Assessing global preparedness for the next pandemic: development and application of an Epidemic Preparedness Index

A preliminary validation of the public's emergency preparedness questionnaire for major emerging infectious diseases

BACKGROUND

Major emerging infectious diseases (MEIDs) have been considered as a pressing challenge to global public health. The world will face ongoing and increasing challenges posed by these diseases in the future. However, efficient emergency preparedness among the public could greatly reduce the risk of the spread of MEIDs. There is a scarcity of studies that evaluate the emergency preparedness of the public during MEIDs, which makes it difficult to clarify the emergency preparedness of the public during MEIDs. This study aims to validate the public's emergency preparedness questionnaire for MEIDs to assess the emergency preparedness of public during the outbreak of MEIDs.

METHODS

The questionnaire was constructed through a literature review, the Delphi method, and the analytic hierarchy process. From March to July 2023, experts were invited to conduct the content validity of the questionnaire, and then a cross-sectional survey online and in person was conducted to evaluate the validity and reliability of the questionnaire. Internal consistency, split-half reliability and test-retest reliability were used to test the reliability. Exploratory factor analysis was used to measure the construct validity.

RESULTS

The final questionnaire is composed of 48 items and five factors (cooperating with prevention and control work, preparing knowledge and coping strategies, securing supplies and equipment, preparing economic resources, and maintaining physical and mental health), and adopted the 5-point scoring method. The cumulative contribution of variance was 50.864%. The internal consistency, split-half reliability and test-retest reliability of the questionnaire were 0.953, 0.834 and 0.900, respectively.

CONCLUSIONS

The developed questionnaire exhibits strong reliability and validity for assessing public emergency preparedness during major emerging infectious diseases (MEIDs). Based on these findings, we recommend enhancing public education, implementing supportive policies, fostering community engagement, improving resource accessibility, and providing health support to better prepare the public for future outbreaks, thereby strengthening global public health security.

Perceived Preparedness and Mental Health in Response to the COVID-19 Pandemic in the UK Population

OBJECTIVE

Preparedness levels have been shown to improve the outcomes for people who find themselves in an emergency. However, uptake of preparedness behaviors by the public prior to a major disaster is limited. This 2-part study examined perceived preparedness in the UK during the first months of the COVID-19 pandemic (Study 1), and 2 years later (Study 2).

METHODS

Both studies investigated the effect of individual demographics (gender, age, perceived socioeconomic and health status) on perceived preparedness. Next, the studies examined the extent to which perceived preparedness was associated with mental health outcomes (anxiety, depression, and stress symptoms). Participants (Study 1, N = 409) completed an online survey in May to June 2020 during a national lockdown, with another sample (Study 2, N = 87) completing the same survey from March to July 2022.

RESULTS

Across both studies, participants completed 2 to 3 different preparedness activities. Greater subjective perceptions of socioeconomic status were associated with perceived preparedness. Preparedness levels were related with better mental health, and unrelated to age and gender.

CONCLUSIONS

Encouraging the public to engage with preparedness behaviors may not only have practical benefits but also help to protect mental well-being during a disaster.

Determining the best mathematical model for implementation of non-pharmaceutical interventions

At the onset of the SARS-CoV-2 pandemic in early 2020, only non-pharmaceutical interventions (NPIs) were available to stem the spread of the infection. Much of the early interventions in the US were applied at a state level, with varying levels of strictness and compliance. While NPIs clearly slowed the rate of transmission, it is not clear how these changes are best incorporated into epidemiological models. In order to characterize the effects of early preventative measures, we use a Susceptible-Exposed-Infected-Recovered (SEIR) model and cumulative case counts from US states to analyze the effect of lockdown measures. We test four transition models to simulate the change in transmission rate: instantaneous, linear, exponential, and logarithmic. We find that of the four models examined here, the exponential transition best represents the change in the transmission rate due to implementation of NPIs in the most states, followed by the logistic transition model. The instantaneous and linear models generally lead to poor fits and are the best transition models for the fewest states.

Constructing a global human epidemic database using open-source digital biosurveillance

We developed a dataset consisting of outbreak data collected from official, open-source surveillance reports representing more than 170 pathogens, 237 countries and territories, and more than 3300 events that occurred primarily between 1963 and 2023. Here we present and analyze a subset of these data, comprising a dataset of human epidemic events with onset between 2015 and 2020. Structuring of epidemiological data in the dataset follows a specific methodology to ensure consistency across all events. This methodology has been designed to produce the most reliable spatiotemporal view of an outbreak as possible. To ensure data are true-to-source, the structured data undergoes multiple rounds of both manual and automated review and validation. The extensive and standardized nature of the dataset makes it well-suited for both descriptive epidemiology and exploring outbreak dynamics and disease emergence.

The Importance of Studying Infectious and Parasitic Diseases of Wild Animals in the Amazon Biome with a Focus on One Health

The Amazon Biome is home to an extraordinary diversity of wildlife, many of which are reservoirs or vectors for infectious and parasitic diseases that can impact not only the health of wild animals but also human and domestic animal populations. This narrative review highlights the critical importance of studying infectious and parasitic diseases in wild animals within the Amazon, particularly in the context of the One Health approach, which recognizes the interconnectedness of human, animal, and environmental health. This narrative review examines key pathogens, including viruses, bacteria, and parasites, that pose significant risks to wildlife conservation and public health. Through a synthesis of recent literature, this article emphasizes the need for comprehensive surveillance, research, and collaboration between the veterinary, medical, and environmental sectors. The results underscore the urgent necessity for an integrated response to emerging diseases, particularly as environmental changes and human activities increasingly disrupt ecosystems in the region. The conclusions advocate for the reinforcement of One Health initiatives in the Amazon Biome to ensure the protection of biodiversity and the prevention of zoonotic disease transmission to human populations.

Interventions to Maintain HIV/AIDS, Tuberculosis, and Malaria Service Delivery During Public Health Emergencies in Low- and Middle-Income Countries: Protocol for a Systematic Review

BACKGROUND

Although existing disease preparedness and response frameworks provide guidance about strengthening emergency response capacity, little attention is paid to health service continuity during emergency responses. During the 2014 Ebola outbreak, there were 11,325 reported deaths due to the Ebola virus and yet disruption in access to care caused more than 10,000 additional deaths due to measles, HIV/AIDS, tuberculosis, and malaria. Low- and middle-income countries account for the largest disease burden due to HIV, tuberculosis, and malaria and yet previous responses to health emergencies showed that HIV, tuberculosis, and malaria service delivery can be significantly disrupted. To date, there has not been a systematic synthesis of interventions implemented to maintain the delivery of these services during emergencies.

OBJECTIVE

This study aimed to synthesize the interventions implemented to maintain HIV/AIDS, tuberculosis, and malaria services during public health emergencies in low- and middle-income countries.

METHODS

The systematic review was registered in the international register for prospective systematic reviews. It will include activities undertaken to improve human health either through preventing the occurrence of HIV, tuberculosis, or malaria, reducing the severity among patients, or promoting the restoration of functioning lost as a result of experiencing HIV, tuberculosis, or malaria during health emergencies. These will include policy-level (eg, development of guidelines), health facility-level (eg, service rescheduling), and community-level interventions (eg, community drug distribution). Service delivery will be in terms of improving access, availability, use, and coverage. We will report on any interventions to maintain services along the care cascade for HIV, tuberculosis, or malaria. Peer-reviewed study databases including MEDLINE, Web of Science, Embase, Cochrane, and Global Index Medicus will be searched. Reference lists from global reports on HIV/AIDS, tuberculosis, or malaria will also be searched. We will use the GRADE-CERQual (Grading of Recommendations Assessment, Development, and Evaluation-Confidence in Evidence from Reviews of Qualitative Research) approach to report on the quality of evidence in each paper. The information from the studies will be synthesized at the disease or condition level (HIV/AIDS, tuberculosis, and malaria), implementation level (policy, health facility, and community), and outcomes (improving access, availability, use, or coverage). We will use the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist to report findings and discuss implications for strengthening preparedness and response, as well as strengthening health systems in low- and middle-income countries.

RESULTS

The initial search for published literature was conducted between January 2023 and March 2023 and yielded 8119 studies. At the time of publication, synthesis and interpretation of results were being concluded. Final results will be published in 2025.

CONCLUSIONS

The findings will inform the development of national and global guidance to minimize disruption of services for patients with HIV/AIDS, tuberculosis, and malaria during public health emergencies.

TRIAL REGISTRATION

PROSPERO CRD42023408967; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=408967.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/64316.

Global patterns in access and benefit-sharing: a comprehensive review of national policies

ABSTRACT

Introduction

The goal of access and benefit-sharing (ABS) in global health governance is to ensure that countries that provide access to genetic resources, including pathogens, receive equitable access to the benefits derived from their use. The increasing digitalisation of health data has brought this issue to the forefront of discussions on global health security and health equity. While originally conceptualised in supranational agreements, implementation of these treaties requires national-level legislation in each country. This descriptive analysis represents to our knowledge the first open-access comprehensive effort to map ABS policies in all 193 United Nations member states.

