As of October 18, 2023, there have been 771,407,825 confirmed cases of coronavirus disease 2019 (COVID-19) worldwide, resulting in 6,972,152 deaths [1]. The swift development of vaccines mitigated the death toll. Now, as this Public Health Emergency of International Concern draws to an end, it is crucial to reflect on the lessons learned.
First and foremost, overcoming a disease is only possible through proper communication and an evidence-based scientific approach. Media during the COVID-19 pandemic underscored the importance of discovering scientific truth, as policies grounded in this truth garner public support. Evidence-based scientific communication is of fundamental importance in this regard. However, what we perceive as truth does not always align with scientific fact. Our decision-making has frequently been skewed due to false beliefs in uncertain situations, resulting in frequent errors. Unfortunately, scholars and journalists, who are primarily interested in novelty, often suppress or distort facts due to intense competition for coverage. Moreover, individuals frequently present false beliefs, which conflict with established theories, as truths due to political biases or religious faith [2]. Even some scientists have discussed unproven and potentially dangerous ideas as alternatives for new diseases based on past experiences, often presenting them to the public under the guise of science. This misleads the public. For instance, they have proposed managing the disease through herd immunity by exposing the younger population to protect the elderly, or advocate for the use of malaria medication, claiming it to be highly effective. Such propositions have been openly discussed in the media by some medical professionals. As a result, individuals with religious backgrounds who support the politician have refused to wear masks or rejected vaccines. We have observed similar phenomena in our society as well.
Secondly, we need to establish an research and development (R&D) system that can quickly discover scientific facts. How can we expediently verify scientific evidence and facts in anticipation of a new “Disease X” and devise a response strategy? Prompt efforts are required to identify the gap between our current knowledge and the unknown, but only well-prepared countries can accomplish this. In the initial stages of COVID-19, an external evaluation team from the World Health Organization (WHO) visited China and underscored the need to develop alternatives through rapid research. They discussed the nature and transmission route of the virus, as well as strategies to prevent its spread. Systems should be pre-established to efficiently execute a series of processes, including regular surveillance, enhanced surveillance, natural history and other clinical studies, observation of drug administration and responses, clinical intervention trials for vaccines and treatments, and large-scale clinical trials in the community. With such preparations for evidence-based science, we can triumph over this disease and future infectious diseases.
Thirdly, for a victorious battle, it is crucial to establish a prototype for the virus and have preparations in place. This approach can save time and effort in real-world scenarios. As Sun Tzu states in The Art of War, “If you know the enemy and know yourself, you need not fear the result of a hundred battles.” Dr. Anthony Fauci, wrote an insightful article discussing the top 10 lessons from a scientist’s perspective [3]. Some key points are: “1. Expect the unexpected,” “6. The prototype pathogen approach to pandemic preparedness and response should be implemented,” “9. Misinformation and disinformation are the enemy of public health and pandemic control,” and “10. Emerging infections are a constant threat.” It is challenging to predict what will emerge, and responding is difficult as viruses mutate. Fauci and Folkers [3] also emphasized the importance of preparing in advance with a prototype virus, a perspective shared by many scholars and WHO officials. Experience has shown that new infectious diseases re-emerge due to changes in the human-animal interface, alterations in bacterial antibiotic resistance, issues within the healthcare system, or the resurgence of diseases on the brink of eradication like poliomyelitis. Therefore, being prepared for these situations is vitally important. I had the privilege of meeting Dr. Fauci when I discussed the Republic of Korea’s experience during the middle east respiratory syndrome outbreak in 2015 at Georgetown University. After a lecture on the theme “Emerging Infections: A Perpetual Challenge,” I asked him what he thought the next epidemic would be. His response was, “I don’t know.” At the time, many scholars considered influenza as a likely candidate, and I found myself questioning his expertise due to his uncertainty. However, since most scholars failed to accurately predict the COVID-19 pandemic, it appears that Dr. Fauci’s admission of uncertainty was indeed correct. The question of how to prepare for Disease X when we do not know what it is might seem paradoxical. Therefore, the current realistic approach for Disease X, particularly in vaccine development, appears to be preparation through a prototype [4].
Fourthly, we need to devise a strategy for rapid vaccine production in a winner-takes-all market. Is it truly possible to identify Disease X and develop a vaccine for it? Are we prepared as a nation? Scholars argue that the government's policy will and the enthusiastic expansion of corporate investments are crucial. However, we seem to be reverting to the pre-COVID-19 era. There seems to be a lack of participants for clinical trials, and due to market monopolization by pre-secured products, emerging companies appear to lack the incentive to invest in R&D. At the 2022 G7 meeting, a declaration was made to develop and distribute a vaccine within 100 days for any new infectious disease. This is a significant political statement. The goal for a Disease X vaccine is to further reduce the development time, building on the experience of the COVID-19 vaccine, which took 1.5 years. This strategy was outlined in the New England Journal of Medicine’s roadmap, which theoretically details how to cut the 250-day development time [5]. Extraordinary measures would seem to be needed for our country to emulate a successful model like that of the United States. In the COVID-19 vaccine market, much like the sentiment in ABBA’s song “The Winner Takes It All,” Moderna and Pfizer emerged as leaders. What facilitated their rapid progress? Several points remain uncertain for us: (1) Can we, with our distinct ecosystem, can overcome intellectual property barriers? (2) Can we self-sustain or procure essential raw materials? (3) Is swift scaled-up production feasible? (4) Is there a budget for phase 3 clinical trials? (5) Is there a robust coordinating body like the U.S. National Institutes of Health's Biomedical Advanced Research and Development Authority? (6) How will regulatory rigidity (e.g., emergency use authorization) be scientifically addressed? (7) Will companies invest in vaccine development considering the risks? (8) Will the government prioritize the use of developed products?
