing,
- the use of social withdrawal measures to limit adult contact in the community and workplace, including, for example, the cancellation of large public gatherings,
- introducing environmental change and changing work schedules in workplaces to reduce community density and maintain as much as possible without disrupting essential services,
- enabling the introduction of a policy of mandated leave in the workplace, which will facilitate compliance with the non-pharmacological interventions outlined above (30, 31, 33–35).
All these community-based strategies should be used in combination with individual infection control measures such as hand washing and cough etiquette.
Timely and coordinated implementation of these interventions requires advance planning. Communities must be prepared for the cascading effects of second- and third-line interventions, such as increased absenteeism associated with childcare responsibilities if schools dismiss students and childcare programmes close.
In both the European Union and the United States, the purpose of the above measures is to try to delay the exponential increase in the number of cases of the disease and shift the epidemic curve to the right. To buy time for the production and distribution of the vaccine. The second objective is to reduce the peak of the epidemic and reduce the total number of cases requiring hospitalisation, thereby protecting the health system of the area and minimising the mortality in the community from the infection. Reducing the number of infected persons is ultimately the main goal of pandemic planning.
Transmission of the biological agent responsible for causing a pandemic can only be eliminated in a naive, i.e., susceptible, population to a given infection by limiting contact between sick and uninfected persons. This will reduce the number of infected persons and, in effect, reduce the need for health services and, ultimately, the impact on the national economy and the social and psychological state of society.
In the absence of contact reduction, the number of sick people will increase, thereby increasing the need for demanding medical care, which can only partly be addressed by increasing the capacity of hospitals and other facilities providing specialist care. This is a highly financially demanding matter and, compared with the very simple organisational restriction of contacts, it is not economically viable.
Education and information campaigns need to be focused on this, as both are and will be most useful in the early stages of an epidemic.
Federal, state, local, or territorial governments and the private sector have an important and interdependent role in preparing for, responding to, and recovering from a pandemic. Public officials at all levels of government must provide clear and consistent guidance throughout the crisis that will be useful for planning and can help all segments of society recognize and understand the extent to which their collective actions will affect the course of the pandemic. By doing so, public officials will also maintain the trust and respect of community members (33–35, 39, 40).
The United States is clearly ahead of the curve in this regard; so-called Community Planning Guides for Pandemic Mitigation are already available, purposefully providing information for countermeasure planning at the level of individual businesses and other employers, childcare programmes, elementary and secondary schools, colleges and universities, faith-based and community organizations, and individuals and institutions (39, 40).
All these recommendations conform to a general axiom–it is not a question of if the next pandemic will come, but a question of when it will. Some form of answer to this question, then, may be provided by the World Health Assembly, an international platform initiative that is developing tools to improve pandemic prevention, preparedness, and rapid response to future biological threats. This is in everyone’s interest (30–38).
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*This text has received support from the National Recovery Plan under project 1.4 CEDMO 1 – Z220312000000, Support for increasing the impact, innovation, and sustainability of CEDMO in the Czech Republic, which is financed by the EU Recovery and Resilience Facility.
