Multi-criteria decision analysis tools for prioritising emerging or re-emerging infectious diseases associated with climate change in Canada

Human factors methods in the design of digital decision support systems for population health: a scoping review

BACKGROUND

While Human Factors (HF) methods have been applied to the design of decision support systems (DSS) to aid clinical decision-making, the role of HF to improve decision-support for population health outcomes is less understood. We sought to comprehensively understand how HF methods have been used in designing digital population health DSS.

MATERIALS AND METHODS

We searched English documents published in health sciences and engineering databases (Medline, Embase, PsychINFO, Scopus, Comendex, Inspec, IEEE Xplore) between January 1990 and September 2023 describing the development, validation or application of HF principles to decision support tools in population health.

RESULTS

We identified 21,581 unique records and included 153 studies for data extraction and synthesis. We included research articles that had a target end-user in population health and that used HF. HF methods were applied throughout the design lifecycle. Users were engaged early in the design lifecycle in the needs assessment and requirements gathering phase and design and prototyping phase with qualitative methods such as interviews. In later stages in the lifecycle, during user testing and evaluation, and post deployment evaluation, quantitative methods were more frequently used. However, only three studies used an experimental framework or conducted A/B testing.

CONCLUSIONS

While HF have been applied in a variety of contexts in the design of data-driven DSSs for population health, few have used Human Factors to its full potential. We offer recommendations for how HF can be leveraged throughout the design lifecycle. Most crucially, system designers should engage with users early on and throughout the design process. Our findings can support stakeholders to further empower public health systems.

A Generalizable Prioritization Protocol for Climate-Sensitive Zoonotic Diseases

Emerging and re-emerging zoonotic diseases pose a significant threat to global health and economic security. This threat is further aggravated by amplifying drivers of change, including climate hazards and landscape alterations induced by climate change. Given the complex relationships between climate change and zoonotic disease health outcomes, a structured decision-making process is required to effectively identify pathogens of greatest concern to prioritize prevention and surveillance efforts. Here, we describe a workshop-based expert elicitation process in six steps to prioritize climate-sensitive zoonoses based on a structured approach to defining criteria for climate sensitivity. Fuzzy analytical hierarchy process methodology is used to analyze data provided by experts across human, animal, and environmental health sectors accounting for uncertainties at different stages of the prioritization process. We also present a new interactive expert elicitation interface that facilitates data collection and real-time visualization of prioritization results. The novel approach presented in this paper offers a generalized platform for prioritizing climate-sensitive zoonoses at a national or regional level. This allows for a structured decision-making support process when allocating limited financial and personnel resources to enhance preparedness and response to zoonotic diseases amplified by climate change.

Mapping Vulnerability to Potential Crisis Events in Surabaya City: A GIS-Based Approach

Background

This study aims to develop a vulnerability map for Surabaya using GIS-based Multi-Criteria Decision Analysis (MCDA) to assess the city's vulnerability to COVID-19.

Methods

Six key factors influencing vulnerability were identified and their relative importance determined through the Analytic Hierarchy Process (AHP) pairwise comparison matrix. GIS was utilized to classify Surabaya's vulnerability into five levels: very low, low, medium, high, and very high.

Results

The resulting vulnerability map provides essential insights for decision-makers, healthcare professionals, and disaster management teams. It enables strategic resource allocation, targeted interventions, and formulation of comprehensive response strategies tailored to specific needs of vulnerable districts.

Conclusions

Through these measures, Surabaya can enhance its resilience and preparedness, ensuring the well-being of its residents in the face of potential emergency outbreaks.

Development of a decision support tool to compare diagnostic strategies for establishing the herd status for infectious diseases: An example with Salmonella Dublin infection in dairies

The diagnosis of infectious diseases at herd level can be challenging as different stakeholders can have conflicting priorities. The current study proposes a "proof of concept" of an approach that considers a reasonable number of criteria to rank plausible diagnostic strategies using multi-criteria decision analysis (MCDA) methods. The example of Salmonella Dublin diagnostic in Québec dairy herds is presented according to two epidemiological contexts: (i) in herds with no history of S. Dublin infection and absence of clinical signs, (ii) in herds with a previous history of infection, but absence of clinical signs at the moment of testing. Multiple multiparty exchanges were conducted to determine: 1) stakeholders' groups; 2) the decision problem; 3) solutions to the problem (options) or diagnostic strategies to be ordered; 4) criteria and indicators; 5) criteria weights; 6) the construction of a performance matrix for each option; 7) the multi-criteria analyses using the visual preference ranking organization method for enrichment of evaluations approach; 8) the sensitivity analyses, and 9) the final decision. A total of nine people from four Québec's organizations (the dairy producers provincial association along with the DHI company, the ministry of agriculture, the association of veterinary practitioners, and experts in epidemiology) composed the MCDA team. The decision problem was "What is the optimal diagnostic strategy for establishing the status of a dairy herd for S. Dublin infection when there are no clinical signs of infection?". Fourteen diagnostic strategies composed of the three following parameters were considered: 1) biological samples (bulk tank milk or blood from 10 heifers aged over three months); 2) sampling frequencies (one to three samples collection visits); 3) case definitions to conclude to a positive status using imperfect milk- or blood-ELISA tests. The top-ranking diagnostic strategy was the same in the two contexts: testing the bulk tank milk and the blood samples, all samples collected during one visit and the herd being assigned a S. Dublin positive status if one sample is ELISA-positive. The final decision favored the top-ranking option for both contexts. This MCDA approach and its application to S. Dublin infection in dairy herds allowed a consensual, rational, and transparent ranking of feasible diagnostic strategies while taking into account the diagnostic tests accuracy, socio-economic, logistic, and perception considerations of the key actors in the dairy industry. This promising tool can be applied to other infectious diseases that lack a well-established diagnostic procedure to define a herd status.

Parallel multi-criteria decision analysis for sub-national prioritization of zoonoses and animal diseases in Africa: The case of Cameroon

The use of multi-criteria decision analysis (MCDA) for disease prioritization at the sub-national level in sub-Sahara Africa (SSA) is rare. In this research, we contextualized MCDA for parallel prioritization of endemic zoonoses and animal diseases in The Adamawa and North regions of Cameroon. MCDA was associated to categorical principal component analysis (CATPCA), and two-step cluster analysis. Six and seven domains made of 17 and 19 criteria (out of 70) respectively were selected by CATPCA for the prioritization of zoonoses and animal diseases, respectively. The most influencing domains were "public health" for zoonoses and "control and prevention" for animal diseases. Twenty-seven zoonoses and 40 animal diseases were ranked and grouped in three clusters. Sensitivity analysis resulted in high correlation between complete models and reduced models showing the robustness of the simplification processes. The tool used in this study can be applied to prioritize endemic zoonoses and transboundary animal diseases in SSA at the sub-national level and upscaled at the national and regional levels. The relevance of MCDA is high because of its contextualization process and participatory nature enabling better operationalization of disease prioritization outcomes in the context of African countries or other low and middle-income countries.

