Over the last two decades, seven Public Health Emergencies of International

Concern (PHEICs) have been declared by the World Health Organisation (WHO).
These include the H1N1 influenza (2009), Ebola Virus Disease (EVD) (2014-16, 2018-
2020), Zika Virus Disease (ZVD) (2016), Poliomyelitis (2014), COVID-19 (2020),
and Monkey Pox (2022). In addition, the world has tackled public health threats of
SARS, Avian influenza (bird flu), MERS-CoV, and Nipah virus outbreak which have
challenged health systems across countries. However, it is worth mentioning that
the COVID-19 pandemic was more complex in terms of high public health impact,
recurring waves and unpredictable course due to changing pathogenicity associated
with virus mutations and variants. This has highlighted the importance of a targeted
approach towards zoonotic and other potential pathogens that are likely to emerge
in the future. Such threats could be due to emerging and re-emerging pathogens,
or could also arise due to newly emerging pathogens from viruses which routinely
are infective for bats or other avian populations but may cross over to humans due
to frequent mutations directly or via vectors due to environmental or occupational
aspects of human animal interface. Considering the above aspects, the Government
of India is in the process of launching the One Health (OH) Mission, focusing on
multi-disciplinary human, animal and environmental sectors through an effective
integrated surveillance ecosystem, joint outbreak response system and targeted
research.
While the One Health (OH) approach is crucial for addressing many pandemic threats,
there are challenges from CBRN agents, threats from bioterrorism, the possibilities of
deliberate release of pathogens for malicious purposes and pandemic scenarios that
extend beyond its scope and require strategies which are beyond the OH approach
involving national security, international collaborations with inter-disciplinary
approach and high-tech systems. Further, factors like increased travel and trade
due to globalisation, effects of climate change on pathogens, and determinants of
pathogenicity among vulnerable groups, including emerging resistant pathogens
and social determinants of health, require a separate mechanism.
Globally, countries and multi-lateral organisations are working towards preparedness
to deal with novel pathogens and disease outbreaks. WHO has already identified
around 30 viral and bacterial families, which could have potential for epidemics or
pandemics and hence need to be targeted for future research, development of new
laboratory techniques for diagnosis, and countermeasures. The WHO has revised
the International Health Regulations (IHR) to reflect the post pandemic reality; Inter-
governmental negotiations on a Pandemic Accord were also conducted and a global
scientific framework for epidemic and pandemic research preparedness is being
developed. The recent 77th World Health Assembly also highlighted the need for a
collaborative surveillance framework and developing a roadmap for epidemiological
capacity building at all levels and aligning with regional and global initiatives.
Therefore, it is imperative that countries also take stock of their needs and prepare
a robust road map aligned with global instruments like Preparedness and Resilience
for Emerging Threats (PRET) and obligations under International Health Regulations
(IHR), which are legally binding on all WHO member countries for preparing and
responding to future pandemic threats to public health systems.

Future Pandemic Preparedness and Emergency Response 11 A Framework for Action

 1.2 Setting up of the Expert Group
In response to SARS-COV2, India made efforts to produce novel countermeasures
and strengthened its research and development framework. These included
mechanisms for funding of industry and researchers, establishment of shared
resources; policy and guidelines for sharing of data, samples, regulation; public-
private partnerships and global collaborations. India also invested in digital tools for
pandemic response and vaccination, which helped manage data of more than 1.4
billion population. Despite this, a huge number of lives were lost, and the economy
took a big hit. The country must learn from planning and implementing such a
multi-modal pandemic response. More importantly, it is paramount to envision an
approach on tackling a future challenge of this magnitude due to a new pathogen
with even greater efficacy and speed building upon the networks and frameworks
established during the Covid-19 pandemic.
Consequently, an Expert Group was set up to examine these issues in depth, consult
other experts (national/global), learn from the positive experiences and challenges,
and develop a detailed analysis of what worked and what did not. The report looks
at the lessons learnt from the country’s response and global experiences and offers
a clear strategy and road map on what our preparedness should be to handle any
such and even more dangerous public health crisis in future.

