Insights Series Issue 11: "How can expanding precision medicine help in effectively managing pandemics?"

This thought leadership paper discusses 5 critical domains for success in public health in managing and preparing for pandemics. 

Insights Series Issue 11 expanding-precision-medicine The New Normal PANDEMIC O 56 61 61 6E 6E 65 65 65 173 6C 6F 73 6C 6E 6D 73 65 61 20 20 69 52 73 2 61 70 Moving toward precision in managing pandemics: 5 critical domains for success in public health A thought leadership paper on how to “Expand precision medicine” in public health SIEMENS Healthineers Preface The Insights Series The Siemens Healthineers Insights Series is our preeminent thought leadership platform, drawing on the knowledge and experience of some of the world’s most respected healthcare leaders and innovators. The Series explores emerging issues and provides you with practical solutions to today’s most pressing healthcare challenges. We believe that increasing value in healthcare – delivering better outcomes at lower cost – rests on four strategies. These four principles serve as the cornerstones of the Insights Series. Expanding Transforming Improving Digitalizing precision care patient healthcare medicine delivery experience The New Normal The New Normal is a special edition of our Insights Series focusing on the COVID-19 pandemic. This series provides recommendations on how to confront the current SARS-CoV-2 outbreak and its implications, as well as strategies and ideas on how to emerge from the current crisis stronger, more resilient, and better prepared to address the healthcare challenges that lie ahead. Please visit Executive summary How can nations around the world be better prepared for the “new normal” and the next pandemic? While there isn’t one single solution to prepare for new COVID-19 waves and other pandemics, this paper highlights critical elements learned from managing COVID-19 and other outbreaks. A new pandemic is inevitable, but health systems can be better prepared for the next event. Testing, tracing, surveillance, public health infrastructure, global collaboration, and trusted communication are key to successfully navigating pandemics. And since not all patients are the same, it is vital to identify high-risk subpopulations to help develop tailored precision medicine approaches among them. The steps described here will help health systems to be better prepared for pandemics. And the experience gained in managing infectious disease outbreaks can help transform care delivery for other medical conditions, spark innovation, and increase the value of care delivered to patients around the globe. Siemens Healthineers Insights Series · Issue 11 3 The challenge The COVID-19 pandemic is an ongoing challenge to personal protective equipment (PPE), ventilators, and public health systems around the world. It has exposed other vital supplies. Hospital workflows have been radically the stark reality that many of these systems could be adapted to the new situation and important diagnostic better prepared to make effective and coordinated equipment has been provided at unprecedented speed responses to combat and contain the spread of a novel under difficult circumstances. And control measures such infectious disease. as social distancing have significantly slowed the spread of the virus. COVID-19 has caused severe and immediate health and economic consequences. Millions have been infected and Both the successes and the shortcomings of the response hundreds of thousands have died. At the same time, to COVID-19 demonstrate the need for precise, coordinated, massive unemployment and supply chain challenges have data-driven responses to infectious disease outbreaks pushed social safety nets to the breaking point. And in order to contain or even prevent the next pandemic. the long-term physical and psychological effects of the pandemic will only become clear over time. In the midst of this crisis, “infodemics” ‒ rapidly spreading outbreaks of false, misleading, or unsafe information on the pandemic and its fallout ‒ have left many people wondering who they can trust for reliable information on the pandemic. With the advent of online channels and social media platforms, disinformation can spread rapidly and cause serious harm on top of the devastation inflicted by the disease itself. Rapid progress has already been made on a number of fronts. Vaccine development efforts are proceeding at a record pace. Manufacturing concerns have responded by retooling plants and increasing capacity to produce 4 Issue 11 Siemens Healthineers Insights Series · The solutions 1. Testing 2. Tracing and surveillance 3. Public health infrastructure 4. Global collaboration/coordination 5. Addressing vulnerable populations Testing Public health Addressing vulnerable infrastructure populations 1 2 3 4 5 Tracing and Global collaboration/ surveillance coordination Siemens Healthineers Insights Series · Issue 11 5 1 Testing Molecular testing (by a technique called polymerase chain reaction or PCR) detects viral RNA from a sample taken Effective management of the pandemic, both on the by a swab inside the nose. People with symptoms or at high individual case level and on the population level, starts risk to contract and spread COVID-19, like healthcare with testing. Testing programs should be extensive and workers, should be considered for PCR testing. A positive massive enough to quickly and accurately identify patients, PCR test has implications not only for the patient, but