Impact of climate change on the global circulation of West Nile virus and adaptation responses: a scoping review

BACKGROUND

West Nile virus (WNV), the most widely distributed flavivirus causing encephalitis globally, is a vector-borne pathogen of global importance. The changing climate is poised to reshape the landscape of various infectious diseases, particularly vector-borne ones like WNV. Understanding the anticipated geographical and range shifts in disease transmission due to climate change, alongside effective adaptation strategies, is critical for mitigating future public health impacts. This scoping review aims to consolidate evidence on the impact of climate change on WNV and to identify a spectrum of applicable adaptation strategies.

MAIN BODY

We systematically analyzed research articles from PubMed, Web of Science, Scopus, and EBSCOhost. Our criteria included English-language research articles published between 2007 and 2023, focusing on the impacts of climate change on WNV and related adaptation strategies. We extracted data concerning study objectives, populations, geographical focus, and specific findings. Literature was categorized into two primary themes: 1) climate-WNV associations, and 2) climate change impacts on WNV transmission, providing a clear understanding. Out of 2168 articles reviewed, 120 met our criteria. Most evidence originated from North America (59.2%) and Europe (28.3%), with a primary focus on human cases (31.7%). Studies on climate-WNV correlations (n = 83) highlighted temperature (67.5%) as a pivotal climate factor. In the analysis of climate change impacts on WNV (n = 37), most evidence suggested that climate change may affect the transmission and distribution of WNV, with the extent of the impact depending on local and regional conditions. Although few studies directly addressed the implementation of adaptation strategies for climate-induced disease transmission, the proposed strategies (n = 49) fell into six categories: 1) surveillance and monitoring (38.8%), 2) predictive modeling (18.4%), 3) cross-disciplinary collaboration (16.3%), 4) environmental management (12.2%), 5) public education (8.2%), and 6) health system readiness (6.1%). Additionally, we developed an accessible online platform to summarize the evidence on climate change impacts on WNV transmission ( https://2xzl2o-neaop.shinyapps.io/WNVScopingReview/ ).

CONCLUSIONS

This review reveals that climate change may affect the transmission and distribution of WNV, but the literature reflects only a small share of the global WNV dynamics. There is an urgent need for adaptive responses to anticipate and respond to the climate-driven spread of WNV. Nevertheless, studies focusing on these adaptation responses are sparse compared to those examining the impacts of climate change. Further research on the impacts of climate change and adaptation strategies for vector-borne diseases, along with more comprehensive evidence synthesis, is needed to inform effective policy responses tailored to local contexts.

The study on setting priorities of zoonotic agents for medical preparedness and allocation of research resources

The aim of this study is to develop a scoring platform to be used as a reference for both medical preparedness and research resource allocation in the prioritization of zoonoses. Using a case-control design, a comprehensive analysis of 46 zoonoses was conducted to identify factors influencing disease prioritization. This analysis provides a basis for constructing models and calculating prioritization scores for different diseases. The case group (n = 23) includes diseases that require immediate notification to health authorities within 24 hours of diagnosis. The control group (n = 23) includes diseases that do not require such immediate notification. Two different models were developed for primary disease prioritization: one model incorporated the four most commonly used prioritization criteria identified through an extensive literature review. The second model used the results of multiple logistic regression analysis to identify significant factors (with p-value less than 0.1) associated with 24-hour reporting, allowing for objective determination of disease prioritization criteria. These different modeling approaches may result in different weights and positive or negative effects of relevant factors within each model. Our study results highlight the variability of zoonotic disease information across time and geographic regions. It provides an objective platform to rank zoonoses and highlights the critical need for regular updates in the prioritization process to ensure timely preparedness. This study successfully established an objective framework for assessing the importance of zoonotic diseases. From a government perspective, it advocates applying principles that consider disease characteristics and medical resource preparedness in prioritization. The results of this study also emphasize the need for dynamic prioritization to effectively improve preparedness to prevent and control disease.

Multi-criteria decision analysis method for differential diagnosis of tropical febrile diseases

This paper employs the Analytical Hierarchy Process (AHP) to enhance the accuracy of differential diagnosis for febrile diseases, particularly prevalent in tropical regions where misdiagnosis may have severe consequences. The migration of health workers from developing countries has resulted in frontline health workers (FHWs) using inadequate protocols for the diagnosis of complex health conditions. The study introduces an innovative AHP-based Medical Decision Support System (MDSS) incorporating disease risk factors derived from physicians' experiential knowledge to address this challenge. The system's aggregate diagnostic factor index determines the likelihood of febrile illnesses. Compared to existing literature, AHP models with risk factors demonstrate superior prediction accuracy, closely aligning with physicians' suspected diagnoses. The model's accuracy ranges from 85.4% to 96.9% for various diseases, surpassing physicians' predictions for Lassa, Dengue, and Yellow Fevers. The MDSS is recommended for use by FHWs in communities lacking medical experts, facilitating timely and precise diagnoses, efficient application of diagnostic test kits, and reducing overhead expenses for administrators.

Multi-criteria decision analysis for supporting the selection of subclinical mastitis screening tests to use in large- and small-scale dairy farms in Türkiye

The production of high-quality and safe milk is closely associated with the udder health of dairy cows. While there are many mastitis diagnostic tests/methods available, choosing the most appropriate diagnostic test for a sustainable udder health control program could be a challenge. This study was aimed at selecting tests for the screening of subclinical mastitis on small- and large-scale dairy farms in Türkiye, using multi-criteria decision-making methods. An integrated approach employing the analytical hierarchy process (AHP) and technique for order preference by similarity to ideal solution (TOPSIS) together was used to select subclinical mastitis screening tests for on-farm use. While the AHP determines the weights of the evaluation criteria, the TOPSIS provides a final ranking. Nine different subclinical mastitis screening (SCM) methods (DeLaval somatic cell counter, PortaSCC test, California mastitis test (CMT), rapid culture, portable/hand-held electrical conductivity meter, infrared thermography, leukocyte esterase strip test, milk pH, UdderCheck test) were analyzed on the basis of five selection criteria (the market availability of the test, the diagnostic accuracy of the test, the cost of the test, the cow-side use of the test, and the practicality of the test). The selection criteria were determined based on literature review and stakeholder input. The weighting of the criteria with the AHP was based on the pairwise comparison of the criteria by stakeholders. The criteria were weighted from 1 to 9 according to their relative importance as follows: "1: equally important," "3: moderately important," "5: strongly important," "7: very strongly important," "9: extremely important," and "2, 4, 6, 8: intermediate values." Final ranking of SCM tests with the TOPSIS was based on the stakeholder evaluations of fulfillment of the criteria by the alternatives. The most appropriate screening test for both large- and small-scale dairy farms was determined to be the CMT. The CMT is a very useful, easy to perform, and low-cost tool for detecting subclinical mastitis. Being a major element of udder health control programs, the CMT, if regularly used on dairy farms in Türkiye, would enable the culling of chronically infected animals and the reduction of mastitis-associated economic losses. Furthermore, regular CMTs would contribute to reducing milk SCC and improving milk quality. In conclusion, multi-criteria decision-making methods not only provide a systematic approach that may assist both veterinarians and farmers in deciding on the best choice among the different tests available for the screening of subclinical mastitis but also offer potential benefits to policymakers, researchers, and other industry stakeholders.