Methods

We conducted a standardised review of the legislation for 193 United Nations Member States across three global legal databases (ABS Clearing House, WIPOLEX and FAOLEX), national legal databases and a systematic Google search. Legally enforceable policies were identified, and data were extracted across the following eight aspects of ABS legislation: Scope of Legislation, Digital Sequence Information (DSI), Access to Resources, Prior Informed Consent, Contractual Terms, Benefit-Sharing, Compliance and Legal Sanctions.

Results

We found that 104 countries have legally enforceable policies on ABS, with 92 countries having ABS policies relevant to microorganisms. Of these, 74 countries have chosen to restrict access to their domestic pathogens, and 53 have chosen to link access to pathogenic resources with an obligation to share benefits. Altogether 22 countries have a codified position on DSI with regard to ABS in legally enforceable policy: 16 have explicitly included it, 2 have explicitly excluded it and 4 have ambiguous wording. WHO regional coverage of ABS policy on genetic resources ranged from 28% (3/11) of countries in the Eastern Mediterranean Region to 57% (21/35) in the Region of the Americas. Likewise, regional coverage of legally enforceable ABS policy related to DSI ranged from 0% in the Eastern Mediterranean and European Regions to 36% (4/11) of countries in the Southeast Asian Region.

Conclusion

These findings highlight the heterogeneity found in the global policy landscape as it pertains to ABS, and provide data to inform future agreements and research efforts related to ABS.

A Survey on Companion Animal Owners' Perception of Veterinarians' Communication About Zoonoses and Antimicrobial Resistance in Germany

The intimate bonds between humans and their pets create favourable conditions that support the mutual transmission of pathogens in either direction. In this context, veterinarians are essential in informing and educating pet owners about health risks linked to zoonotic pathogens and antimicrobial resistance (AMR). To effectively convey this information, veterinarians should have strong communication skills. To gather insights on pet ownership, veterinary consultations, and risk communication, an online questionnaire was used to survey dog and cat owners in Germany. The survey evaluated the frequency and perception of communication concerning zoonotic pathogens and AMR, deriving a communication score. The findings showed that pet owners rated veterinarian communication with a high average score, reflecting a high satisfaction level. The longer pet owners had been clients, the more frequently they received information on zoonoses and AMR, and the better they rated the communication. However, the results also indicated that the amount of information on zoonoses and/or AMR provided by veterinarians was still lower than desired by pet owners. Risk factors, including pathogen detection, vulnerable individuals, owning imported animals, and feeding them raw meat, fish, offal, or uncooked bones, were regularly present. These findings underscore the critical role of risk communication in preventing zoonoses and AMR.

Evaluation and comparison of hospital preparedness levels against mass-casualty disasters and the COVID-19 pandemic

BACKGROUND

Inadequate preparedness of hospitals is associated with negative outcomes in the treatment procedure. During the coronavirus disease 2019 (COVID-19) pandemic, healthcare systems faced many problems due to the widespread prevalence of the disease. This study was designed and conducted with the aim of investigating and comparing the preparedness levels of hospitals against mass-casualty disasters and the COVID-19 pandemic.

METHOD

This research was a cross-sectional, descriptive-analytical study conducted in January 2022 in five educational hospitals affiliated with Qom University of Medical Sciences, Qom, Iran, admitting COVID-19 patients. The National Hospital Preparedness Checklist and the Hospital Preparedness Checklist for the COVID-19 pandemic were used to collect the required data.

RESULTS

The total preparedness level against mass-casualty disasters was estimated to be 79.81 percent. The lowest and highest average preparedness scores were related to the dimensions of "Logistic and management of supplies" (74 percent) and "command and control" (96.66 percent), respectively. In addition, the overall preparedness level against COVID-19 was estimated to be 87.20 percent. The lowest and highest average percentage of preparedness scores were related to the fields of "supply management" (71.81 percent) and "laboratory services" (97.14 percent), respectively.

CONCLUSION

The duration of exposure to emergency situations and managerial perspectives are among the factors affecting the preparedness of -medical systems against disasters. It is assumed that some kind of adaptation exists in healthcare systems, which leads to an improvement in their preparedness level. In order to deal with crises, it is suggested to set up specialized hospitals (such as trauma centers), train crisis managers, and use them in the management of medical centers.

Influenza-Like Illness in Lesotho From July 2020 to July 2021: Population-Based Participatory Surveillance Results

Background

Participatory surveillance involves at-risk populations reporting their symptoms using technology. In Lesotho, a landlocked country of 2 million people in Southern Africa, laboratory and case-based COVID-19 surveillance systems were complemented by a participatory surveillance system called "LeCellPHIA" (Lesotho Cell Phone Population-Based HIV Impact Assessment Survey).

Objective

This report describes the person, place, and time characteristics of influenza-like illness (ILI) in Lesotho from July 15, 2020, to July 15, 2021, and reports the risk ratio of ILI by key demographic variables.

Methods

LeCellPHIA employed interviewers to call participants weekly to inquire about ILI. The average weekly incidence rate for the year-long period was created using a Quasi-Poisson model, which accounted for overdispersion. To identify factors associated with an increased risk of ILI, we conducted a weekly data analysis by fitting a multilevel Poisson regression model, which accounted for 3 levels of clustering.

Results

The overall response rate for the year of data collection was 75%, which resulted in 122,985 weekly reports from 1776 participants. ILI trends from LeCellPHIA mirrored COVID-19 testing data trends, with an epidemic peak in mid to late January 2021. Overall, any ILI symptoms (eg, fever, dry cough, and shortness of breath) were reported at an average weekly rate of 879 per 100,000 (95% CI 782-988) persons at risk. Compared to persons in the youngest age group (15-19 years), all older age groups had an elevated risk of ILI, with the highest risk of ILI in the oldest age group (≥60 years; risk ratio 2.6, 95% CI 1.7-3.8). Weekly data were shared in near real time with the National COVID-19 Secretariat and other stakeholders to monitor ILI trends, identify and respond to increases in reports of ILI, and inform policies and practices designed to reduce COVID-19 transmission in Lesotho.

Conclusions

LeCellPHIA, an innovative and cost-effective system, could be replicated in countries where cell phone ownership is high but internet use is not yet high enough for a web- or app-based surveilance system.

Factors influencing healthcare workers' and health system preparedness for the COVID-19 pandemic: A qualitative study in Ghana

Adequate preparedness of health systems, particularly healthcare workers (HCWs), to respond to COVID-19 is critical for the effective control of the virus, especially in low- and middle-income countries where health systems are overburdened. We examined Ghanaian HCWs' perceived preparedness to respond to the pandemic and the factors that shaped their preparedness and that of the health system. Semi-structured in-depth interviews were conducted with n = 26 HCWs responsible for the clinical management of COVID-19 patients and three administrators responsible for developing and implementing COVID-19 policies at the facility level. Interviews were conducted over the phone in English, transcribed, and analyzed using a thematic analysis approach. Generally, HCWs felt inadequately prepared to contain the spread of COVID-19 due to resource shortages and inadequate training. HCWs, similarly, perceived the health system to be unprepared due to insufficient clinical infrastructure and logistical challenges. The few who felt prepared identified readiness in managing high consequence infectious disease cases and pre-existing protocols as enablers of HCW preparedness. The health system and HCWs were unprepared to manage the COVID-19 pandemic due to inadequate training, logistical challenges, and weak clinical infrastructure. Interventions are urgently needed to improve the health system's preparedness for future pandemics.

The effect of adaptive capacity on resilience to the COVID-19 pandemic: A cross-country analysis

The COVID-19 pandemic's profound impacts on global health, driven by preparedness gaps and systemic risks, underscore the need to enhance societies' ability to manage both predictable risks and uncertainties inherent in disasters. While disaster research emphasises risk management for predictable threats and adaptive capacity for unexpected challenges, there is a lack of empirical examination of the impact of adaptive capacity on disaster resilience. This study addresses this gap by identifying three key adaptive capacities - quality of institutions, collaborative governance, and social capital - and examining their effects on COVID-19 resilience outcomes, measured by the ability to reduce excess mortality. Analysing secondary data from 129 nations using partial least squares structural equation modelling, the research finds significant positive effects of institutional quality and social capital on resilience outcomes. Conversely, collaborative governance shows a significant negative association, suggesting potentially intricate impacts beyond initial expectations. The findings highlight the need to enhance institutional quality and social capital to address preparedness gaps and unexpected challenges posed by biological hazards such as COVID-19. Future research should explore collaborative governance using a disaggregated approach that considers the roles of different stakeholders in various disaster phases.