so that community transmission can be reduced with also for people who have had exposure to that patient. control measures and care management. It is vital that contacts of a patient with COVID-19 self- quarantine as soon as possible, ideally within 24 hours. There are two main testing categories for COVID-19: molecular testing detects active disease; antibody PCR testing has important limitations. The test technology (or serological) testing detects patients’ prior exposure and collection techniques are prone to potential errors. to SARS-CoV-2, the virus that causes COVID-19. Thus, a negative molecular result does not necessarily preclude viral infection. Poor specimen quality, very early infection, improper handling, as well as technical reasons inherent to the test or even potential virus mutation can produce a false negative result. For these reasons, PCR test results must be combined with clinical observations, patient history, and epidemiologic information to guide Self- treatment and quarantine decisions. quarantine L It is vital that contacts of a patient with COVID-19 self-quarantine as soon as possible, ideally within 24 hours. 6 Issue 11 Siemens Healthineers Insights Series · “We shouldn’t jump to conclusions and use antibody test results as the sole basis for a return to work and other activities.” David Nash, MD The other type of testing for COVID-19 is serologic (antibody) Serologic testing has also been considered a factor in testing. Serologic testing is vital to gauge overall developing “immunity passports,” government-backed population exposure to the virus. This type of test also certificates that indicate the bearer has immunity to has significant limitations. For example, an apparently the virus and can therefore return to work and other activities. low false positive rate in a population where less than However, there is currently no definitive evidence 1% of people have been exposed can mean a substantial that antibodies produced during COVID-19 recovery confer absolute number of false positives. prolonged immunity and protection from a second infection.1 “We shouldn’t jump to conclusions and use Test quality is vital, and new tests require high accuracy, antibody test results as the sole basis for a return to work with close to 100% sensitivity and specificity and and other activities,” said David Nash, MD, Founding proper validation. Clearly, the need for precision and Dean Emeritus, Jefferson College of Population Health at accuracy is an absolute requirement in both molecular Thomas Jefferson University in Philadelphia, PA. “That and serologic testing. could potentially lead to continued transmission if it turns out immunity is not conferred by prior exposure,” he continued. We will need more time and studies to confirm the clinical and prognostic significance of the presence of antibodies, beyond the virus infection information they provide. Test The key to effective use of both PCR and serologic testing quality is volume. Testing programs must be massive, coordinated, and well regulated. “Testing, more testing, and even more testing. That is the key to controlling the spread of Test quality is this virus,” according to Nash. vital, and new tests require high accuracy, with close to 100% sensitivity and specificity and proper validation. Siemens Healthineers Insights Series · Issue 11 7 2 Tracing and surveillance Contact tracing doesn’t need to be 100% perfect but needs to be widespread to be highly effective. According to Contact tracing is a valuable tool to control outbreaks, initial estimations referenced by MIT Technology Review, and even more valuable when the prevalence of infection at least 50% of new cases need to be detected ‒ and at is relatively low. Effective contact tracing requires a least 50% of their contacts isolated ‒ to reduce transmission veritable army of tracer personnel and can be enabled by by 10% or more. And 90% detection and 90% reach of properly used digital tools. contacts, with 100% testing, can reduce transmission by more than 45%.2 South Korea’s COVID-19 success : as of June 8, 2020. These measures allowed Korea Data-driven approach supported to flatten the COVID-19 curve without taking draconian measures. How did South Korea manage by public IT infrastructure its COVID-19 response? The government focused on data generation, SARS, undertook aggressive measures to mitigate transparency, and sharing to support key decisions. the risks of COVID-19. South Korea implemented a South Korea quickly rolled out innovative data-based number of practices that, considering its high methods like drive-thru and walk-thru screening population density, proximity to the epicenter of the centers, extensive free testing, quick diagnosis, COVID-19 outbreak, and relatively open travel tracking and tracing confirmed cases, the use of policies, appear to have been highly successful to information technology to share data, and an effective date, as the country has only reported 274 deaths public and private partnership for the implementation.3 Data Mobile phone Institutional Sources Movement carriers records trackers Data Location data Personal Immigration Prescription CCTV Credit/debit Transit pass Categories identification records and medical footage transactions records information records South Korea leveraged its IT infrastructure to enable data-driven decision making based on multiple complementary data sources. 