Terms of Reference of the Expert Group:

The Expert Group on India’s Future Pandemic Preparedness was set up with the following
Terms of Reference:
1. Study emerging information on pathogens with the potential to power large outbreaks
in the future and suggest mechanisms for focusing on surveillance taking ‘one earth one
world’ approach to ensure that we are prepared for diseases of potentially unknown
agents.
2. With a focus on the scientific and technological approaches, tools, products and systems
deployed in the COVID-19 pandemic response, prepare a synthesis report on the learnings
thereof and propose preparedness pathways for the country. In particular, undertake this
task with specific reference to pandemic epidemiology, forecasting, surveillance, testing
and containment, virus characterisation including genome sequencing, and diagnostics,
digital tools, therapeutics, medical technologies and vaccines.
3. Recommend specific action to be taken for strengthening and creating a robust
ecosystem for pandemic prediction and prevention, biomedical research, and new
innovative, affordable and accessible countermeasures.
a) Further, identify gaps that exist in infrastructure, human resources and systems in
this regard and recommend actions to be taken to build this at a world-class level
through Atma Nirbhar effort.
b) Suggest how to create systems that allow complete forward and backward linkages
to ensure no dependency on imported raw material; and recommend building
networks for clinical trials to take up disease-based vaccine and therapeutics
research ensuring compliance with global regulatory standards.
c) Recommend scale-up mechanisms to promote the capacities of our industry to
become manufacturing hubs to be able to meet the needs of the country and also
supply to the world.

Future Pandemic Preparedness and Emergency Response 12 A Framework for Action

 d) Suggest improvements to strengthen the framework for data and sample
sharing.
4. Provide guidance on meaningful national and international, including bilateral,
multilateral, and public-private partnerships.
The Composition of the Expert Group is as follows -
• Chairperson: Dr Renu Swarup, Former Secretary to Govt of India, Department of
Biotechnology
• Members:
» Dr Soumya Swaminathan, Former Chief Scientist WHO & Former DG ICMR
» Dr Sujeet Singh, Former Director NCDC
• Member Secretary: Sh. Rajib Kumar Sen, Senior Adviser Health, NITI Aayog
This report offers a blueprint for the country to prepare for any future public health
emergency or pandemic to have a rapid response system. From examining the
lessons learned and challenges faced from the country’s response and global
experience during the COVID-19 pandemic to recommendations and a roadmap for
governance and management of public health emergencies in the future, this report
is a starting point for the country’s pandemic preparedness efforts.
Target audience - This report is intended to inform policymakers, National and State
governments, partners and researchers, industry and academia working on health
system resilience and preparedness for public health emergencies. It may also be
helpful to the lay public.
Caveats (if any): The contents of this report are the views and recommendations
of the expert group.

Future Pandemic Preparedness and Emergency Response 13 A Framework for Action

2. Methodology
2.1 Consultations
The Expert Group has consulted with national and international experts from public
health, clinical medicine, epidemiology, microbiology, industry and academia, and
senior government officials at the Centre and State level. These experts were at
the frontline of the COVID-19 response at the local, national and international levels
and played an important role in the policy, planning and implementation of the
COVID response. Expert views on the learnings and challenges of dealing with the
COVID-19 pandemic and recommendations for future preparedness were sought.
Fourteen consultations have been held with more than sixty experts.
An overview of the institutions, organizations and experts consulted are annexed at
Annexure III.

» Presentation to concerned Ministries/Departments

Following the consultations with experts, members of the expert group prepared
the critical recommendations for future preparedness. The recommendations
were discussed with Secretaries and senior officers of concerned ministries and
departments in a meeting held on 24 May 2024 at NITI Aayog; co-chaired by Member
(Health), NITI Aayog and the Principal Scientific Adviser to the Government of India.
The participants welcomed the comprehensive recommendations of the expert
group prepared through a thorough assessment of the current preparedness status
and lessons learnt from COVID-19. Recommendations for a separate legislation
managing public health emergencies, earmarking a separate Pandemic Preparedness
and Emergency Response fund, strengthening surveillance and data management,
and investing in research and development of countermeasures (diagnostics,
vaccines, therapeutics, protective equipment) were appreciated by the participants
as timely and actionable recommendations that would also serve to strengthen
current activities and facilitate improved implementation.

