Still Unprepared for the Next Pandemic

There is nothing like a highly contagious and dangerous virus pathogen for exposing weaknesses in a national health system, and the SARS-2 coronavirus behind COVID-19 certainly did just that. Unfortunately, as Khahlil A. Louisy makes clear in “Preventing the Next Public Health Emergency” (Issues, Summer 2025), more major epidemics or pandemics will likely follow, and the United States is still unprepared.

Here are my three biggest concerns:

The first relates to catastrophic respiratory viruses. These include avian and other zoonotic influenza viruses; major coronaviruses of the type that cause COVID-19 and Middle East respiratory syndrome (MERS); Nipah and Hendra viruses; and filoviruses such as those that cause Ebola or Marburg disease. In the case of bat-transmitted viruses (coronaviruses, Nipah, and filoviruses), climate change is adding to worries, causing altered bat migratory behaviors that, together with urbanization and deforestation, bring people and bats closer (either directly or through intermediate animal hosts).

The second are tropical viruses transmitted by mosquitoes, especially the Aedes aegypti species found along the US Gulf Coast and in South Texas. Dengue, Zika, chikungunya, and even yellow fever are accelerating in South America (also likely due to climate change and deforestation), and there are concerns that these illnesses will soon enter the Caribbean and the US South.

The third, much less discussed, threat is deliberate bioweapons attacks from an adversary. This is especially concerning in light of reports of a potential build up on this front by Iran, North Korea, and Russia.

Clearly, the United States must modernize its public health infrastructure, especially at the local and state levels. In response, our Texas Medical Center institutions are applying cutting-edge science to the challenge of disease surveillance and detection.

The United States must modernize its public health infrastructure, especially at the local and state levels.

One of the unexpected (and exciting) findings during the COVID-19 pandemic was the accuracy of measuring coronavirus genomes in wastewater to both detect emerging variants and anticipate impending new waves of illness. It is now also clear that wastewater analysis is an excellent means to detect the genomes of other new respiratory virus pathogens, including the H5N1 bird flu virus, and even non-respiratory viruses (https://dashboard.tephi.texas.gov/public-dashboard).

In parallel, we have begun trapping arthropod vectors of emerging illnesses (including mosquitoes, ticks, fleas, and triatomine bugs) and sequencing their genomes to identify the diversity and ecology of viruses within individual hosts. This approach was pioneered by scientists in Australia and China, as reported by Yuen-Fai Pan and colleagues in Nature Ecology & Evolution, and could become a robust means to detect previously unknown arthropod-carried pathogens. Unlike with the current use of PCR analysis of collected mosquitoes (done currently in the Houston area for West Nile virus), sequencing the full genomes is agnostic to whatever is out there.

Our hope is that through innovation we can go beyond what we currently do for disease surveillance at the local, state, and national levels. Other than lack of funds, perhaps the only thing holding us back is rising health disinformation that blocks our ability to effectively communicate with the populations at risk or their health-care providers. We will require innovative approaches for that as well.

Peter J. Hotez