8 Issue 11 Siemens Healthineers Insights Series · “Technology, including smartphone apps, can certainly supplement human contact tracing.” Achieving the results described above is a daunting Complementary, well coordinated digital and non-digital challenge and quickly becomes unattainable as infection tracing strategies can work in tandem to prevent rates rise. In countries where there’s high prevalence, community transmission. New Zealand accomplished its relatively low testing rates, and a general distrust of favorable results by quickly interviewing each patient guidelines by national agencies, contact tracing is unlikely who tested positive in order to identify recent contacts. to be effective on a national level.2 This approach was complemented by mobile device apps that help people track recent contacts, in order to Yet it is important to create the infrastructure for widespread rapidly identify and isolate those who may have been contact tracing now. Contact tracing can help prevent exposed to the virus. Similar approaches in other countries, localized outbreaks from becoming regional epidemics. like Uruguay, have produced positive results to date. In order for countries like the US to lift social distancing and other precautions and safely reengage in social In addition to contact tracing, coordinated international and economic activity, informed policy guided by data surveillance and information sharing will be vital gathered through extensive testing and contact tracing to managing this pandemic and any that may arise in programs is a necessity. According to US CDC Director the future. Robert Redfield, a “ … substantial expansion of public health fieldworkers” will be needed to undertake the aggressive contact tracing needed to allow social, recreational, and economic activity to resume safely. Technology, including smartphone apps, can certainly supplement human contact tracing. However it raises privacy concerns and requires wide uptake and public support to be effective. Such technology-based solutions may be Contact viewed skeptically because of potential privacy risks tracing and the specter of governmental surveillance. Conforming with data privacy regulations in many Western nations, like GDPR in Europe, further complicates technology- Contact tracing based pandemic surveillance efforts. Even in such doesn’t need circumstances, apps and other digital enablers might to be 100% play an important role in syndromic surveillance, perfect but patient education (surveys/chatbots), and population needs to be morbidity aggregation. widespread to be highly effective. Siemens Healthineers Insights Series · Issue 11 9 3 Public health infrastructure In addition, upgrading and standardizing healthcare IT infrastructure will allow real-time data sharing and will help In order to respond more effectively to ‒ or even prevent mobilize resources needed to cope with a surge in cases. future outbreaks of COVID-19 or other potential Real-time data is critical since outbreaks begin as local ‒ pandemics, many nations would benefit from upgrading events. The prime objective in a local outbreak is to stop their public health infrastructure. Pandemic preparedness community transmission. Precision in early detection has emerged as a key national security and economic and mitigation can produce powerful results, as seen in imperative. According to one estimate, every month of New Zealand and other nations that generated a partial economic shutdown reduces the US gross domestic rapid, comprehensive, and data-driven initial response product by 5%, leading to a loss of $2 trillion and tens to COVID-19. of millions of jobs in just the first couple of months of shutdown in the US.4 Tracking and increasing reserves of personal protective equipment, as well as other critical resources (hospital Contrast this impact with the estimated investments in and ICU beds, ventilators), should align with the creation public health that can reduce the impact of future of plans to rapidly scale up production and distribution as outbreaks. The costs of contact tracing infrastructure and needed. A robust, data-driven strategy will enable a widespread molecular and serological testing have precise, timely response that can mitigate some of the been estimated at roughly $5 billion USD, or 0.3% of the clinical and economic impacts of infectious disease initial loss to GDP.4 outbreaks. Perhaps one of the most important learnings is that governments should invest in communication and patient education systems that provide their people with Costs of accurate, up-to-date information and combat the plague contact tracing $ of misleading, fragmented, or false information that has left residents of some nations confused as to what they should be doing to protect themselves and others. The costs of This will require cooperation and commitment from across contact tracing the socio-political spectrum in order to create and infrastructure distribute the most accurate and helpful information and widespread available. Centralized guidelines should work in tandem molecular and with tailored regional and local efforts to support and inform serological the public about what to do during a pandemic. testing have been estimated at roughly $5 billion USD. 10 Issue 11 Siemens Healthineers Insights Series · “We're taking that data and giving it extra analytics firepower.” Beth Blauer 4 Global collaboration/coordination This global collaboration should respect the vast global diversity of cultures and regulations. For example, Viruses and other pathogens do not respect national borders. some measures