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insecure contexts. The world is at acute risk for devastating regional or global disease epidemics or pandemics that not only cause loss of life but upend economies and create social chaos. A world at risk Vulnerability is heightened by an increase in outbreaks occurring in complex humanitarian emergencies, as well as a novel convergence of ecological, political, economic and social trends including population growth, increased urbanization, a globally integrated economy, widespread and faster travel, conflict, migration and climate change (2). Specific risks are described below. The world is confronted by increasing infectious disease outbreaks. Between 2011 and 2018, WHO tracked 1483 epidemic events in 172 countries (3). Epidemic-prone diseases such as influenza, severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), Ebola, Zika, plague, yellow fever and others, are harbingers of a new era of high-impact, potentially fast-spreading outbreaks that are more frequently detected and increasingly difficult to manage. Figure 1 demonstrates the global emergence of selected pathogens over the past 50 years, including both those that naturally emerge/re-emerge and those that are deliberately released. FIGURE 1 Global examples of emerging and re-emerging diseases C. difficile: Clostridium difficile; CRE: carbapenem-resistant Enterobacteriaceae; E. coli: Escherichia coli; MDR: multidrugresistant [tuberculosis]; MERS-CoV: Middle East respiratory syndrome coronavirus; MRSA: meticillin-resistant Staphylococcus aureus; N. gonorrhoeae; Neisseria gonorrhoeae; SFTSV: severe fever with thrombocytopenia syndrome virus; XDR: extensively drug-resistant [tuberculosis]. Source: United States National Institutes of Health, National Institute for Allergies and Infectious Diseases (4). A WORLD AT RISK 2 SARS Cryptosporidiosis E. coli O157:H7 Plague Human monkeypox Cyclosporiasis Lassa fever Ebola virus Enterovirus D68 Heartland virus Powassan virus Cholera Dengue Hantavirus pulmonary syndrome Rift Valley fever vCJD Diphtheria HIV Lyme disease Hepatitis C West Nile virus Marburg virus Acute flaccid myelitis Hendra virus Yellow fever Zika virus Zika virus Enterovirus 71 Nipah virus Human monkeypox Antimicrobialresistant threats - CRE - MRSA - C. difficile - N. gonorrhoeae Newly emerging Re-emerging/resurging “Deliberately emerging” Human African trypanosomiasis Chikungunya Adenovirus 14 Akhmeta virus MERS-CoV Listeriosis Measles Nipah virus Anthrax bioterrorism H3N2v influenza H5N1 influenza E. coli O157:H7 H10N8 influenza H5N6 influenza Typhoid fever SFTSV bunyavirus H7N9 influenza 2009 H1N1 influenza Bourbon virus Drug-resistant malaria Ebola virus E. coli O104:H4 A WORLD AT RISK 3 The poor suffer the most Any country without basic primary health care, public health services, health infrastructure and effective infection control mechanisms faces the greatest losses, including death, displacement and economic devastation. Disease outbreaks disrupt the entire health system reducing access to health services for all diseases and conditions, which leads to even greater mortality and further economic depression. Negative impacts are particularly profound in fragile and vulnerable settings, where poverty, poor governance, weak health systems, lack of trust in health services, specific cultural and religious aspects and sometimes ongoing armed conflict greatly complicate outbreak preparedness and response. All economies are vulnerable In addition to loss of life, epidemics and pandemics devastate economies. Estimated costs of past events include: a loss of over US$ 40 billion in productivity from the 2003 SARS epidemic (5); US$ 53 billion loss from the economic and social impact of the 2014-2016 West Africa Ebola outbreak (6,7); and the US$ 45 to 55 billion cost of the 2009 H1N1 influenza pandemic (8) (Figure 2). The World Bank estimates that a global influenza pandemic akin to the scale and virulence of the one in 1918 would cost the modern economy US$ 3 trillion, or up to 4.8% of gross domestic product (GDP); the cost would be 2.2% of GDP for even a moderately virulent influenza pandemic (9). Models predict the annual cost of a global influenza