Contribution

This study advances disaster research by presenting practical methodologies for operationalising adaptive capacities and empirically examining their effects on disaster resilience. For practitioners and policymakers, it highlights the need to adopt a long-term perspective in building disaster resilience, focussing on improving institutional quality and social capital to manage the uncertainties and complexities inherent in disaster scenarios effectively.

Resilience dimensions in health system performance assessments, European Union

Objective

To explore the definition and operationalization of resilience in health system performance assessments in European Union countries.

Methods

We conducted multiple empirical case study analyses. We identified relevant cases through a literature review from 2014 to 2023 using Google Scholar and through a snowball technique to retrieve additional information. We included only documents that explicitly mentioned resilience in health system performance assessments. We performed a content analysis to identify common patterns in defining resilience.

Findings

The final sample consisted of six countries: Belgium, Croatia, Czechia, Estonia, Ireland and Italy. Each country adopted a distinct approach to conceptualizing resilience, with countries prioritizing specific aspects based on lessons learnt from the coronavirus disease 2019 (COVID-19) pandemic. Some countries focused on maintaining essential health-care services and protecting vulnerable groups. Other countries prioritized management capacity, staff preparedness, digital health utilization and strengthening of primary health care. Content analysis revealed six resilience definitions derived from the key performance indicators: addressing unmet needs and maintaining outcomes; protecting vulnerable groups; acquiring and using resources; having trained and prepared staff in place; using digital health; and strengthening primary health care.

Conclusion

Integration of resilience into the health profiles of European Union countries preceded its inclusion in national health system performance assessments, the latter of which became more prominent after the COVID-19 pandemic. Variations in interpretations within health system performance assessments reflect differences in indicators and policy responses.

Community interventions for pandemic preparedness: A scoping review of pandemic preparedness lessons from HIV, COVID-19, and other public health emergencies of international concern

Community action is broadly recognised as central to comprehensive and effective system responses to pandemics. However, there is uncertainty about how and where communities can be best supported to bolster long-term resilience and preparedness. We applied a typology of community interventions (Community Informing, Consulting, Involving, Collaborating or Empowering-or CICICE) to cover the diverse range of interventions identified across the literature and used this to structure a scoping review addressing three linked topics: (i) how CICICE interventions have been understood and applied in the literature on epidemic and pandemic preparedness; (ii) the spectrum of interventions that have been implemented to strengthen CICICE and (iii) what evidence is available on their effectiveness in influencing preparedness for current and future emergencies. We drew on peer-reviewed and grey literature from the HIV (from 2000) and COVID-19 pandemics and recent public health emergencies of international concern (from 2008), identified through systematic searches in MEDLINE, Scopus, the Cochrane Collaboration database, supplemented by keyword-structured searches in GoogleScholar and websites of relevant global health organisations. Following screening and extraction, key themes were identified using a combined inductive/deductive approach. 130 papers met the criteria for inclusion. Interventions for preparedness were identified across the spectrum of CICICE. Most work on COVID-19 focused on informing and consulting rather than capacity building and empowerment. The literature on HIV was more likely to report interventions emphasising human rights perspectives and empowerment. There was little robust evidence on the role of CICICE interventions in building preparedness. Evidence of effect was most robust for multi-component interventions for HIV prevention and control. Much of the reporting focused on intermediate outcomes, including measures of health service utilisation. We put forward a series of recommendations to help address evidence shortfalls, including clarifying definitions, organising and stratifying interventions by several parameters and strengthening evaluation methods for CICICE.

What do clinicians mean by epidemics' preparedness

BACKGROUND

Infectious disease pandemics and epidemics pose significant global threats, and the risk of emerging infectious diseases has increased because of factors such as international connections, travel, and population density. Despite investments in global health surveillance, much of the world remains unprepared to manage infectious disease threats.

OBJECTIVES

This review article discusses the general considerations and lessons learned from the COVID-19 pandemic in terms of epidemic preparedness.

SOURCES

Non-systematic search on PubMed, scientific society websites, and scientific newspapers (performed in April 2023).

CONTENT

Key factors for preparedness include robust public health infrastructure, adequate allocation of resources, and effective communication between stakeholders. This narrative review emphasizes the need for timely and accurate dissemination of medical knowledge, as well as addressing the challenges of misinformation and infodemics. It also highlights the importance of quick availability of diagnostic tests and vaccines, ensuring equitable access to these technologies. The role of scientific coordination in developing treatment strategies and the safety and mental well-being of healthcare workers are discussed. Lastly, it should be emphasized the need for medical training, multidisciplinary teams, new technologies and artificial intelligence, and the active role of infectious disease physicians in epidemic preparedness efforts.

IMPLICATIONS

From clinicians' perspective, healthcare authorities play a crucial role in epidemic preparedness even by providing resource management plans, ensuring availability of essential supplies and training, facilitating communication, and improving safe infection management.

Quantifying holistic capacity response and healthcare resilience in tackling COVID-19: Assessment of country capacity by MCDM

The resilience of a country during the COVID-19 pandemic was determined based in whether it was holistically prepared and responsive. This resilience can only be identified through systematic data collection and analysis. Historical evidence-based response indicators have been proven to mitigate pandemics like COVID-19. However, most databases are outdated, requiring updating, derivation, and explicit interpretation to gain insight into the impact of COVID-19. Outdated databases do not show a country's true preparedness and response capacity, therefore, it undermines pandemic threat. This study uses up-to-date evidence-based pandemic indictors to run a cross-country comparative analysis of COVID-19 preparedness, response capacity, and healthcare resilience. PROMETHEE-a multicriteria decision making (MCDM) technique-is used to quantify the strengths (positive) and weaknesses (negative) of each country's COVID-19 responses, with full ranking (net) from best to least responsive. From 22 countries, South Korea obtained the highest net outranking value of 0.1945, indicating that it was the most resilient, while Mexico had the lowest (-0.1428). Although countries were underprepared, there was a robust response to the pandemic, especially in developing countries. This study demonstrates the performance and response capacity of 22 key countries to resist COVID-19, from which other countries can compare their statutory capacity ranking in order to learn/adopt the evidence-based responses of better performing countries to improve their resilience.

The biosafety incident response competence scale for clinical nursing staff: a development and validation study

AIMS

This study was designed to develop a biosafety incident response competence scale and evaluate its validity and reliability among clinical nurses.

DESIGN

This study employed a sequential approach, comprising four phases: (1) the establishment of a multidimensional conceptual model, (2) the preliminary selection of the items, (3) further exploration and psychometric testing of the items, (4) the application of the scale among clinical nurses.

METHODS

The biosafety incident response competence conceptual model was developed through literature review and the Delphi method. A total of 1,712 clinical nurses participated in the preliminary items selection, while 1,027 clinical nurses were involved in the further psychometric testing from July 2023 to August 2023. The item analysis, exploratory factor analysis and confirmatory factor analysis were conducted to evaluate the construct validity. Reliability was measured using Cronbach's alpha, split-half reliability, and test-retest reliability, while validity analysis included content validity, structural validity, convergent validity, and discriminant validity. From September to November 2023, we conducted a survey using the established scale with a total of 4338 valid questionnaires collected. T-test and variance analysis was employed to determine potential variations in biosafety incident response competence based on participants characteristics.

RESULTS

The final scale is composed of 4 factors and 29 items, including monitoring and warning abilities, nursing disposal abilities, biosafety knowledge preparedness, and infection protection abilities. The explanatory variance of the 4 factors was 75.100%. The Cronbach's alpha, split-half reliability and test-retest reliability were 0.974, 0.945 and 0.840 respectively. The Scale-level content validity index was 0.866. The Average Variance Extracted of the 4 factors was larger than 0.5, the Construct Reliability was larger than 0.7, and the Heterotrait-Monotrait ratio were less than 0.9. There were significant differences in the scores of response competence among nurses of different ages, working years, titles, positions, departments, marital status and participation in biosafety training (all P < 0.05).

CONCLUSIONS

The biosafety incident response competence scale for nurses exhibits satisfactory reliability and validity, making it a valuable tool for assessing clinical nurses' abilities in responding to biosafety incidents.

Local management of the COVID-19 pandemic in Norway: a longitudinal interview study of municipality chief medical officers

OBJECTIVE

To explore the experiences and views of Norwegian Municipality Chief Medical Officers (MCMOs) on preparedness, collaboration, and organization during the COVID-19 pandemic to gain insight into local crisis management of value for future pandemic responses.

DESIGN

Longitudinal qualitative interview study. We conducted semi-structured digital interviews with nine MCMOs working in different municipalities in Norway from September to December 2020. Five MCMOs were re-interviewed from January to April 2021. We used thematic analysis to analyze the data.