may be viewed with suspicion where they The ease and prevalence of global trade and travel run contrary to established social mores and political means that a disease outbreak anywhere in the world norms. Education and communication programs, along can quickly become a pandemic everywhere in the world. with culturally appropriate community outreach, can This calls for an effective coordination at a global level, help build trust and increase participation in and success on top of national and regional efforts. of infectious disease mitigation programs. A critical element for success is a global infectious disease The full potential of international cooperation can only surveillance system established to provide early warning be reached if sensitive data are protected from both of, and support for, initial localized outbreaks that could corruption and misuse by bad actors. Blockchain technology broaden. and other safeguards can help ensure data security and patient privacy. Lessons learned in earlier outbreaks led East Asian nations to take aggressive actions to stem the spread of COVID-19, Finally, wealthy nations should consider assisting or leading to lower caseloads than those seen in many cooperating with lower-income countries to help manage Western nations that were slower to adopt similar actions. the spread of infectious diseases. Working closely with This know-how needs to be shared in a collaborative countries that don’t have the resources of an industrialized manner, as well as information on the equipment and nation is a priority in terms of both ethics and national technology requirements to accomplish rapid testing, self-interest. tracing, and quarantine. This collaboration can be strengthened by coordination between the public and private sectors for a timely, technology-driven, innovative, Global and coordinated response to future pandemics. collaboration Having more scientists and analysts working on the problem and sharing information from a variety of contexts The full potential and social settings will enhance the effectiveness of local of international -000 and global responses to future pandemics. “We're taking cooperation can that data and giving it extra analytics firepower,” only be reached said Beth Blauer, Executive Director of the Centers for if sensitive data Civic Impact.5 are protected from both corruption and misuse by bad actors. Siemens Healthineers Insights Series · Issue 11 11 5 Addressing the most vulnerable patient A clear roadmap to managing infectious disease outbreaks populations and high-risk groups is emerging. Widespread, precise testing is a must. When outbreaks are detected, rapid contact tracing coupled People around the world are not homogeneously exposed with isolation and other appropriate measures can lower to the same morbidity/mortality risk, nor to the same infection rates substantially and prevent widespread risk of infection. Identifying the subpopulations that are infection. Immediate and substantial investments in most vulnerable provides a more tailored approach for health infrastructure will help countries cope with the addressing their specific needs. current pandemic and prepare for future events. International cooperation can help identify and contain outbreaks, We know that the elderly and people with chronic potentially preventing pandemics. comorbidities are at greater risk of morbidity and mortality from COVID-19 than others. But there are other dynamics It is vitally important to identify groups that might face at play that put additional populations at risk. structurally higher risks of both exposure and mortality during outbreaks of infectious disease. Identifying Some people face an increased risk of contracting COVID-19 subpopulations ‒ including the elderly, minorities, because of higher exposure. This is the case for essential immigrants, and LGBTQ people in the current pandemic workers, like healthcare workers and workforces in food enables development of tailored prevention and ‒ industries. treatment strategies: in other words, precision medicine at scale. There are many other viruses with the potential to cause a pandemic with an impact equal to or even greater than the current pandemic. We don’t know the answer Risk of to the question of when the next pandemic will disease happen. We do know how to mitigate this risk significantly. Now is the time to pursue improved public health infrastructure, national/regional coordination, technology- Some people driven solutions, and pandemic preparedness on a face an increased global scale. risk of contracting COVID-19 because of higher exposure. 12 Issue 11 Siemens Healthineers Insights Series · Conclusion A comprehensive response to infectious disease outbreaks requires prompt and accurate identification of subpopulations Suggested follow-up on that are disproportionately affected due to social determinants like income, education, access to care, and expanding-precision-medicine geography. • Insights Series Issue 8: “Challenges and opportunities in a healthcare Racial and ethnic disparities play a role, due to economic environment transformed by COVID-19.” conditions and unequal healthcare access. In the US, Available at: for example, African-Americans face an increased risk of news/how-can-healthcare-organizations-thrive- covid-19.html hospitalization and death from COVID-19.6 This gap is • Insights Series Issue 9: correlated with a lack of access to healthcare and the high “Managing the impact of caregiver stress and trauma