Why the Next Pandemic May Strike Before We Know It

Now that COVID has receded to endemic status, too few of us are thinking about what might attack us next, which likely means we will be woefully underprepared whenever the next pandemic hits.

Don’t get me wrong: We have developed tools in fighting COVID that will help us in the next viral war. But our public health response has been inconsistent and hardly inspired confidence, stopping and starting like a car with a brand-new driver behind the wheel.

Before COVID, the scientific community was on high alert on and off, anticipating the next pandemic. At the beginning of this century, amid post 9/11 vulnerability, it was anthrax, smallpox, SARS, and then bird flu that kept health-care leaders up at night.

Of course, the “retrospectoscope” of history tells us that fear outweighed the actual risk. None of these worrisome pathogens have emerged to threaten us on a mass scale. 

H5N1 is harbored in ducks, gulls and other wild birds but kills millions of chickens and turkeys every year. We have feared a human bird flu pandemic since 2005 but are protected by a natural barrier between species, which keeps H5N1 several mutations away from crossing. Unfortunately, in 2012, Dutch virologist Ron A.M. Fouchier and others provided the exact roadmap of mutations necessary to overcome this barrier via gain-of-function research, and only luck has kept this formula from getting into the wrong hands since then. 

I am far more worried about a pandemic pathogen leaking from a lab than about one developing on its own in nature. Indeed, we have a history of worrying about the wrong bug at the wrong time. Before COVID, few experts talked about coronaviruses, although clearly we should have been. Whether COVID-19 came from a lab or nature or both, scientists in several parts of the world, including China, were performing serious virus-altering experiments on coronaviruses that put the whole world at risk — yet no one was talking about it.

Creating successful vaccines is part of the justification for manipulating viruses with gain-of-function research, yet that can backfire by creating the very monster virus we are trying to prevent. When it comes to the next pandemic, I still am most concerned about the flu, which is constantly mutating and infecting most mammals.

Smallpox already exists in a form in which it can cause mass deaths without further mutations; in fact, smallpox killed more than 300 million people during the 20^th century before being stamped out by a highly successful live-virus vaccine. The only viable samples supposedly are held in the highest-biosecurity lab at the U.S. Centers for Disease Control and Prevention (CDC) and also in Russia (where, of course, we can’t vouch for the level of security, especially given today’s U.S.-Russia relations). A brief scare occurred in 2021 when vials marked “smallpox” were found in a lab in Philadelphia, but those were determined to not contain smallpox. 

The point, however, is that the smallpox samples which do exist could find their way into the wrong hands and be released into society. Those of us over the age of 50 received a smallpox vaccine when we were infants, but it is not clear how much protection we still have — and those who are younger have none.

Smallpox vaccine is part of the nation’s strategic stockpile of emergency medicines (including ACAM 2000 vaccine), with more than 100 million doses of three vaccines. That is considered to be enough to significantly slow or stop an outbreak. 

A popular HBO series, “The Last of Us,” has made many worried about fungi sparking the next pandemic. Yet, despite mutations, the worst fungi (Candida Auris, commonly called Zombie-Ant Fungus) still do best in cold-blooded creatures like ants and frogs. Interestingly, a form of fungus is spreading among warm-blooded bats, but only because the bats’ blood cools when they hibernate.

Ebola and Marburg are viruses that originated in bats that will never get us on a mass scale — in part because, although both are quite lethal, neither is very contagious. Plus, we have a vaccine against the former and another in clinical trials against the latter. Rabies is endemic in vampire bats and, according to research, is only a few mutations away from going airborne. I am keeping my eye on this one, both in nature and in the lab. 

Whatever gets us next, be it a monstrous flu or something else, it  will be made more possible because birds and mammals are living too close to humans and some of them — the animals, that is — are being consumed uncooked. And, in the lull between pandemics, we are now too preoccupied with returning to unfettered life to keep our eyes on what unfettered scientists are doing to dangerous viruses in their laboratories.

Dr. Marc Siegel, clinical professor of medicine at New York University’s Langone Medical Center, is the author of numerous books on the COVID pandemic and other medical topics. He is medical director and host of SiriusXM’s “Doctor Radio” program. Follow him on Twitter @DrMarcSiegel.