RESULTS

Through the analysis, three major themes were identified in the material; 1) The view of preparedness changed from being low-priority and dormant to the desire to strengthen preparedness as a permanent measure; 2) The nature of the pandemic forced a change in internal and external communication and collaboration for the MCMOs towards direct dialogue, teamwork and digital networking; 3) The pandemic changed the role and position of the MCMO within the municipal organization. Although most MCMOs were given a leading role in the municipal pandemic response, some MCMOs experienced that they were not positioned to fully exercise their intended role. In our material, de-authorization of the MCMO role seemed to coincide with the increasing size and organizational complexity of the municipality.

CONCLUSIONS

The Norwegian pandemic response and outcome have been regarded as successful internationally. Although the MCMOs managed to implement flexible and quick responses facilitated by teamwork, dialogue, and joint sensemaking, they also identified several challenges and shortcomings of the Norwegian pandemic preparedness requiring organizational and financial changes to sustain future health system resilience.

Preparing healthcare facilities in sub-Saharan Africa for future outbreaks: insights from a multi-country digital self-assessment of COVID-19 preparedness

BACKGROUND

Despite previous experience with epidemics, African healthcare systems were inadequately prepared and substantially impacted by the coronavirus disease 2019 (COVID-19) pandemic. Limited information about the level of COVID-19 preparedness of healthcare facilities in Africa hampers policy decision-making to fight future outbreaks in the region, while maintaining essential healthcare services running.

METHODS

Between May-November 2020, we performed a survey study with SafeCare4Covid - a free digital self-assessment application - to evaluate the COVID-19 preparedness of healthcare facilities in Africa following World Health Organization guidelines. The tool assessed (i) COVID-19-related capabilities with 31 questions; and (ii) availability of essential medical supplies with a 23-supplies checklist. Tailored quality improvement plans were provided after assessments. Information about facilities' location, type, and ownership was also collected.

RESULTS

Four hundred seventy-one facilities in 11 African countries completed the capability assessment; 412 also completed the supplies checklist. The average capability score on a scale of 0-100 (n=471) was 58.0 (interquartile range 40.0-76.0), and the average supplies score (n=412) was 61.6 (39.0-83.0). Both scores were significantly lower in rural (capability score, mean 53.6 [95%CI:50.3-57.0]/supplies score, 59.1 [55.5-62.8]) versus urban facilities (capability score, 65.2 [61.7-68.7]/supplies score, 70.7 [67.2-74.1]) (P<0.0001 for both comparisons). Likewise, lower scores were found for public versus private clinics, and for primary healthcare centres versus hospitals. Guidelines for triage and isolation, clinical management of COVID-19, staff mental support, and contact tracing forms were largely missing. Handwashing stations were partially equipped in 33% of facilities. The most missing medical supply was COVID-19 specimen collection material (71%), while 43% of facilities did not have N95/FFP2 respirators and 19% lacked medical masks.

CONCLUSIONS

A large proportion of public and private African facilities providing basic healthcare in rural areas, lacked fundamental COVID-19-related capabilities and life-saving personal protective equipment. Decentralization of epidemic preparedness efforts in these settings is warranted to protect healthcare workers and patients alike in future epidemics. Digital tools are of great value to timely measure and improve epidemic preparedness of healthcare facilities, inform decision-making, create a more stakeholder-broad approach and increase health-system resilience for future disease outbreaks.

Review of Israel's action and response during the COVID-19 pandemic and tabletop exercise for the evaluation of readiness and resilience-lessons learned 2020-2021

Background

Reevaluating response plans is essential to ensuring consistent readiness and resilience to the COVID-19 pandemic. The "During Action Review" and Tabletop (DART) methodology provides a retrospective and prospective assessment to inform the adaptive response. Israel introduced COVID-19 vaccinations in December 2020 and was the first country to implement booster vaccination to address waning immunity and surges caused by new variants. We assessed Israel's readiness and resilience related to COVID-19 response while capturing the pre-vaccination and vaccination periods.

Methods

A DART analysis was conducted between December 2020 and August 2021 among experts involved in the management of the COVID-19 pandemic in Israel. During the retrospective stage, a role-based questionnaire and discussions were undertaken in a participant-led review of the response, focusing on epidemiology and surveillance, risk communication, and vaccines. The prospective stage included tabletop exercises to evaluate short to long-term simulated scenarios.

Results

Participants emphasized the pivotal role of Israel globally by sharing experiences with the pandemic, and vaccination. Perceived strengths included multi-sectoral collaboration between the Ministry of Health, healthcare providers, academia, military, and others, stretching capacities, expanding laboratory workload, and establishing/maintaining surveillance. The vaccine prioritization plan and strong infrastructure, including computerized databases, enabled real-life assessment of vaccine uptake and impact. Challenges included the need to change case definitions early on and insufficient staffing. Quarantine of patients and contacts was particularly challenging among underprivileged communities. Risk communication approaches need to focus more on creating norms in behavior. Trust issues and limited cooperation were noted, especially among ethnic and religious minorities. To ensure readiness and resiliency, participants recommended establishing a nationally deployed system for bringing in and acting upon feedback from the field, especially concerning risk communication and vaccines.

Conclusion

Our study appraised strengths and weaknesses of the COVID-19 pandemic response in Israel and led to concrete recommendations for adjusting responses and future similar events. An efficient response comprised multi-sectoral collaboration, policy design, infrastructure, care delivery, and mitigation measures, including vaccines, while risk communication, trust issues, and limited cooperation with minority groups were perceived as areas for action and intervention.

Building a resilient health system for universal health coverage and health security: a systematic review

BACKGROUND

Resilient health system (RHS) is crucial to achieving universal health coverage (UHC) and health security. However, little is known about strategies towards RHS to improve UHC and health security. This systematic review aims to synthesise the literature to understand approaches to build RHS toward UHC and health security.

METHODS

A systematic search was conducted including studies published from 01 January 2000 to 31 December 2021. Studies were searched in three databases (PubMed, Embase, and Scopus) using search terms under four domains: resilience, health system, universal health coverage, and health security. We critically appraised articles using Rees and colleagues' quality appraisal checklist to assess the quality of papers. A systematic narrative synthesis was conducted to analyse and synthesise the data using the World Health Organization's health systems building block framework.

RESULTS

A total of 57 articles were included in the final review. Context-based redistribution of health workers, task-shifting policy, and results-based health financing policy helped to build RHS. High political commitment, community-based response planning, and multi-sectorial collaboration were critical to realising UHC and health security. On the contrary, lack of access, non-responsive, inequitable healthcare services, poor surveillance, weak leadership, and income inequalities were the constraints to achieving UHC and health security. In addition, the lack of basic healthcare infrastructures, inadequately skilled health workforces, absence of clear government policy, lack of clarity of stakeholder roles, and uneven distribution of health facilities and health workers were the challenges to achieving UHC and health security.

CONCLUSIONS

Advanced healthcare infrastructures and adequate number of healthcare workers are essential to achieving UHC and health security. However, they are not alone adequate to protect the health system from potential failure. Context-specific redistribution of health workers, task-shifting, result-based health financing policies, and integrated and multi-sectoral approaches, based on the principles of primary health care, are necessary for building RHS toward UHC and health security.

The UK's pandemic preparedness and early response to the COVID-19 pandemic

This article focuses on the UK's pre-COVID 19 pandemic preparedness and its early response to the COVID-19 pandemic (January '20 - March '20). The aim of this article is to explain the high excess mortality the UK experienced compared to many of its international and European peers in the first wave, which is contrary to the country's high ranking in pre-COVID-19 preparedness rankings. The article assesses the various components of pre-COVID-19 pandemic preparedness such as pandemic strategy, exercises, and stockpiles, and it covers government decision making processes on the early response, including questions around post-travel quarantining, test and trace, and mobility restrictions. The article concludes that there were important deficiencies in the UK's pandemic preparedness and early response in the COVID-19 pandemic. These include the centrality of the 'inevitability of spread'-assumption underpinning the UK's pandemic planning pre-COVID, the insufficient implementation of pandemic exercise recommendations, the lack of early and 'live learning' from other countries' experiences, the lack of adoption of public health advice of the World Health Organisation early on, the late implementation of internal mobility restrictions, the lack of timely consideration of alternative early pandemic response models, and fragilities in the SAGE/governmental interplay.

Orphans in Syria and Iraq Juggling Balls: Wars, COVID-19, and the NGO's financial crisis

The COVID-19 pandemic's impact varies between and within nations, causing new forms of inequality. Refugee and orphan children in conflicted areas are more likely to suffer due to poverty, vulnerability, and limited access to essential services including reduction in donor funding. This qualitative study is the first to assess the effects of the COVID-19 pandemic and the financial crisis on Iraqi and Syrian orphaned children and their mothers. The Modified Grounded Theory was used for the preliminary analysis to expand the range of themes. This study has identified five major themes: financial crisis, low educational attainment, child labour, mental health issues, violence, and social problems. The impact of COVID-19 children and adolescents' mental health is of great concern. These multiple crises may significantly impact orphan children and adolescents' cognitive, mental health, and physical development. It is critical to address mental health issues during the current crisis and to plan for possible future pandemics and their intersecting outcomes. A Holistic approach requires providers to be aware of their clients' intersecting circumstances and needs using a range of lenses, including the person in the environment, family dynamics, culture, politics, and structural challenges. Offering food, medical supplies, and housing are considered basic needs.