A rapid review of best practices in the development of risk registers for public health emergency management

Introduction

Public health organizations (PHO) must prepare to respond to a range of emergencies. This represents an ongoing challenge in an increasingly connected world, where the scope, complexity, and diversity of public health threats (PHT) have expanded, as exemplified by the COVID-19 pandemic. Risk registers (RR) offer a framework for identifying and managing threats, which can be employed by PHOs to better identify and characterize health threats. The aim of this review is to establish best practices (BP) for the development of RRs within Public Health Emergency Management (PHEM).

Methods

In partnership with a librarian from Health Canada (HC), and guided by the Cochrane Rapid Review Guideline, journal articles were retrieved through MEDLINE, and a comprehensive search strategy was applied to obtain grey literature through various databases. Articles were limited to those that met the following criteria: published on or after January 1, 2010, published in the English language and published within an Organisation for Economic Co-operation and Development setting.

Results

57 articles were included for synthesis. 41 papers specifically discussed the design of RRs. The review identified several guidelines to establish RRs in PHEM, including forward-looking, multidisciplinary, transparent, fit-for-purpose, and utilizing a systems approach to analyze and prioritize threats. Expert consultations, literature reviews, and prioritization methods such as multi-criteria-decision-analysis (MCDA) are often used to support the development of RRs. A minimum five-year-outlook is applied to assess PHTs, which are revisited yearly, and iteratively revised as new knowledge arises.

Discussion

Based upon this review, RRs offer a systems approach to PHEM that can be expanded to facilitate the analysis of disparate threats. These approaches should factor in the multidimensionality of threats, need for multi-sectoral inputs, and use of vulnerability analyses that consider inherent drivers. Further research is needed to understand how drivers modify threats. The BPs and recommendations highlighted in our research can be adopted in the practice of PHEM to characterize the public health (PH) risk environment at a given point in time and support PHOs policy and decision-making.

First Expert Elicitation of Knowledge on Possible Drivers of Observed Increasing Human Cases of Tick-Borne Encephalitis in Europe

Tick-borne encephalitis (TBE) is a viral disease endemic in Eurasia. The virus is mainly transmitted to humans via ticks and occasionally via the consumption of unpasteurized milk products. The European Centre for Disease Prevention and Control reported an increase in TBE incidence over the past years in Europe as well as the emergence of the disease in new areas. To better understand this phenomenon, we investigated the drivers of TBE emergence and increase in incidence in humans through an expert knowledge elicitation. We listed 59 possible drivers grouped in eight domains and elicited forty European experts to: (i) allocate a score per driver, (ii) weight this score within each domain, and (iii) weight the different domains and attribute an uncertainty level per domain. An overall weighted score per driver was calculated, and drivers with comparable scores were grouped into three terminal nodes using a regression tree analysis. The drivers with the highest scores were: (i) changes in human behavior/activities; (ii) changes in eating habits or consumer demand; (iii) changes in the landscape; (iv) influence of humidity on the survival and transmission of the pathogen; (v) difficulty to control reservoir(s) and/or vector(s); (vi) influence of temperature on virus survival and transmission; (vii) number of wildlife compartments/groups acting as reservoirs or amplifying hosts; (viii) increase of autochthonous wild mammals; and (ix) number of tick species vectors and their distribution. Our results support researchers in prioritizing studies targeting the most relevant drivers of emergence and increasing TBE incidence.

Prioritisation of zoonotic diseases for coordinated surveillance systems under the One Health approach for cross-border pathogens that threaten the Union

In the context of the initiative 'CP-g-22-04.01 Direct grants to Member States' authorities', EFSA was requested to develop and conduct a prioritisation of zoonotic diseases, in collaboration with Member States, to identify priorities for the establishment of a coordinated surveillance system under the One Health approach. The methodology developed by EFSA's Working Group on One Health surveillance was based on a combination of multi-criteria decision analysis and the Delphi method. It comprised the establishment of a list of zoonotic diseases, definition of pathogen- and surveillance-related criteria, weighing of those criteria, scoring of zoonotic diseases by Member States, calculation of summary scores, and ranking of the list of zoonotic diseases according to those scores. Results were presented at EU and country level. A prioritisation workshop was organised with the One Health subgroup of EFSA's Scientific Network for Risk Assessment in Animal Health and Welfare in November 2022 to discuss and agree on a final list of priorities for which specific surveillance strategies would be developed. Those 10 priorities were Crimean-Congo haemorrhagic fever, echinococcosis (both E. granulosus and E. multilocularis), hepatitis E, influenza (avian), influenza (swine), Lyme borreliosis, Q-fever, Rift Valley fever, tick-borne encephalitis and West Nile fever. 'Disease X' was not assessed in the same way as other zoonotic diseases on the list, but it was added to the final list of priorities due to its relevance and importance in the One Health context.

The right strategy for you: Using the preferences of beef farmers to guide biosecurity recommendations for on-farm management of endemic disease

Effective on-farm biosecurity measures are crucial to the post-border protection of emerging agricultural diseases and are the foundation of endemic disease control. Implementation of on-farm biosecurity measures are contingent on the priorities of individual producers, which can often be neglected for other aspects of the farming enterprise. The on-farm approach to prevention of endemic diseases, like bovine viral diarrhoea virus (BVDV), is inconsistent between farms and it is not realistic to assume that farmers take an entirely normative approach to on-farm decision making. Multi-criteria decision analysis (MCDA) has been used for disease prioritisation and national disease control in human and animal health; however, it is yet to be used as a decision tool for disease control at the farm level. This study used MCDA to determine the most appropriate biosecurity combinations for management of BVDV, based on the preferences of Australian beef producers. Beef producer preferences were obtained from an online survey using indirect collection methods. Point of truth calibration was used to aggregate producer preferences and the performance scores of 23 biosecurity combinations for control of BVDV based on four main criteria: the probability of BVDV introduction, the on-farm impact of BVDV, the off-farm impact of BVDV and the annual input cost of the practice. The MCDA found that biosecurity combinations that included "double-fencing farm boundaries" used in conjunction with "vaccination against BVDV" were most appropriate for management of BVDV in an initially naïve, self-replacing seasonal single-calving beef herd over a 15-year period. Beef producers prioritised practices that preserved the on-farm health of their cattle more than any other criteria, a finding that was persistent regardless of demographic or farming type. Consequently, combinations with "vaccination against BVDV" were consistently ranked higher than those that included "strategic exposure of a persistently infected cow," which is sometimes used by Australian beef producers instead of vaccination. Findings of this study indicate that the benefits of "double-fencing farm boundaries" and "vaccination against BVDV" outweigh the relatively high cost associated with these practices based on the priorities of the Australian beef producer and may be used to demonstrate the benefits of on-farm biosecurity during discussions between livestock veterinarians and beef farmers.

Digital health for climate change mitigation and response: a scoping review

OBJECTIVE

Climate change poses a major threat to the operation of global health systems, triggering large scale health events, and disrupting normal system operation. Digital health may have a role in the management of such challenges and in greenhouse gas emission reduction. This scoping review explores recent work on digital health responses and mitigation approaches to climate change.

MATERIALS AND METHODS

We searched Medline up to February 11, 2022, using terms for digital health and climate change. Included articles were categorized into 3 application domains (mitigation, infectious disease, or environmental health risk management), and 6 technical tasks (data sensing, monitoring, electronic data capture, modeling, decision support, and communication). The review was PRISMA-ScR compliant.