For the Republic of Korea, transitioning from a “fast follower” to a “fast mover” in terms of unique rapid product production requires strong leadership. Nonetheless, there seems to be a lack of willingness to invest and a reluctance to conduct research to improve processes without infringing on existing patents. As the pandemic subsides and R&D momentum decreases, the government’s commitment to R&D investment becomes especially important.
Fifthly, meticulous measures are required concerning the efficacy and side effects of vaccines. The public’s fatigue due to the prolonged COVID-19 pandemic has heightened skepticism about the effectiveness and adverse reactions of vaccines. The aim of vaccination is not to prevent and eradicate infections, but rather to prevent severe illness, with a focus on high-risk groups instead of the general population. Convincing the public of the necessity for multiple additional doses and annual vaccinations is becoming increasingly difficult. Concerns related to adverse reactions and compensation for vaccine-related injuries also deter people from getting vaccinated. Therefore, it is crucial to persuade the public using accurate data. The imported vaccines we use appear to be no different from those in other countries. There does not seem to be a significant difference in the reported frequency of severe cases or deaths. Therefore, the fact that we have approximately 50 times more claims temporally for adverse reaction compensation than neighboring Japan suggests that the crux of the problem may lie in the explanations provided by healthcare professionals.
The government’s lackluster investigation into injuries and the mechanical responses of frontline public servants is exacerbating the problem. Furthermore, it seems that healthcare professionals are not providing sufficient comprehensive explanations to those receiving vaccinations. Population-based studies have identified adverse reactions including acute flaccid myelitis, abnormal uterine bleeding, lymphadenitis, anaphylaxis, facial paralysis, encephalitis/encephalopathy, and meningitis, which largely align with preexisting knowledge [6]. The National Academy of Korea of Medicine, tasked with investigating these adverse reactions, is diligently reviewing statistical associations and mechanistic validity. Concurrently, it stays abreast of international trends to promptly provide research feedback and apply equal effort to compensation issues related to adverse reactions. However, compensation for vaccination-induced injuries, unlike population-based association studies, necessitates a comprehensive evaluation of individual cases, taking into account factors such as underlying diseases, overall health assessment, epidemiological investigations, and autopsies. There appears to be a lack of societal consensus on this matter. To overcome the limitations in investigating individual cases, it may be beneficial to establish centers for each type of adverse reaction, where all similar cases can be collected and investigated to enable causality assessment. In other words, we should actively consider improving the framework for disease-specific prospective and retrospective cohorts, active surveillance networks, and causality assessment. However, compensation for damages extends beyond causality assessment, necessitating different approaches within societal norms and on a social integrative level.
Sixthly, managing a disease requires, above all, a bold determination to eradicate it. Political will must be mobilized. However, there is a paradoxical phenomenon that occurs as a disease approaches eradication: the program itself first disappears, meaning the budget, organization, and institutional memory fade away [7]. This fall, even before the start of the vaccination campaign, next year's program budget has been slashed. With the government's policy on R&D changing, research funds are shrinking and the desire to eradicate the disease is disappearing. Therefore, it is crucial to actively persuade civil servants in charge of policy, as well as members of the national assembly who handle laws and budgets.
Finally, the above-discussed policies require public support, which can be achieved through effective communication. It is crucial to actively engage the public in the creation of scientific knowledge, the development and use of vaccines, the management of adverse reactions, and the securing of program budgets. As the COVID-19 pandemic shifts from a crisis stage to a regular management phase (i.e., becoming endemic), and as society begins to return to normal, this fall’s vaccination rate will probably be lower than that of last year. Many have noted that the government's communication with the public regarding the vaccine’s efficacy, the scientific rationale and cost-effectiveness due to changes in the target vaccination group, and compensation for adverse reactions, has been inadequate. Communicating with the public based on evidence fosters trust and establishes a support base for the policy, an important lesson we must remember in our efforts to eradicate disease. The principles for effective communication outlined in “The Lancet COVID-19 Commission Task Force on Public Health Measures to Suppress the Pandemic” review (Table 1) [8] should be actively referenced.
Article information
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Ethics Approval
Not applicable.
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Conflicts of Interest
Jong-Koo Lee has been the editor-in-chief of Osong Public Health and Research Perspectives since October 2021.
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Funding
None.
Table 1.Principles of effective communication
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1 |
Communicate broadly and early to shaping public opinion |
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2 |
Use trusted sources and networks to deliver localized messages, in addition to mass media |
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3 |
Engage end-users in message design |
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4 |
Emphasize positive descriptive norms |
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5 |
Emphasize collective efficacy |
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6 |
Highlight alternative behaviors (e.g. food delivery services) |
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7 |
Use clear, concise, consistent and frequently repeated messages |
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8 |
In multiethnic and multilingual countries, ensure that all population groups are reached through customized messages |
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9 |
Be honest about uncertainty and failure |
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10 |
Emphasize benefits to the recipient and others |
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11 |
Align with the recipient's moral values |
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12 |
Highlight the prospect of social group approval |
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13 |
Avoid stigmatizing groups for not adhering to recommendations |
References
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