2.2 Research
Research complementing future pandemic priorities has also been undertaken by
the Expert Group. This includes research on the work being undertaken by global
health organisations, multi-lateral groups like the Independent Panel for Pandemic
Preparedness and Response Secretariat (IPPRS), the 100 days Mission, etc.
Published literature on the COVID-19 pandemic, evolving science about the SARS-
CoV2 pathogen, COVID-19 disease and its sequelae have also been considered
by the Expert Group in its deliberations. Details of key references are included at
Annexure IV.

Future Pandemic Preparedness and Emergency Response 14 A Framework for Action

3. Lesson from the Past -dealing with epidemics in the last two
decades
Between 2009- 2022, WHO has declared seven Public Health Emergency of
International Concern (PHEICs) —Influenza A in 2009, poliomyelitis in 2014, Ebola
West Africa in 2014, Zika in 2016, Ebola Democratic Republic of Congo 2018, COVID-19
in 2020 and Monkey-pox in 2022. Public Health Emergency of International Concern
(PHEIC), as per IHR, is “an extraordinary event which is determined as per IHR
decision instrument (1) to constitute a public health risk to other countries through
the international spread, and (2) to potentially require a coordinated international
response”. Further, during the last few years, many countries have witnessed the
occurrence of several infectious diseases, outbreaks/public health threats which
were potential pandemic threats both outside and inside the country, which resulted
in the loss of lives, property, and economic consequences.
Important events/outbreaks during last two decades (which caused pandemic
threat) are described below. These also have the potential to cause future pandemics;
hence, preparedness measures should also be developed to manage their outbreaks.

Event/Outbreak Description Learnings

SARS in 2003 The first infectious disease in • Need for International
this century, which started in two legally binding rules/
provinces of China, spread to over regulations.
50 countries in a very short time • Novel pathogens are
through international travel and difficult to identify and
resulted in around 850 deaths hence the primers and
within a period of 3-4 months. probes for developing
diagnostic tests/facilities
Highly infectious and contagious;
take time and; thus,
R0 of around 8 spread primarily
detection of infection
through respiratory mode. A
among exposed persons
multi-country high-level expert
is a challenge during the
group got exposed in a group
initial phase.
meeting in Hong Kong Hotel
• Need for core capacities
(event) which caused multi-
for screening, sample
country spread during air travel
collection and quarantine
and also after return. Countries
facilities at international
used ad hoc measures in absence
airports.
of any international provisions,
primarily on basis of past
experience.

Future Pandemic Preparedness and Emergency Response 15 A Framework for Action

 Avian Flu (H5N1) Since 2005 onwards, repeated • An effective strategy of
outbreaks in birds (primarily surveillance of at-risk
in poultry) have caused populations and culling sick
significant harm to at-risk human birds was developed as a
populations. coordinated surveillance
and response plan for both
human and animal sectors.
In 2024, H5N1 has been circulating This helped the country
among cattle farms in the US, and in effective containment
a few human cases have been and prevented spillover
reported. of infection among at
-populations from birds.
• A standing committee on
zoonosis was established
following avian influenza.
H1N1 pandemic Emerged in 2009 in Mexico, it • IHR (2005), a legally
(pandemic spread through respiratory routes binding regulation, was in
declared as to over 74 countries, causing place.
PHEIC)) about 491000 lab-confirmed • Countries were
cases and 18449 deaths. This was developing core
the first pandemic to be declared capacities as per IHR
as PHEIC in accordance with IHR at points of entry and
(2005). inside the country for
surveillance and response.
• Countries adopted
public health measures
like screening at POEs,
early detection of
suspects, quarantine,
contact tracing of
suspect surveillance and
management of cases
in isolation in dedicated
wards.
• Public health measures
were helpful in mitigating
and delaying the entry of
infection.
• Need for coordinated
surveillance between
Points of entry and in-
country surveillance
system.