Evaluating the Added Value of Digital Contact Tracing Support Tools for Citizens: Framework Development

BACKGROUND

The COVID-19 pandemic revealed that with high infection rates, health services conducting contact tracing (CT) could become overburdened, leading to limited or incomplete CT. Digital CT support (DCTS) tools are designed to mimic traditional CT, by transferring a part of or all the tasks of CT into the hands of citizens. Besides saving time for health services, these tools may help to increase the number of contacts retrieved during the contact identification process, quantity and quality of contact details, and speed of the contact notification process. The added value of DCTS tools for CT is currently unknown.

OBJECTIVE

To help determine whether DCTS tools could improve the effectiveness of CT, this study aims to develop a framework for the comprehensive assessment of these tools.

METHODS

A framework containing evaluation topics, research questions, accompanying study designs, and methods was developed based on consultations with CT experts from municipal public health services and national public health authorities, complemented with scientific literature.

RESULTS

These efforts resulted in a framework aiming to assist with the assessment of the following aspects of CT: speed; comprehensiveness; effectiveness with regard to contact notification; positive case detection; potential workload reduction of public health professionals; demographics related to adoption and reach; and user experiences of public health professionals, index cases, and contacts.

CONCLUSIONS

This framework provides guidance for researchers and policy makers in designing their own evaluation studies, the findings of which can help determine how and the extent to which DCTS tools should be implemented as a CT strategy for future infectious disease outbreaks.

The application of policy composite indicators to predicting the health risk and recovery: a global comparative investigation

OBJECTIVES

There emerges increasing doubt regarding whether the policy composite indicators are applicable to the COVID-19 pandemic. A few early studies demonstrate that the association between some composite indicators of policy preparedness and the risk of COVID-19 is statistically insignificant, and the relation between any composite indicators and recovery process (e.g., vaccination coverage) remains unexplored. To examine the relation between composite indicators and pandemic risk (as well as the vaccination coverage) with robustness, this study applies different policy preparedness indicators by using data from multi-sources.

STUDY DESIGN

A cross-sectional analysis was performed.

METHOD

Regression analysis is adopted to examine the relation between four policy preparedness indicators (i.e., [1] International Health Regulations core capacity index, [2] Global Health Security Index, [3] epidemic preparedness index, and [4] World Governance Index) and COVID-19-confirmed cases/death/vaccination coverage at different time points. The linear regression is performed, and the spatial distribution of indicators are illustrated.

RESULTS

Countries with higher ranking in policy preparedness indexes can experience less severity of pandemic risk (e.g., confirmed cases and mortality) and faster recovery process (e.g., higher vaccination coverage). However, slight disparity in effectiveness exists across different indicators.

CONCLUSION

Results show that the policy preparedness indicators have predictive value of the confirmed cases, mortality, and vaccination coverage of COVID-19 pandemic, given sufficiently long-time span is observed.

Train-the-trainers intervention for national capacity building in infection prevention and control for COVID-19 in Nigeria

Background

The first case of COVID-19 in Nigeria was reported on February 27, 2020, and over time, spread across the country leading to many healthcare worker infections. The risk of transmission of COVID-19 within healthcare facilities makes it necessary to establish infection prevention and control measures. The World Health Organisation supported the Nigeria Centre for Disease Control to conduct a train-the-trainers workshop on infection prevention and control for key healthcare workers across Nigeria.

Aim/Objectives

This study aims to describe the process and results of train-the-trainers as an intervention for national capacity building in infection prevention and control for COVID-19 among healthcare workers in Nigeria.

Methods

Eight-hour sessions were held over three days with face-to-face instruction and practical hands-on experience in April 2020. A total of 61 healthcare workers participated across the six geographic zones of Nigeria: North Central, North East, North West, South West, South East, and South South. The training included slide presentations, case-based scenarios, and practical hands-on sessions with plenary discussions. Pre- and post-test assessments were used to evaluate knowledge of COVID-19, triage, and infection prevention and control among healthcare workers.

Finding/Results

69 % (42) of the participants were male 31 % (19) were female, and the majority (67 %) were medical doctors. Others attending were nurses or health administrators. Of the 70 % (26) of the states with existing infection prevention and control structures within the COVID emergency response, only 40 % were functional. The average percentage of pre-test and post-test scores were 60.8 ± 13.4 and 67.8 ± 9 0.3 respectively, showing a statistically significant difference (p > 0.001) in trainee knowledge. Additionally, 70 % of participants evaluated the training workshop as "satisfactory" or higher in training format, relevance for daily clinical work, active participation, learning new concepts, and logistics.

Conclusion

Nationwide infection prevention and control training is feasible during a national health crisis. Infection prevention and control is cardinal in the containment of epidemic-prone diseases like COVID-19 and is invaluable in the prevention of healthcare-associated infections in healthcare settings.

Enhanced EPIRISK tool for rapid epidemic risk analysis

OBJECTIVES

This study aims to create an enhanced EPIRISK tool in order to correctly predict COVID-19 severity in various countries. The original EPIRISK tool was developed in 2018 to predict the epidemic risk and prioritise response. The tool was validated against nine historical outbreaks prior to 2020. However, it rated many high-income countries that had poor performance during the COVID-19 pandemic as having lower epidemic risk.

STUDY DESIGN

This study was designed to modify EPIRISK by reparameterizing risk factors and validate the enhanced tool against different outbreaks, including COVID-19.

METHODS

We identified three factors that could be indicators of poor performance witnessed in some high-income countries: leadership, culture and universal health coverage. By adding these parameters to EPIRISK, we created a series of models for the calibration and validation. These were tested against non-COVID outbreaks in nine countries and COVID-19 outbreaks in seven countries to identify the best-fit model. The COVID-19 severity was determined by the global incidence and mortality, which were equally divided into four levels.

RESULTS

The enhanced EPIRISK tool has 17 parameters, including seven disease-related and 10 country-related factors, with an algorithm developed for risk level classification. It correctly predicted the risk levels of COVID-19 for all seven countries and all nine historical outbreaks.

CONCLUSIONS

The enhanced EPIRSIK is a multifactorial tool that can be widely used in global infectious disease outbreaks for rapid epidemic risk analysis, assisting first responders, government and public health professionals with early epidemic preparedness and prioritising response to infectious disease outbreaks.

Preparing for the next outbreak: A review of indices measuring outbreak preparedness, vulnerability, and resilience

The COVID-19 pandemic has highlighted the need for relevant metrics describing the resources and community attributes that affect the impact of communicable disease outbreaks. Such tools can help inform policy, assess change, and identify gaps to potentially reduce the negative outcomes of future outbreaks. The present review was designed to identify available indices to assess communicable disease outbreak preparedness, vulnerability, or resilience, including articles describing an index or scale developed to address disasters or emergencies which could be applied to addressing a future outbreak. This review assesses the landscape of indices available, with a particular focus on tools assessing local-level attributes. This systematic review yielded 59 unique indices applicable to assessing communicable disease outbreaks through the lens of preparedness, vulnerability, or resilience. However, despite the large number of tools identified, only 3 of these indices assessed factors at the local level and were generalizable to different types of outbreaks. Given the influence of local resources and community attributes on a wide range of communicable disease outcomes, there is a need for local-level tools that can be applied broadly to various types of outbreaks. Such tools should assess both current and long-term changes in outbreak preparedness with the intent to identify gaps, inform local-level decision makers, public policy, and future response to current and novel outbreaks.

Healthcare resilience: a meta-narrative systematic review and synthesis of reviews

OBJECTIVES

The COVID-19 pandemic has tested global healthcare resilience. Many countries previously considered 'resilient' have performed poorly. Available organisational and system frameworks tend to be context-dependent and focus heavily on physical capacities. This study aims to explore and synthesise evidence about healthcare resilience and present a unified framework for future resilience-building.

DESIGN

Systematic review and synthesis of reviews using a meta-narrative approach.

SETTING

Healthcare organisations and systems.

PRIMARY AND SECONDARY OUTCOME MEASURES

Definitions, concepts and measures of healthcare resilience. We used thematic analysis across included reviews to summarise evidence on healthcare resilience.