RESULTS

The 142 included publications reported a wide variety of research designs. Publication numbers have grown substantially in recent years, but few come from low- and middle-income countries. Digital health has the potential to reduce health system greenhouse gas emissions, for example by shifting to virtual services. It can assist in managing changing patterns of infectious diseases as well as environmental health events by timely detection, reducing exposure to risk factors, and facilitating the delivery of care to under-resourced areas.

DISCUSSION

While digital health has real potential to help in managing climate change, research remains preliminary with little real-world evaluation.

CONCLUSION

Significant acceleration in the quality and quantity of digital health climate change research is urgently needed, given the enormity of the global challenge.

Health Decision Analysis: Evolution, Trends, and Emerging Topics

Health remains one of the most challenging realms for decision makers and policy making while critical for the well-being of humans, the stability of societies, and the development of economies. Decision making in this field ranges from medical doctors identifying the best treatments for patients, healthcare companies selecting the most promising drugs for development, healthcare providers deciding for adequate levels of resourcing, health regulators deciding whether to approve a new medicine or health technology, to regional and national health departments identifying how to increase the health security of regions and countries. In this positioning paper, and introduction to this Special Issue, we present the history, evolution, and trends of health decision analysis and suggest that these developments and news trends can be conceptualized as an emerging field of applied research for our discipline: Health Decision Analysis.

First Expert Elicitation of Knowledge on Drivers of Emergence of Bovine Besnoitiosis in Europe

Bovine besnoitiosis (BB) is a chronic and debilitating parasitic disease in cattle caused by the protozoan parasite Besnoitia besnoiti. South European countries are affected and have reported clinical cases of BB. However, BB is considered as emerging in other countries/regions of central, eastern and northern Europe. Yet, data on drivers of emergence of BB in Europe are scarce. In this study, fifty possible drivers of emergence of BB in cattle were identified. A scoring system was developed per driver. Then, the scoring was elicited from eleven recognized European experts to: (i) allocate a score to each driver, (ii) weight the score of drivers within each domain and (iii) weight the different domains among themselves. An overall weighted score was calculated per driver, and drivers were ranked in decreasing order of importance. Regression tree analysis was used to group drivers with comparable likelihoods to play a role in the emergence of BB in cattle in Europe. Finally, robustness testing of expert elicitation was performed for the seven drivers having the highest probability to play a key role in the emergence of BB: i.e., (i) legal/illegal movements of live animals from neighbouring/European Union member states or (ii) from third countries, (iii) risk of showing no clinical sign and silent spread during infection and post infection, (iv) as a consequence, difficulty to detect the emergence, (v) existence of vectors and their potential spread, (vi) European geographical proximity of the pathogen/disease to the country, and (vii) animal density of farms. Provided the limited scientific knowledge on the topic, expert elicitation of knowledge, multi-criteria decision analysis, cluster and sensitivity analyses are very important to prioritize future studies, e.g., the need for quantitative import risk assessment and estimation of the burden of BB to evidence and influence policymaking towards changing (or not) its status as a reportable disease, with prevention and control activities targeting, firstly, the top seven drivers. The present methodology could be applied to other emerging animal diseases.

A Rapid Literature Review of Multi-Criteria Decision Support Methods in the Context of One Health for All-Hazards Threat Prioritization

Background

Multi-Criteria Decision Analysis (MCDA) is a decision support tool that can be used in public health emergency management. The use of a One Health lens in MCDA can support the prioritization of threats and interventions which cut across the human, animal, and environmental domains. Previous literature reviews have focused on creating a snapshot of MCDA methodological trends. Our study provides an update to the MCDA methods literature with key considerations from a One Health perspective and addresses the application of MCDA in an all-hazards decision-making context.

Methods

We conducted a literature search on MEDLINE, EMBASE, SCOPUS, the CAB database, and a limited online gray literature search in partnership with a librarian from Health Canada. Articles were limited to those published in the year 2010 or later in a high-income setting (OECD member countries).

Results

Sixty-two articles were included for synthesis. Of these articles, most were Canadian studies (20%); and prioritized health risks, threats, and interventions in the human domain (69%). Six commonly used prioritization criteria were identified: threat, health, intervention, strategic, social, and economic impact. Stakeholders were engaged in 85% of studies and commonly consisted of government groups, non-governmental groups, subject matter experts, and the public. While most articles (65%) included elements of One Health based on our definition, only 5 studies (9%) explicitly acknowledged One Health as a guiding principle for the study. Forty seven percentage of studies noted that MCDA was beneficial in supporting the decision-making process.

Conclusion

Current literature on health prioritization presents some variability in the depth of integration of the One Health framework and on the use of various MCDA methodologies given prioritization objectives. Studies which applied a comprehensive One Health approach, prioritized disparate threats, or conducted cyclical prioritizations for governing bodies were broad in scope, but sparse. The results of our review indicate the need for better guidance on the integration of a One Health approach and the use of various MCDA methods given the main prioritization objectives.

Model development for evidence-based prioritisation of policy action on emerging chemical and microbial drinking water risks

While the burden of disease from well-studied drinking water contaminants is declining, risks from emerging chemical and microbial contaminants arise because of social, technological, demographic and climatological developments. At present, emerging chemical and microbial drinking water contaminants are not assessed in a systematic way, but reactively and incidence based. Furthermore, they are assessed separately despite similar pollution sources. As a result, risks might be addressed ineffectively. Integrated risk assessment approaches are thus needed that elucidate the uncertainties in the risk evaluation of emerging drinking water contaminants, while considering risk assessors' values. This study therefore aimed to (1) construct an assessment hierarchy for the integrated evaluation of the potential risks from emerging chemical and microbial contaminants in drinking water and (2) develop a decision support tool, based on the agreed assessment hierarchy, to quantify (uncertain) risk scores. A multi-actor approach was used to construct the assessment hierarchy, involving chemical and microbial risk assessors, drinking water experts and members of responsible authorities. The concept of value-focused thinking was applied to guide the problem-structuring and model-building process. The development of the decision support tool was done using Decisi-o-rama, an open-source Python library. With the developed decision support tool (uncertain) risk scores can be calculated for emerging chemical and microbial drinking water contaminants, which can be used for the evidence-based prioritisation of actions on emerging chemical and microbial drinking water risks. The decision support tool improves existing prioritisation approaches as it combines uncertain indicator levels with a multi-stakeholder approach and integrated the risk assessment of chemical and microbial contaminants. By applying the concept of value-focused thinking, this study addressed difficulties in evidence-based decision-making related to emerging drinking water contaminants. Suggestions to improve the model were made to guide future research in assisting policy makers to effectively protect public health from emerging drinking water risks.