Future Pandemic Preparedness and Emergency Response 16 A Framework for Action

 Ebola Outbreaks Multiple Ebola outbreaks (around • Efforts to control these
7 since 1976) occurred in different outbreaks involved
(2014-2016)
regions of Africa. The epidemics screening, surveillance of
(2018-2021)
in the west African countries were exposed, contact tracing,
significant from the perspective data management,
of international spread in over 7 laboratory testing,
countries in Europe and the threat and health education,
of spread in other countries via including use of PPEs.
international travellers. • Public health efforts were
much more effective,
limiting entry into the
country.

MERS-CoV Outbreaks in the Middle Eastern • Zoonotic diseases,

countries have been regularly particularly highly
occurring since 2012 and are infectious diseases that
potential threats from the spread via respiratory/
perspective of international droplets route could be
spread via travellers, for e.g. in challenging to prevent.
South Korea in 2015, leading to • Most of the threats
186 cases and around 34 deaths. leading to pandemics
were due to novel viruses
of zoonotic origin,
possibly transmitted
through the human-
animal interface.
• Infectious diseases
having a respiratory
mode of transmission are
dangerous.
Zika Virus A disease transmitted via Aedes • ZVD- a disease with
disease mosquitos has already spread to over 80% asymptomatic
over 90 countries and has been cases and mild clinical
detected in over 12 states in the symptoms with full
country. recovery cannot be
prevented using public
health measures directed
towards travellers.
• Effective vector
surveillance and control
is essential to prevent
entry and transmission
of vector-transmitted
diseases.
• Need for multi-sectoral
collaborative surveillance.

Future Pandemic Preparedness and Emergency Response 17 A Framework for Action

4. COVID-19 Learnings and Challenges
The COVID-19 pandemic (2019-23) caused by the SARS-CoV-2 virus emerged
in late 2019 and quickly spread worldwide. The world was caught unaware and
although there were strategies for managing outbreaks and epidemics, developing
and deploying countermeasures for the different outbreaks, the magnitude of the
problem faced when the pandemic hit us was overwhelming and required urgent
coordinated action. It resulted in millions of deaths, widespread illness, and significant
economic and social disruptions. Efforts to control the spread of the virus included
cluster containment, disruption of social gatherings, lockdowns, travel restrictions,
mask mandates, and the development of vaccines and mass vaccination.
The country had a well-developed strategy-based response system for earlier
outbreaks, which effectively implemented and successfully managed the disease.
However, there were challenges faced and key gaps noted in the ecosystem which
need urgent attention for better management of any future public health crisis.
These lessons are important to plan a road map for future pandemics. Some of the
key issues are listed below -

4.1 Governance
i. The whole–of-government, whole-of-society approach, and inter-
departmental, inter-ministerial, and centre-state coordination worked well
during COVID -19.
ii. Role of Empowered Group Systems, National Task Forces – NTAGI & NEG-
VAC were critical for quick decision-making and interagency coordination
iii. Science-based evidence played a key role in informed decision-making.
This evolved with a scientific understanding of the pathogen and disease,
iv. The role and responsibility of each agency and organisation however,
required more clarity, and the mechanisms for close coordination of
agencies to work together were not in place.
v. Risk communication systems need to be established. What was missing
in COVID management was a well-developed communication mechanism
which allowed data to flow both ways.
vi. The need was also felt for a well-defined rapid response SOP/instruction
document and delegation of powers to empower key officials to act without
going through the multilayered hierarchal process. This was essential for
speedy time-bound action.

4.2 Legislation
i. The National Disaster Management Act (NDMA) was enforced – enabling
Centre and State government to respond quickly and implement public
health measures.
ii. However, a need is felt for a specific Public Health Act.
iii. Provisions of NDMA are not entirely suited for a public health emergency
and its public health and clinical management.
iv. The previous epidemic act has a limited scope and is not suited to the
modern approach for pandemic/epidemic management.

Future Pandemic Preparedness and Emergency Response 18 A Framework for Action