RESULTS

The main paradigms within healthcare resilience include global health, disaster risk reduction, emergency management, patient safety and public health. Definitions of healthcare resilience recognise various hierarchical levels: individual (micro), facility or organisation (meso), health system (macro) and planetary or international (meta). There has been a shift from a focus on mainly disasters and crises, to an 'all-hazards' approach to resilience. Attempts to measure resilience have met with limited success. We analysed key concepts to build a framework for healthcare resilience containing pre-event, intra-event, post-event and trans-event domains. Alongside, we synthesise a definition which dovetails with our framework.

CONCLUSION

Resilience increasingly takes an all-hazards approach and a process-oriented perspective. There is increasing recognition of the relational aspects of resilience. Few frameworks incorporate these, and they are difficult to capture within measurement systems. We need to understand how resilience works across hierarchical levels, and how competing priorities may affect overall resilience. Understanding these will underpin interdisciplinary, cross-sectoral and multi-level approaches to healthcare resilience for the future.

PROSPERO REGISTRATION NUMBER

CRD42022314729.

Constructing an emergency preparedness evaluation index system for public use during major emerging infectious disease outbreaks: a Delphi study

BACKGROUND

The major emerging infectious diseases (MEIDs) have occurred frequently and become increasingly serious in the world. Sufficient personal emergency preparedness is critical for the general people in efficiently responding to and recovering from MEIDs. Nevertheless, few specific indicators are available for assessing the individual emergency preparedness of the general public during these periods. Therefore, the aim of this study was to construct an index system for comprehensively evaluating the personal emergency preparedness of the public regarding MEIDs.

METHODS

Based on the global national-level emergency preparedness index framework and a literature review, a preliminary index system was constructed. From June 2022 to September 2022, a panel of 20 experts from nine provinces and municipalities across multiple research areas participated in this Delphi study. They rated the importance of pre-defined indicators using a five-point Likert scale and provided their qualitative comments. According to the feedback of each round of experts, the indicators of the evaluation index system were revised.

RESULTS

After two rounds of expert consultation the evaluation index system reached a consensus, containing five first-level indicators, cooperating with prevention and control work, improving emergency response capacity, securing supplies and equipment, preparing economic resources, maintaining physical and mental health with affiliated 20 s-level indicators and 53 third-level indicators. The expert authority coefficient of consultation was 0.88 and 0.90. The Kendall's coefficient of concordance of expert consultations was 0.294 and 0.322, respectively. The differences were statistically significant (P < 0.05).

CONCLUSION

A valid, reliable and scientific evaluation index system was established. This personal emergency preparedness index system, as a precursor form, will further lay the foundation for the formation of an assessment instrument. At the same time, it could provide a reference for future education and training of emergency preparedness for the general public.

Can COVID-19 response inform future health system reforms? Lessons learned from Finland

The COVID-19 pandemic has plagued health systems in an unprecedented way and challenged the traditional ways to respond to epidemics. It has also revealed several vulnerabilities in countries’ health systems and preparedness. In this paper we take the Finnish health system as an example to analyse how pre-COVID-19 preparedness plans, regulations, and health system governance were challenged by the pandemic and what lessons can be learned for the future. Our analysis draws on policy documents, grey literature, published research, and the COVID-19 Health System Response Monitor. The analysis shows how major public health crises often reveal weaknesses in health systems, also in countries which have been ranked highly in terms of crisis preparedness. In Finland, there were apparent regulative and structural problems which challenged the health system response, but in terms of epidemic control, the results appear to be relatively good. The pandemic may have long-term effects on the health system functioning and governance. In January 2023, an extensive health and social services reform has taken place in Finland. The new health system structure needs to be adjusted to take on board the legacy of the pandemic and a new regulatory frame for health security should be considered.

Artificial intelligence in public health: the potential of epidemic early warning systems

The use of artificial intelligence (AI) to generate automated early warnings in epidemic surveillance by harnessing vast open-source data with minimal human intervention has the potential to be both revolutionary and highly sustainable. AI can overcome the challenges faced by weak health systems by detecting epidemic signals much earlier than traditional surveillance. AI-based digital surveillance is an adjunct to-not a replacement of-traditional surveillance and can trigger early investigation, diagnostics and responses at the regional level. This narrative review focuses on the role of AI in epidemic surveillance and summarises several current epidemic intelligence systems including ProMED-mail, HealthMap, Epidemic Intelligence from Open Sources, BlueDot, Metabiota, the Global Biosurveillance Portal, Epitweetr and EPIWATCH. Not all of these systems are AI-based, and some are only accessible to paid users. Most systems have large volumes of unfiltered data; only a few can sort and filter data to provide users with curated intelligence. However, uptake of these systems by public health authorities, who have been slower to embrace AI than their clinical counterparts, is low. The widespread adoption of digital open-source surveillance and AI technology is needed for the prevention of serious epidemics.

How prepared is the world? Identifying weaknesses in existing assessment frameworks for global health security through a One Health approach

The COVID-19 pandemic has exposed faults in the way we assess preparedness and response capacities for public health emergencies. Existing frameworks are limited in scope, and do not sufficiently consider complex social, economic, political, regulatory, and ecological factors. One Health, through its focus on the links among humans, animals, and ecosystems, is a valuable approach through which existing assessment frameworks can be analysed and new ways forward proposed. Although in the past few years advances have been made in assessment tools such as the International Health Regulations Joint External Evaluation, a rapid and radical increase in ambition is required. To sufficiently account for the range of complex systems in which health emergencies occur, assessments should consider how problems are defined across stakeholders and the wider sociopolitical environments in which structures and institutions operate. Current frameworks do little to consider anthropogenic factors in disease emergence or address the full array of health security hazards across the social-ecological system. A complex and interdependent set of challenges threaten human, animal, and ecosystem health, and we cannot afford to overlook important contextual factors, or the determinants of these shared threats. Health security assessment frameworks should therefore ensure that the process undertaken to prioritise and build capacity adheres to core One Health principles and that interventions and outcomes are assessed in terms of added value, trade-offs, and cobenefits across human, animal, and environmental health systems.

SDG5 "Gender Equality" and the COVID-19 pandemic: A rapid assessment of health system responses in selected upper-middle and high-income countries

Introduction

The COVID-19 pandemic disrupted healthcare and societies, exacerbating existing inequalities for women and girls across every sphere. Our study explores health system responses to gender equality goals during the COVID-19 pandemic and inclusion in future policies.

Methods

We apply a qualitative comparative approach, drawing on secondary sources and expert information; the data was collected from March-July 2022. Australia, Brazil, Germany, the United Kingdom, and the USA were selected, reflecting upper-middle and high-income countries with established public health and gender policies but different types of healthcare systems and epidemiological and geo-political conditions. Three sub-goals of SDG5 were analyzed: maternity care/reproductive health, gender-based violence, and gender equality/women's leadership.

Results

We found similar trends across countries. Pandemic policies strongly cut into women's health, constrained prevention and support services, and weakened reproductive rights, while essential maternity care services were kept open. Intersecting gender inequalities were reinforced, sexual violence increased and women's leadership was weak. All healthcare systems failed to protect women's health and essential public health targets. Yet there were relevant differences in the responses to increased violence and reproductive rights, ranging from some support measures in Australia to an abortion ban in the US.

Conclusions

Our study highlights a need for revising pandemic policies through a feminist lens.

The World Health Organization's Disease Outbreak News: A retrospective database

The World Health Organization (WHO) notifies the global community about disease outbreaks through the Disease Outbreak News (DON). These online reports tell important stories about both outbreaks themselves and the high-level decision making that governs information sharing during public health emergencies. However, they have been used only minimally in global health scholarship to date. Here, we collate all 2,789 of these reports from their first use through the start of the Covid-19 pandemic (January 1996 to December 2019), and develop an annotated database of the subjective and often inconsistent information they contain. We find that these reports are dominated by a mix of persistent worldwide threats (particularly influenza and cholera) and persistent epidemics (like Ebola virus disease in Africa or MERS-CoV in the Middle East), but also document important periods in history like the anthrax bioterrorist attacks at the turn of the century, the spread of chikungunya and Zika virus to the Americas, or even recent lapses in progress towards polio elimination. We present three simple vignettes that show how researchers can use these data to answer both qualitative and quantitative questions about global outbreak dynamics and public health response. However, we also find that the retrospective value of these reports is visibly limited by inconsistent reporting (e.g., of disease names, case totals, mortality, and actions taken to curtail spread). We conclude that sharing a transparent rubric for which outbreaks are considered reportable, and adopting more standardized formats for sharing epidemiological metadata, might help make the DON more useful to researchers and policymakers.

COVI-Prim international: Similarities and discrepancies in the way general practices from seven different countries coped with the COVID-19 pandemic

Objectives

General practitioners (GPs) are frequently patients' first point of contact with the healthcare system and play an important role in identifying, managing and monitoring cases. This study investigated the experiences of GPs from seven different countries in the early phases of the COVID-19 pandemic.

Design

International cross-sectional online survey.