GIS-based COVID-19 vulnerability mapping in the West Bank, Palestine

From the beginning of the COVID-19 pandemic, the world stands idly by in the face of the virus spreading. The prediction of highly vulnerable population and the implementation of proper actions are very important steps to break the infection chain of any virus. This will, in turn, reduce the economic and social impact of this virus outbreak. In this study, the COVID-19 vulnerability map for the West Bank, Palestine was developed. Analytic Hierarchy Process (AHP) was used to develop the COVID-19 vulnerability map. The Geographic Information system (GIS) in combination with multi-criteria decision analysis (MCDA) was adopted to estimate the COVID-19 vulnerability index (CVI) based on some selected potential criteria including population, population density, elderly population, accommodation and food service activities, school students, chronic diseases, hospital beds, health insurance, and pharmacy. The results of this study show that Nablus, Jerusalem, and Hebron governorates are under very high vulnerability. Tulkarm, Ramallah & Al-Bireh and Jenin governorates are high vulnerable to COVID-19. Additionally, 82 % of the West Bank population are under high to very high COVID-19 vulnerability classes. Moreover, 14% and 4 % are medium and low to very low vulnerable, respectively. The obtained results are of high value to help decision-makers to take proper actions as early as possible mainly in the highly COVID-19 vulnerable governorates to control the risk associated with the potential outbreak of the virus and accordingly to protect social life and to sustain economic conditions.

Development of an Index for the Inspection of Aedes aegypti Breeding Sites in Brazil: Multi-criteria Analysis

BACKGROUND

Aedes aegypti is a vector for the transmission of diseases such as dengue fever, chikungunya, Zika fever, and yellow fever. In 2016, over 1 million cases of these diseases were reported in Brazil, which is an alarming public health issue. One of the ways of controlling this disease is by inspecting and neutralizing the places where A. aegypti lays its eggs. The Ministry of Planning, Development, and Administration of Brazil maintains the inspection statistics.

OBJECTIVE

We propose a multi-criteria analysis to create an index for A. aegypti inspections reported through the Ministry of Planning, Development, and Administration system of Brazil.

METHODS

Based on the repository from urban cleaning services combined with data on inspections conducted by government agencies in several Brazilian cities and municipalities, we selected and combined metrics, which we further ranked using the analytic hierarchy process methodology. We also developed risk maps based on the analytic hierarchy process ranking of the A. aegypti breeding sites.

RESULTS

Based on our analysis and the available data, the priority for inspections should consider the number of sick people (weight 0.350), medical evaluations (weight 0.239), inspections (weight 0.201), mosquito breeding sites (weight 0.126), and days of absence from work (weight 0.096).

CONCLUSIONS

The proposed index could aid public health practitioners in preventing the appearance of new A. aegypti breeding sites. This information technology application can help solve such public health challenges.

Prioritization of zoonotic diseases of public health significance in Nigeria using the one-health approach

Nigeria, with a population of over 190 million people, is rated among the 10 countries with the highest burden of infectious and zoonotic diseases globally. In Nigeria, there exist a sub-optimal surveillance system to monitor and track priority zoonoses. We therefore conducted a prioritization of zoonotic diseases for the first time in Nigeria to guide prevention and control efforts. Towards this, a two-day in-country consultative meeting involving experts from the human, animal, and environmental health backgrounds prioritized zoonotic diseases using a modified semi-quantitative One Health Zoonotic Disease Prioritization tool in July 2017. Overall, 36 of 52 previously selected zoonoses were identified for prioritization. Five selection criteria were used to arrive at the relative importance of prioritized diseases based on their weighted score. Overall, this zoonotic disease prioritization process marks the first major step of bringing together experts from the human-animal-environment health spectrum in Nigeria. Importantly, the country ranked rabies, avian influenza, Ebola Virus Disease, swine influenza and anthrax as the first five priority zoonoses in Nigeria. Finally, this One Health approach to prioritizing important zoonoses is a step that will help to guide future tracking and monitoring of diseases of grave public health importance in Nigeria.

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Nigeria is among the top ten countries with the highest burden of infectious and zoonotic diseases globally.

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One Health approach resulted in prioritization of important zoonoses and will guide their future tracking and monitoring.

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Rabies, avian influenza, Ebola Virus Disease, swine influenza and anthrax as the first five priority zoonoses in Nigeria.

First expert elicitation of knowledge on drivers of emergence of influenza D in Europe

The influenza D virus (IDV) was first identified and characterized in 2011. Considering the virus' zoonotic potential, its genome nature (segmented RNA virus), its worldwide circulation in livestock and its role in bovine respiratory disease, an increased interest is given to IDV. However, few data are available on drivers of emergence of IDV. We first listed fifty possible drivers of emergence of IDV in ruminants and swine. As recently carried out for COVID-19 in pets (Transboundary and Emerging Diseases, 2020), a scoring system was developed per driver and scientific experts (N = 28) were elicited to (a) allocate a score to each driver, (b) weight the drivers' scores within each domain and (c) weight the different domains among themselves. An overall weighted score was calculated per driver, and drivers were ranked in decreasing order. Drivers with comparable likelihoods to play a role in the emergence of IDV in ruminants and swine in Europe were grouped using a regression tree analysis. Finally, the robustness of the expert elicitation was verified. Eight drivers were ranked with the highest probability to play a key role in the emergence of IDV: current species specificity of the causing agent of the disease; influence of (il)legal movements of live animals (ruminants, swine) from neighbouring/European Union member states and from third countries for the disease to (re-)emerge in a given country; detection of emergence; current knowledge of the pathogen; vaccine availability; animal density; and transport vehicles of live animals. As there is still limited scientific knowledge on the topic, expert elicitation of knowledge and multi-criteria decision analysis, in addition to clustering and sensitivity analyses, are very important to prioritize future studies, starting from the top eight drivers. The present methodology could be applied to other emerging animal diseases.

Malaria Risk Map Using Spatial Multi-Criteria Decision Analysis along Yunnan Border During the Pre-elimination Period

In moving toward malaria elimination, finer scale malaria risk maps are required to identify hotspots for implementing surveillance–response activities, allocating resources, and preparing health facilities based on the needs and necessities at each specific area. This study aimed to demonstrate the use of multi-criteria decision analysis (MCDA) in conjunction with geographic information systems (GISs) to create a spatial model and risk maps by integrating satellite remote-sensing and malaria surveillance data from 18 counties of Yunnan Province along the China–Myanmar border. The MCDA composite and annual models and risk maps were created from the consensus among the experts who have been working and know situations in the study areas. The experts identified and provided relative factor weights for nine socioeconomic and disease ecology factors as a weighted linear combination model of the following: ([Forest coverage × 0.041] + [Cropland × 0.086] + [Water body × 0.175] + [Elevation × 0.297] + [Human population density × 0.043] + [Imported case × 0.258] + [Distance to road × 0.030] + [Distance to health facility × 0.033] + [Urbanization × 0.036]). The expert-based model had a good prediction capacity with a high area under curve. The study has demonstrated the novel integrated use of spatial MCDA which combines multiple environmental factors in estimating disease risk by using decision rules derived from existing knowledge or hypothesized understanding of the risk factors via diverse quantitative and qualitative criteria using both data-driven and qualitative indicators from the experts. The model and fine MCDA risk map developed in this study could assist in focusing the elimination efforts in the specifically identified locations with high risks.

Prioritizing Communication About Radiation Risk Reduction in the United States: Results from a Multi-criteria Decision Analysis

OBJECTIVES

The lack of radiation knowledge among the general public continues to be a challenge for building communities prepared for radiological emergencies. This study applied a multi-criteria decision analysis (MCDA) to the results of an expert survey to identify priority risk reduction messages and challenges to increasing community radiological emergency preparedness.