in prevalence of asthma and other chronic conditions. the COVID-19 era: A strategy toward resilience-building.” Available at: news/managing-the-impact-of-caregiver-stress- This situation may be even more dire for undocumented and-trauma.html immigrants worldwide, who are less likely to seek care • Siemens Healthineers. “Answering the call to for fear of immigration action against them and their address the COVID-19 pandemic.” families. The LGBTQ community also faces a higher risk Available at: laboratory-diagnostics/covid-19-response due to factors including income, comorbidities and access to healthcare. Information: Effective, tailored, trusted community outreach will be vital to assessing the impact on, and serving the needs of, The Siemens Healthineers Insights Series is our preeminent H. vulnerable subpopulations during this and future pandemics. thought leadership platform, drawing on the knowledge and experience of some of the world’s most respected A data-driven precision medicine approach may even healthcare leaders and innovators. It explores predict in advance which subpopulations may be more emerging issues and provides practical solutions to vulnerable and require additional healthcare infrastructure today’s most pressing healthcare challenges. and support. Containing community transmission within All issues of the Insights Series can be found here: these vulnerable groups is vital to effective pandemic management. Contact: If you have further questions or would like to reach out to us, please do not hesitate to contact our expert directly: Reto Merges Global Head of Expanding Precision Medicine [email protected] Siemens Healthineers Insights Series · Issue 11 13 References 1. WHO. “Immunity passports” in the context of COVID-19. April 2020. 2. Temple J. Why contact tracing may be a mess in America. MIT Technology Review. May 2020. 3. Park S, Choi GJ, Ko H. Information technology-based tracing strategy in response to COVID-19 in South Korea ‒ privacy controversies. JAMA. 2020;323(21):2129‒2130. 4. Walensky RP, del Rio C. From mitigation to containment of the COVID-19 pandemic: Putting the SARS-CoV-2 genie back in the bottle. JAMA. 2020;323(19):1889‒1890. 5. Johns Hopkins University staff. Johns Hopkins adds new data visualization tools alongside COVID-19 tracking map. April 2020. 6. Dyer O. Covid-19: Black people and other minorities are hardest hit in US. BMJ 2020; 369:m1483. Duke University Margolis Center for Health Policy. “Advancing a comprehensive response to COVID-19.” May 20, 2020. JAMA. “From mitigation to containment of the COVID-19 pandemic.” JAMA. 2020;323(19):1889‒1890. 14 Issue 11 Siemens Healthineers Insights Series · About the authors Luis Lasalvia, MD, MIB Reto Merges Vice President, Global Medical Officer Global Head of Expanding Precision Medicine Siemens Healthineers Siemens Healthineers Dr. Luis Lasalvia has been keynote guest speaker, panelist, and With more than ten years’ leadership experience in healthcare marketing, moderator at about 500 events and conferences around the world; Reto Merges has a strong track record in building effective teams authoring close to 50 peer reviewed papers and articles in prestigious for clinical and innovation marketing. In addition, he has four years publications; submitting multiple patents in Europe and the US. of work experience in China, ramping up efforts for research collaborations in China and South Korea. Reto Merges holds a degree His experience potentiate clinical and economic outcomes. inspiring in electrical engineering and information technology from the the delivery of concrete high value. He’s been leading numerous Karlsruhe Institute of Technology, Germany, and has studied at teams, being advisory board member, developing new ventures, the Nanjing Normal University, China. His scientific background is in including more than 30 large programs in the US, and other multiple the field of medical imaging where he has authored many publications countries in Europe and Latinamerica. and holds multiple patents. Dr. Lasalvia lives in New York, and is Medical Doctor from the Republic University in Montevideo, holds a Master in International Business from Pompeu Fabra University in Barcelona, postgraduate degrees in Business Administration and in Marketing, and Executive education in Entrepreneurship, Innovation and Risk Management at The Wharton School of Business, New York University, and Harvard Business School. Siemens Healthineers Insights Series · Issue 11 15 At Siemens Healthineers, our purpose is to enable healthcare providers to increase value by empowering them on their journey towards expanding precision medicine, transforming care delivery, and improving patient experience, all enabled by digitalizing healthcare. An estimated five million patients worldwide everyday benefit from our innovative technologies and services in the areas of diagnostic and therapeutic imaging, laboratory diagnostics and molecular medicine as well as digital health and enterprise services. We are a leading medical technology company with over 120 years of experience and 18,500 patents globally. With about 50,000 dedicated colleagues in over 70 countries, we will continue to innovate and shape the future of healthcare. Siemens Healthineers Headquarters Siemens Healthcare GmbH Henkestr. 127 91052 Erlangen, Germany Phone: +49 9131 84-0 Published by Siemens Healthcare GmbH · Printed in Germany · 9446 0820 · ©Siemens Healthcare GmbH, 2020

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