Setting

General practitioners from Australia, Austria, Germany, Hungary, Italy, Slovenia and Switzerland.

Participants

Overall, 1,642 GPs completed the survey.

Main outcome measures

We focused on how well-prepared GPs were, their self-confidence and concerns, efforts to control the spread of the disease, patient contacts, information flow, testing procedures and protection of staff.

Results

GPs gave high ratings to their self-confidence (7.3, 95% CI 7.1-7.5) and their efforts to control the spread of the disease (7.2, 95% CI 7.0-7.3). A decrease in the number of patient contacts (5.7, 95% CI 5.4-5.9), the perception of risk (5.3 95% CI 4.9-5.6), the provision of information to GPs (4.9, 95% CI 4.6-5.2), their testing of suspected cases (3.7, 95% CI 3.4-3.9) and their preparedness to face a pandemic (mean: 3.5; 95% CI 3.2-3.7) were rated as moderate. GPs gave low ratings to their ability to protect staff (2.2 95% CI 1.9-2.4). Differences were identified in all dimensions except protection of staff, which was consistently low in all surveyed GPs and countries.

Conclusion

Although GPs in the different countries were confronted with the same pandemic, its impact on specific aspects differed. This partly reflected differences in health care systems and experience of recent pandemics. However, it also showed that the development of structured care plans in case of future infectious diseases requires the early involvement of primary care representatives.

A framework for measuring timeliness in the outbreak response path: lessons learned from the Middle East respiratory syndrome (MERS) epidemic, September 2012 to January 2019

BackgroundEpidemics are a constant threat in the 21st century, particularly disease outbreaks following spillover of an animal virus to humans. Timeliness, a key metric in epidemic response, can be examined to identify critical steps and delays in public health action.AimTo examine timeliness, we analysed the response to the Middle East respiratory syndrome (MERS) epidemic, with a focus on the international and One Health response efforts.MethodsWe performed a historical review of the MERS epidemic between September 2012 and January 2019 in three steps: (i) the construction of a timeline identifying critical events in the global response, (ii) the performance of a critical path analysis to define outbreak milestones and (iii) a time gap analysis to measure timeliness in the execution of these milestones.ResultsWe proposed 14 MERS-specific milestones at different phases of the epidemic, assessing timeliness of the public health response as well as at the animal-human interface, where we identified the most significant delays.ConclusionsWhen comparing timeliness across three coronavirus epidemics, i.e. MERS (2012), SARS (2002) and COVID-19 (2019), we identified clear improvements over time for certain milestones including laboratory confirmation and diagnostics development, while this was not as apparent for others, as the identification of zoonotic hosts. To more efficiently respond to emerging threats, the global health community should widely assess and tackle specific delays in implementing response interventions by addressing challenges in the sharing of information, data and resources, as well as efficiency, quality, transparency and reliability of reporting events.

Exploring the relationship between national governance indicators and speed of initial government response to COVID-19 in low- and middle-income countries

Objectives

This study aimed to explore the relationship between national governance and country response to the COVID-19 pandemic in low- and middle-income countries, to support preparedness for the next pandemic. We conducted a statistical analysis of 116 countries, examining the relationship between speed of initial response and measures of national governance.

Study design

Observational study, with individual countries as the unit of analysis.

Methods

We used logistic regression to look for associations between quicker initial government response and four national governance indicators: Government Effectiveness, Political Stability and Absence of Violence/Terrorism, Voice and Accountability, and Corruption Perceptions Index.

Results

A quicker initial government response was associated with countries with higher Government Effectiveness (OR 13.92 95% CI 3.69-52.48, p < 0.001) and lower Political Stability and Absence of Violence/Terrorism (OR 0.23, 95% CI 0.09-0.57, p = 0.002). There was no relationship observed between speed of initial government response and Voice and Accountability or Corruption Perceptions Index. Other factors associated with quicker initial response were small population size, experiencing first COVID-19 case after the pandemic declaration, not having previous experience with SARS-CoV1 or MERS and not being an island nation.

Conclusions

This study shows that having higher state policy and implementation capacity, and lower political stability was associated with a quicker initial pandemic response. Limitations of this study include the use of crude national level indicators and broad categorisations of countries into quicker and slower responders. Deeper enquiry into the early decision-making processes taken at the national executive level within individual countries may help clarify the observed associations further.

Identifying the preparedness components in COVID-19: Systematic literature review

In 2019, the COVID-19 pandemic posed a major challenge to the world. Since the world is constantly exposed to communicable diseases, comprehensive preparedness of countries is required. Therefore, the present systematic review is aimed at identifying the preparedness components in COVID-19. In this systematic literature review, PubMed, Scopus, Web of Science, ProQuest, Science Direct, Iran Medex, Magiran, and Scientific Information Database were searched from 2019 to 2021 to identify preparedness components in COVID-19. Thematic content analysis method was employed for data analysis. Out of 11,126 journals retrieved from searches, 45 studies were included for data analysis. Based on the findings, the components of COVID-19 preparedness were identified and discussed in three categories: governance with three subcategories of characteristics, responsibilities, and rules and regulations; society with two subcategories of culture and resilience; and services with three subcategories of managed services, advanced technology, and prepared health services. Among these, the governance and its subcategories had the highest frequency in studies. Considering the need to prepare for the next pandemic, countries should create clear and coherent structures and responsibilities for crisis preparedness through legal mechanisms, strengthening the infrastructure of the health system, coordination between organizations through analysis and identification of stakeholders, culture building and attracting social participation, and service management for an effective response.

Interventions for Maintenance of Essential Health Service Delivery during the COVID-19 Response in Uganda, between March 2020 and April 2021

INTRODUCTION

The COVID-19 pandemic overwhelmed health systems globally and affected the delivery of health services. We conducted a study in Uganda to describe the interventions adopted to maintain the delivery of other health services.

METHODS

We reviewed documents and interviewed 21 key informants. Thematic analysis was conducted to identify themes using the World Health Organization health system building blocks as a guiding framework.

RESULTS

Governance strategies included the establishment of coordination committees and the development and dissemination of guidelines. Infrastructure and commodity strategies included the review of drug supply plans and allowing emergency orders. Workforce strategies included the provision of infection prevention and control equipment, recruitment and provision of incentives. Service delivery modifications included the designation of facilities for COVID-19 management, patient self-management, dispensing drugs for longer periods and the leveraging community patient networks to distribute medicines. However, multi-month drug dispensing led to drug stock-outs while community drug distribution was associated with stigma.

CONCLUSIONS

Health service maintenance during emergencies requires coordination to harness existing health system investments. The essential services continuity committee coordinated efforts to maintain services and should remain a critical element of emergency response. Self-management and leveraging patient networks should address stigma to support service continuity in similar settings and strengthen service delivery beyond the pandemic.

Global mapping of epidemic risk assessment toolkits: A scoping review for COVID-19 and future epidemics preparedness implications

Preparedness and responses to infectious disease epidemics and pandemics require the understanding of communities' and multisectoral systems' characteristics with regards to diseases transmission and population's vulnerabilities. This study aimed to summarize measurement profiles of existing risk assessment toolkits to inform COVID-19 control at global and national levels. An online search in different databases and online sources was performed to identify all epidemic risk and vulnerability assessment instruments. Medline/PubMed, Web of Science databases, and websites of public health organizations were used for the searching process. Of 14 toolkits, levels of setting were mostly at the global or nation level. Components such as Governance and Legislation, Financing, Health Service Provision, and Human Resources are key domains in almost all toolkits. Some important issues for disease detection and surveillance, such as laboratory or capacity of the community for disease control, were not adequately addressed in several toolkits. Limited studies were found that validated the toolkits. Only five toolkits were used in COVID-19 studies. This study provides a summary of risk assessment toolkits to inform epidemic responses. We call for global and national efforts in developing more contextualized and responsive epidemic risk assessment scales incorporating specific-disease and -country factors to inform operational decisions making and strengthen countries' capacities in epidemic responses.

Investigating the Effectiveness of Government Public Health Systems against COVID-19 by Hybrid MCDM Approaches

To elucidate the effectiveness of the containment strategies against the pandemic, a Multi-Criteria Decision Making (MCDM) model is established to evaluate the government’s performance against COVID-19. In this study, the Analytic Hierarchy Process (AHP), Entropy, and Technique for Order of Preference by Similarity to Ideal Solution (TOPSIS) method are used in determining the performance of the public health system. We adopt both subjective and objective weighting methods for a more accurate evaluation. In addition, the evaluation of performance against COVID-19 is conducted in various aspects and divided into different periods. Data Envelopment Analysis (DEA) is applied to evaluate the sustainability of the public health system. Composite scores of the public health system are determined based on the performance and sustainability assessment. The five countries, South Korea, Japan, Germany, Australia, and China are rated with higher composite scores. On the country, the US, Indonesia, Egypt, South Africa, and Brazil receive lower rating scores among the countries for evaluation. This modeling study can provide a practical quantitative justification for developing containment policies and suggestions for improving the public health system in more countries or areas.