METHODS

Professionals with expertise in radiological emergency preparedness, state/local health and emergency management officials, and journalists/journalism academics were surveyed following a purposive sampling methodology. An MCDA was used to weight criteria of importance in a radiological emergency, and the weighted criteria were applied to topics such as sheltering-in-place, decontamination, and use of potassium iodide. Results were reviewed by respondent group and in aggregate.

RESULTS

Sheltering-in-place and evacuation plans were identified as the most important risk reduction measures to communicate to the public. Possible communication challenges during a radiological emergency included access to accurate information; low levels of public trust; public knowledge about radiation; and communications infrastructure failures.

CONCLUSIONS

Future assessments for community readiness for a radiological emergency should include questions about sheltering-in-place and evacuation plans to inform risk communication.

Fuzzy Multicriteria Models for Decision Making in Gamification

Gamification is an innovative teaching technique that may prove hugely beneficial when properly used. For this reason, since 2002, the number of situations in which gamification is used has increased exponentially. This large number of options makes it difficult to choose the best application, especially in circumstances where there is the usual uncertainty that real-life decision making involves. To address this problem, this study creates two models, one using a fuzzy analytic hierarchy process (AHP), and the other, which combines fuzzy AHP with the measuring attractiveness by a categorical-based evaluation technique (MACBETH) approach, to choose the best gamification application for the ‘Operations Management’ course, within the Masters in Industrial Engineering. This is the first contribution in the literature combining fuzzy AHP and MACBETH. The decision centre used was the lecturer who teaches the course. There is no precedent in the literature using fuzzy logic to choose the best gamification application for a course. The results of the study show that Socrative is the best gamification application for this course within the Masters, and, as the models begin to be used in degree courses, the better choice would be Quizizz, the more clearly the earlier the course is taught within the degree programme.

Multi-criteria Decision Analysis Software in Healthcare Priority Setting: A Systematic Review

OBJECTIVE

The objectives of this systematic review were to identify studies using Multi-Criteria Decision Analysis (MCDA) software tools to support health prioritisation processes and describe the technical capabilities of the MCDA software tools identified.

METHODS

First, a systematic literature review was conducted in the MEDLINE, EMBASE, Web of Science, EconLit and Cochrane databases in July 2019 to identify studies that have used MCDA software for priority setting in health-related problems. Second, the MCDA software tools found in the review were downloaded (full versions, where freely available, and trial versions otherwise) and tested to extract their key technical characteristics.

RESULTS

Nine studies were included, from which seven different software tools, 1000minds^®, M-MACBETH, Socio Technical Allocation of Resources (STAR), Strategic Multi-Attribute Ranking Tool (SMART), Visual PROMETHEE, EVIDEM and the Prioritisation Framework, were identified. These software tools differed in terms of the operating systems (including web interface), MCDA technique(s) available for use, visualisation features, and the capability to perform Value for Money (VfM) and sensitivity analyses.

CONCLUSIONS

The use of MCDA software in prioritisation processes has a number of advantages such as inclusion of several types of stakeholders and the ability to analyse a greater number of alternatives and criteria and perform real-time sensitivity analyses. Proprietary software (i.e. software with licensing fees) seemed to have more features than freely available software. However, this field is still developing, with only a few studies where MCDA software was used to support health priority setting and opportunity costs not explicitly captured in many software tools.

Prioritization of livestock transboundary diseases in Belgium using a multicriteria decision analysis tool based on drivers of emergence

During the past decade, livestock diseases have (re-)emerged in areas where they had been previously eradicated or never been recorded before. Drivers (i.e. factors of (re-)emergence) have been identified. Livestock diseases spread irrespective of borders, and therefore, reliable methods are required to help decision-makers to identify potential threats and try stopping their (re-)emergence. Ranking methods and multicriteria approaches are cost-effective tools for such purpose and were applied to prioritize a list of selected diseases (N = 29 including 6 zoonoses) based on the opinion of 62 experts in accordance with 50 drivers-related criteria. Diseases appearing in the upper ranking were porcine epidemic diarrhoea, foot-and-mouth disease, low pathogenic avian influenza, African horse sickness and highly pathogenic avian influenza. The tool proposed uses a multicriteria decision analysis approach to prioritize pathogens according to drivers and can be applied to other countries or diseases.

Emerging infectious diseases and biological invasions: a call for a One Health collaboration in science and management

The study and management of emerging infectious diseases (EIDs) and of biological invasions both address the ecology of human-associated biological phenomena in a rapidly changing world. However, the two fields work mostly in parallel rather than in concert. This review explores how the general phenomenon of an organism rapidly increasing in range or abundance is caused, highlights the similarities and differences between research on EIDs and invasions, and discusses shared management insights and approaches. EIDs can arise by: (i) crossing geographical barriers due to human-mediated dispersal, (ii) crossing compatibility barriers due to evolution, and (iii) lifting of environmental barriers due to environmental change. All these processes can be implicated in biological invasions, but only the first defines them. Research on EIDs is embedded within the One Health concept-the notion that human, animal and ecosystem health are interrelated and that holistic approaches encompassing all three components are needed to respond to threats to human well-being. We argue that for sustainable development, biological invasions should be explicitly considered within One Health. Management goals for the fields are the same, and direct collaborations between invasion scientists, disease ecologists and epidemiologists on modelling, risk assessment, monitoring and management would be mutually beneficial.

Human infectious diseases and the changing climate in the Arctic

Climatic factors, especially temperature, precipitation, and humidity play an important role in disease transmission. As the Arctic changes at an unprecedented rate due to climate change, understanding how climatic factors and climate change affect infectious disease rates is important for minimizing human and economic costs. The purpose of this systematic review was to compile recent studies in the field and compare the results to a previously published review. English language searches were conducted in PubMed, ScienceDirect, Scopus, and PLOS One. Russian language searches were conducted in the Scientific Electronic Library "eLibrary.ru". This systematic review yielded 22 articles (51%) published in English and 21 articles (49%) published in Russian since 2012. Articles about zoonotic and vector-borne diseases accounted for 67% (n = 29) of the review. Tick-borne diseases, tularemia, anthrax, and vibriosis were the most researched diseases likely to be impacted by climatic factors in the Arctic. Increased temperature and precipitation are predicted to have the greatest impact on infectious diseases in the Arctic.