Pandemic Preparedness and Response: A Foldable Tent to Safely Remove Contaminated Dental Aerosols—Clinical Study and Patient Experience

The D-DART (Droplet and Aerosol Reducing Tent) is a foldable design that can be attached to the dental chair to prevent the spread of contaminated dental aerosols. The objective of this study was to evaluate the ability of the D-DART to reduce spread of aerosols generated during dental treatment. Thirty-two patients (sixteen per group) undergoing deep ultrasonic scaling were recruited and randomly allocated to groups D-DART or Control (no D-DART). After 20 min from the start of the treatment, the clinician’s face shield and dental chair light were swabbed and the viable microbial load was quantified (ATP bioluminescence analysis, blinded operator). Statistical analyses were performed with Tukey’s Honest Test with a level of significance pre-set at 5%. There were significant increases in ATP values obtained from the operator’s face shield and dental chair light for the Control compared with baseline (31.3 ± 8.5 and fold increase). There was no significant change in microbial load when the D-DART was used compared with baseline (1.5 ± 0.4 fold increase). The D-DART contained and prevented the spread of aerosols generated during deep scaling procedures.

Are preparedness indices reflective of pandemic preparedness? A COVID-19 reality check

The paper contributes to the body of knowledge working towards enhancing the understanding of crisis and disaster preparedness and effective response, via the lens of the ongoing global pandemic and responding to the questions: do the current measures for pandemic preparedness reflect preparedness adequately, and what does pandemic preparedness mean? We analysed how the reported cumulative mortality rates, during the spring of 2020 and in the 60 days after the date of a country's first COVID-19 related death, compared to the expected preparedness rank according to the existing global preparedness indices (IHR and GHSI) on a country level. We found, at country level, that the health-related outcomes from the first wave of the pandemic were primarily negatively correlated with the expected preparedness. We contend that our results indicate a need to investigate further development and enhancement of the preparedness indices.

Socioecological vulnerability and the risk of zoonotic disease emergence in Brazil

In developing countries, outbreaks of zoonotic diseases (ZDs) result from intertwined ecological, socioeconomic, and demographic processes that shape conditions for (i) increased contact between vulnerable human population and wildlife in areas undergoing environmental degradation and (ii) the rapid geographic spread of infections across socially vulnerable regions. In Brazil, recent increases in environmental and social vulnerabilities, amplified by economic and political crises, are potential triggers for outbreaks. We discuss Brazilian features that favor outbreaks and show a novel quantitative method for zoonotic risk assessment. Using data on nine ZDs from 2001 to 2019, we found that the most significant causal variables were vegetation cover and city remoteness. Furthermore, 8 of 27 states presented low-level risk of ZD outbreaks. Given the ZD-bushmeat connection, we identified central hunted mammals that should be surveilled to prevent spillover events. The current challenge is to coordinate intersectoral collaboration for effective One Health management in megadiverse countries with high social vulnerability and growing environmental degradation like Brazil.

Infectious Disease Underreporting Is Predicted by Country-Level Preparedness, Politics, and Pathogen Severity

Underreporting of infectious diseases is a pervasive challenge in public health that has emerged as a central issue in characterizing the dynamics of the COVID-19 pandemic. Infectious diseases are underreported for a range of reasons, including mild or asymptomatic infections, weak public health infrastructure, and government censorship. In this study, we investigated factors associated with cross-country and cross-pathogen variation in reporting. We performed a literature search to collect estimates of empirical reporting rates, calculated as the number of cases reported divided by the estimated number of true cases. This literature search yielded a dataset of reporting rates for 32 pathogens, representing 52 countries. We combined epidemiological and social science theory to identify factors specific to pathogens, country health systems, and politics that could influence empirical reporting rates. We performed generalized linear regression to test the relationship between the pathogen- and country-specific factors that we hypothesized could influence reporting rates, and the reporting rate estimates that we collected in our literature search. Pathogen- and country-specific factors were predictive of reporting rates. Deadlier pathogens and sexually transmitted diseases were more likely to be reported. Country epidemic preparedness was positively associated with reporting completeness, while countries with high levels of media bias in favor of incumbent governments were less likely to report infectious disease cases. Underreporting is a complex phenomenon that is driven by factors specific to pathogens, country health systems, and politics. In this study, we identified specific and measurable components of these broader factors that influence pathogen- and country-specific reporting rates and used model selection techniques to build a model that can guide efforts to diagnose, characterize, and reduce underreporting. Furthermore, this model can characterize uncertainty and correct for bias in reported infectious disease statistics, particularly when outbreak-specific empirical estimates of underreporting are unavailable. More precise estimates can inform control policies and improve the accuracy of infectious disease models.

Quality of National Disease Surveillance Reporting before and during COVID-19: A Mixed-Method Study in Indonesia

Background: Global COVID-19 outbreaks in early 2020 have burdened health workers, among them surveillance workers who have the responsibility to undertake routine disease surveillance activities. The aim of this study was to describe the quality of the implementation of Indonesia’s Early Warning and Response Alert System (EWARS) for disease surveillance and to measure the burden of disease surveillance reporting quality before and during the COVID-19 epidemic in Indonesia. Methods: A mixed-method approach was used. A total of 38 informants from regional health offices participated in Focus Group Discussion (FGD) and In-Depth Interview (IDI) for informants from Ministry of Health. The FGD and IDI were conducted using online video communication. Yearly completeness and timeliness of reporting of 34 provinces were collected from the application. Qualitative data were analyzed thematically, and quantitative data were analyzed descriptively. Results: Major implementation gaps were found in poorly distributed human resources and regional infrastructure inequity. National reporting from 2017–2019 showed an increasing trend of completeness (55%, 64%, and 75%, respectively) and timeliness (55%, 64%, and 75%, respectively). However, the quality of the reporting dropped to 53% and 34% in 2020 concomitant with the SARS-CoV2 epidemic. Conclusions: Report completeness and timeliness are likely related to regional infrastructure inequity and the COVID-19 epidemic. It is recommended to increase report capacities with an automatic EWARS application linked systems in hospitals and laboratories.

Constructing and validating a transferable epidemic risk index in data scarce environments using open data: A case study for dengue in the Philippines

Epidemics are among the most costly and destructive natural hazards globally. To reduce the impacts of infectious disease outbreaks, the development of a risk index for infectious diseases can be effective, by shifting infectious disease control from emergency response to early detection and prevention.

In this study, we introduce a methodology to construct and validate an epidemic risk index using only open data, with a specific focus on scalability. The external validation of our risk index makes use of distance sampling to correct for underreporting of infections, which is often a major source of biases, based on geographical accessibility to health facilities. We apply this methodology to assess the risk of dengue in the Philippines.

The results show that the computed dengue risk correlates well with standard epidemiological metrics, i.e. dengue incidence (p = 0.002). Here, dengue risk constitutes of the two dimensions susceptibility and exposure. Susceptibility was particularly associated with dengue incidence (p = 0.048) and dengue case fatality rate (CFR) (p = 0.029). Exposure had lower correlations to dengue incidence (p = 0.193) and CFR (p = 0.162). Highest risk indices were seen in the south of the country, mainly among regions with relatively high susceptibility to dengue outbreaks.

Our findings reflect that the modelled epidemic risk index is a strong indication of sub-national dengue disease patterns and has therefore proven suitability for disease risk assessments in the absence of timely epidemiological data. The presented methodology enables the construction of a practical, evidence-based tool to support public health and humanitarian decision-making processes with simple, understandable metrics. The index overcomes the main limitations of existing indices in terms of construction and actionability.

Epidemics are among the most costly and destructive natural hazards occurring globally; currently, the response to epidemics is still focused on reaction rather than prevention or preparedness. The development of an epidemic risk index can support identifying high-risk areas and can guide prioritization of preventive action and humanitarian response. While several frameworks for epidemic risk assessment exist, they suffer from several limitations, which resulted in limited uptake by local health actors—such as governments and humanitarian relief workers—in their decision-making processes. In this study, we present a methodology to develop epidemic risk indices, which overcomes the major limitations of previous work: strict data requirements, insufficient geographical granularity, validation against epidemiological data. We take as a case study dengue in the Philippines and develop an epidemic risk index; we correct dengue incidence for underreporting based on accessibility to healthcare and show that it correlates well with the risk index (Pearson correlation coefficient 0.69, p-value 0.002). Our methodology enables the development of disease-specific epidemic risk indices at a sub-national level, even in countries with limited data availability; these indices can guide local actors in programming prevention and response activities. Our findings on the case study show that the epidemic risk index is a strong indicator of sub-national dengue disease patterns and is therefore suitable for disease risk assessments in the absence of timely and complete epidemiological data.