Development and validation of a scoring system to assess the relative vulnerability of swine breeding herds to the introduction of PRRS virus

Biosecurity is defined as the set of practices carried out to prevent the introduction and spread of infectious agents in a herd. These practices are essential in swine production, especially for highly infectious agents such as porcine reproductive and respiratory syndrome virus (PRRSv). Even with years of research and experience over the last three decades, PRRSv is still causing productivity losses and is the major health problem affecting the global swine industry. Despite knowledge of the various ways in which the virus can be transmitted from one herd to another (e.g. animals, semen, truck, air, and people), determining the most frequent ways in which the virus is transmitted in the field is difficult. A systematic approach to assess vulnerabilities at a herd level related to PRRSv transmission could help producers prioritize biosecurity practices to reduce or avoid the occurrence of outbreaks. The aim of this study was to develop a biosecurity vulnerability score that represents the relative vulnerability of swine breeding herds to the introduction of PRRSv. To create the biosecurity vulnerability score (outcome), a multi-criteria decision analysis methodology was used to rank and quantify biosecurity practices based on expert opinion. To validate the biosecurity vulnerability score, a survey of biosecurity practices and PRRS outbreak histories in 125 breed-to-wean herds in the U.S. swine industry was used. Data on the frequency of PRRS outbreaks was used to test the hypothesis that biosecurity vulnerability scores were different between farms that have a low incidence of PRRS outbreaks, compared to farms that have a high incidence. In the two databases used, the scores consistently showed that farms with higher scores have a higher frequency of PRRS outbreaks. In the first validation, farms that had never had an outbreak investigation before had a significant (p < 0.02) lower score (0.29; 0.21-0.37) when compared to farms that had 2 or more outbreaks (0.43; 0.39-0.46). In the second, the farms of the control group also had significant (p < 0.004) lower scores (0.30; 0.27-0.33) compared to the case group (0.35; 0.33-0.38). Also, the results suggest that events related to swine movements, transmission by air and water, and people movements should be prioritized. The biosecurity vulnerability scores may be useful to assess vulnerabilities on biosecurity protocols in order to reduce the frequency of PRRS outbreaks and may help producers and veterinarians prioritize investments in improving biosecurity practices over time.

World Health Organization Methodology to Prioritize Emerging Infectious Diseases in Need of Research and Development

The World Health Organization R&D Blueprint aims to accelerate the availability of medical technologies during epidemics by focusing on a list of prioritized emerging diseases for which medical countermeasures are insufficient or nonexistent. The prioritization process has 3 components: a Delphi process to narrow down a list of potential priority diseases, a multicriteria decision analysis to rank the short list of diseases, and a final Delphi round to arrive at a final list of 10 diseases. A group of international experts applied this process in January 2017, resulting in a list of 10 priority diseases. The robustness of the list was tested by performing a sensitivity analysis. The new process corrected major shortcomings in the pre-R&D Blueprint approach to disease prioritization and increased confidence in the results.

Emerging risks identification on food and feed - EFSA

The European Food Safety Authority's has established procedures for the identification of emerging risk in food and feed. The main objectives are to: (i) to carry out activities aiming at identifying, assessing and disseminating information on emerging issues and ensure coordination with relevant networks and international organisations; (ii) promote the identification of data sources and data collection and /or data generation in prioritised emerging issues; and the (iii) evaluate of the collected information and identify of emerging risks. The objective(s) of the Standing Working Group on Emerging Risks (SWG-ER) is to collaborate with EFSA on the emerging risks identification (ERI) procedure and provide strategic direction for EFSA work building on past and ongoing projects related to EFSA ERI procedure. The SWG-ER considered the ERI methodologies in place and results obtained by EFSA. It was concluded that a systematic approach to the identification of emerging issues based on experts' networks is the major strength of the procedure but at present, it is mainly focused on single issues, over short to medium time horizons, no consistent weighting or ranking is applied and clear governance of emerging risks with follow-up actions is missing. The analysis highlighted weaknesses with respect to data collection, analysis and integration. No methodology is in place to estimate the value of the procedure outputs in terms of avoided risk and there is urgent need for a communication strategy that addresses the lack of data and knowledge uncertainty and addresses risk perception issues. Recommendations were given in three areas: (i) Further develop a food system-based approach including the integration of social sciences to improve understanding of interactions and dynamics between actors and drivers and the development of horizon scanning protocols; (ii) Improve data processing pipelines to prepare big data analytics, implement a data validation system and develop data sharing agreements to explore mutual benefits; and (iii) Revise the EFSA procedure for emerging risk identification to increase transparency and improve communication.

Zika Virus in Ontario: Evaluating a Rapid Risk Assessment Tool for Emerging Infectious Disease Threats

To determine the Ontario-specific risk of local and travel-related Zika virus transmission in the context of a public health emergency of international concern, Public Health Ontario (PHO) completed a rapid risk assessment (RRA) on January 29, 2016, using a newly developed RRA guidance tool. The RRA concluded that risk of local mosquito-borne transmission was low, with a high risk of imported cases through travel. The RRA was updated 3 times based on predetermined triggers. An independent evaluation assessed both the application of the RRA guidance tool (process evaluation) and the usefulness of the RRA (outcome evaluation). We conducted face-to-face, semi-structured interviews with 7 individuals who participated in the creation or review of the Zika virus RRA and 4 end-users at PHO and the Ministry of Health and Long-Term Care. An inductive thematic analysis of responses was undertaken, whereby themes were directly informed by the data. The process evaluation determined that most steps outlined in the RRA guidance tool were adhered to, including forming a cross-functional writing team, clarifying the scope and describing context, completing the RRA summary report, and updating the RRA based on predefined triggers. The outcome evaluation found that end-users judged the Zika virus RRA as evidence-informed, useful, consistent, and timely. The evaluation established that the locally tailored guidance tool, adapted from national and international approaches to RRAs, facilitated a systematic, evidence-informed, and timely formal RRA process at PHO for the Zika virus RRA, which met the needs of end-users. Based on the evaluation, PHO will modify future RRAs by incorporating some flexibility into the literature review process to support timeliness of the RRA, explicitly describing the limitations of studies used to inform the RRA, and refining risk algorithms to better suit emerging infectious disease threats. It is anticipated that these refinements will improve upon the timely assessment of novel or reemerging infectious diseases.

Criteria for the prioritization of public health interventions for climate-sensitive vector-borne diseases in Quebec

Prioritizing resources for optimal responses to an ever growing list of existing and emerging infectious diseases represents an important challenge to public health. In the context of climate change, there is increasing anticipated variability in the occurrence of infectious diseases, notably climate-sensitive vector-borne diseases. An essential step in prioritizing efforts is to identify what considerations and concerns to take into account to guide decisions and thus set disease priorities. This study was designed to perform a comprehensive review of criteria for vector-borne disease prioritization, assess their applicability in a context of climate change with a diverse cross-section of stakeholders in order to produce a baseline list of considerations to use in this decision-making context. Differences in stakeholder choices were examined with regards to prioritization of these criteria for research, surveillance and disease prevention and control objectives. A preliminary list of criteria was identified following a review of the literature. Discussions with stakeholders were held to consolidate and validate this list of criteria and examine their effects on disease prioritization. After this validation phase, a total of 21 criteria were retained. A pilot vector-borne disease prioritization exercise was conducted using PROMETHEE to examine the effects of the retained criteria on prioritization in different intervention domains. Overall, concerns expressed by stakeholders for prioritization were well aligned with categories of criteria identified in previous prioritization studies. Weighting by category was consistent between stakeholders overall, though some significant differences were found between public health and non-public health stakeholders. From this exercise, a general model for climate-sensitive vector-borne disease prioritization has been developed that can be used as a starting point for further public health prioritization exercises relating to research, surveillance, and prevention and control interventions in a context of climate change. Multi-stakeholder engagement in prioritization can help broaden the range of criteria taken into account, offer opportunities for early identification of potential challenges and may facilitate acceptability of any resulting decisions.

Insight into "Calculated Risk": An Application to the Prioritization of Emerging Infectious Diseases for Blood Transfusion Safety

Increasing identification of transmissions of emerging infectious diseases (EIDs) by blood transfusion raised the question which of these EIDs poses the highest risk to blood safety. For a number of the EIDs that are perceived to be a threat to blood safety, evidence on actual disease or transmission characteristics is lacking, which might render measures against such EIDs disputable. On the other hand, the fact that we call them "emerging" implies almost by definition that we are uncertain about at least some of their characteristics. So what is the relative importance of various disease and transmission characteristics, and how are these influenced by the degree of uncertainty associated with their actual values? We identified the likelihood of transmission by blood transfusion, the presence of an asymptomatic phase of infection, prevalence of infection, and the disease impact as the main characteristics of the perceived risk of disease transmission by blood transfusion. A group of experts in the field of infectious diseases and blood transfusion ranked sets of (hypothetical) diseases with varying degrees of uncertainty associated with their disease characteristics, and used probabilistic inversion to obtain probability distributions for the weight of each of these risk characteristics. These distribution weights can be used to rank both existing and newly emerging infectious diseases with (partially) known characteristics. Analyses show that in case there is a lack of data concerning disease characteristics, it is the uncertainty concerning the asymptomatic phase and the disease impact that are the most important drivers of the perceived risk. On the other hand, if disease characteristics are well established, it is the prevalence of infection and the transmissibility of the disease by blood transfusion that will drive the perceived risk. The risk prioritization model derived provides an easy to obtain and rational expert assessment of the relative importance of an (emerging) infectious disease, requiring only a limited amount of information. Such a model might be used to justify a rational and proportional response to an emerging infectious disease, especially in situations where little or no specific information is available.

How have systematic priority setting approaches influenced policy making? A synthesis of the current literature

BACKGROUND

There is a growing body of literature on systematic approaches to healthcare priority setting from various countries and different levels of decision making. This paper synthesizes the current literature in order to assess the extent to which program budgeting and marginal analysis (PBMA), burden of disease & cost-effectiveness analysis (BOD/CEA), multi-criteria decision analysis (MCDA), and accountability for reasonableness (A4R), are reported to have been institutionalized and influenced policy making and practice.

METHODS

We searched for English language publications on health care priority setting approaches (2000-2017). Our sources of literature included PubMed and Ovid databases (including Embase, Global Health, Medline, PsycINFO, EconLit).

FINDINGS

Of the four approaches PBMA and A4R were commonly applied in high income countries while BOD/CEA was exclusively applied in low income countries. PBMA and BOD/CEA were most commonly reported to have influenced policy making. The explanations for limited adoption of an approach were related to its complexity, poor policy maker understanding and resource requirements.

CONCLUSIONS

While systematic approaches have the potential to improve healthcare priority setting; most have not been adopted in routine policy making. The identified barriers call for sustained knowledge exchange between researchers and policy-makers and development of practical guidelines to ensure that these frameworks are more accessible, applicable and sustainable in informing policy making.

Ad hoc method for the assessment on listing and categorisation of animal diseases within the framework of the Animal Health Law

The European Commission has requested EFSA to assess animal diseases according to the criteria as laid down in Articles 5, 7, 8 and Annex IV for the purpose of categorisation of diseases in accordance with Article 9 of the Regulation (EU) No 2016/429 (Animal Health Law). This scientific opinion addresses the ad hoc method developed for assessing any animal disease for the listing and categorisation of diseases within the Animal Health Law (AHL) framework. The assessment of individual diseases is addressed in distinct scientific opinions that are published separately. The assessment of Articles 5, 8 and 9 criteria is performed on the basis of the information collected according to Article 7 criteria. For that purpose, Article 7 criteria were structured into parameters and the information was collected at parameter level. The resulting fact sheets on the profile and impact of each disease were compiled by disease scientists. A mapping was developed to identify which parameters from Article 7 were needed to inform each Article 5, 8 and 9 criterion. Specifically, for Articles 5 and 9 criteria, a categorical assessment was performed, by applying an expert judgement procedure, based on the mapped information. The judgement was performed by EFSA Panel experts on Animal Health and Welfare in two rounds, individual and collective judgement. The output of the expert judgement on the criteria of Articles 5 and 9 for each disease is composed by the categorical answer, and for the questions where no consensus was reached, the different supporting views are reported.

Best practices in ranking communicable disease threats: a literature review, 2015

The threat of serious, cross-border communicable disease outbreaks in Europe poses a significant challenge to public health and emergency preparedness because the relative likelihood of these threats and the pathogens involved are constantly shifting in response to a range of changing disease drivers. To inform strategic planning by enabling effective resource allocation to manage the consequences of communicable disease outbreaks, it is useful to be able to rank and prioritise pathogens. This paper reports on a literature review which identifies and evaluates the range of methods used for risk ranking. Searches were performed across biomedical and grey literature databases, supplemented by reference harvesting and citation tracking. Studies were selected using transparent inclusion criteria and underwent quality appraisal using a bespoke checklist based on the AGREE II criteria. Seventeen studies were included in the review, covering five methodologies. A narrative analysis of the selected studies suggests that no single methodology was superior. However, many of the methods shared common components, around which a 'best-practice' framework was formulated. This approach is intended to help inform decision makers' choice of an appropriate risk-ranking study design.

DISCONTOOLS: a database to identify research gaps on vaccines, pharmaceuticals and diagnostics for the control of infectious diseases of animals

BACKGROUND

The public and private sector in the EU spend around €800 million per year on animal health and welfare related research. An objective process to identify critical gaps in knowledge and available control tools should aid the prioritisation of research in order to speed up the development of new or improved diagnostics, vaccines and pharmaceuticals and reduce the burden of animal diseases.

METHOD

Here, we describe the construction of a database based on expert consultation for 52 infectious diseases of animals.

RESULTS

For each disease, an expert group produced a disease and product analysis document that formed the basis for gap analysis and prioritisation. The prioritisation model was based on a closed scoring system, employing identical weights for six evaluation criteria (disease knowledge; impact on animal health and welfare; impact on public health; impact on wider society; impact on trade; control tools). The diseases were classified into three groups: epizootic diseases, food-producing animal complexes or zoonotic diseases.

DISCUSSION

The highly ranked diseases in the prioritisation model comprised mostly zoonotic and epizootic diseases with important gaps identified in vaccine development and pharmaceuticals, respectively. The most important outcome is the identification of key research needs by disease. The rankings and research needs by disease are provided on a public website ( www.discontools.eu ) which is currently being updated based on new expert consultations.

CONCLUSION

As such, it can become a reference point for funders of research including the European Commission, member states, foundations, trusts along with private industry to prioritise research. This will deliver benefits in terms of animal health and welfare but also public health, societal benefits and a safe and secure food supply.

D2R2: an evidence-based decision support tool to aid prioritisation of animal health issues for government funding

An evidence-based decision support tool, 'D2R2', has been developed by Defra. It contains a wide range of standardised information about exotic and endemic diseases held in 'disease profiles'. Each profile includes 40 criteria used for scoring, enabling D2R2 to provide relative priority rankings for every disease profiled. D2R2 also provides a range of reports for each disease and the functionality to explore the impact of changes in any criterion or weighting on a disease's ranking. These outputs aid the prioritisation and management of animal diseases by government. D2R2 was developed with wide stakeholder engagement and its design was guided by clear specifications. It uses the weighted scores of a limited number of criteria to generate impact and risk scores for each disease, and relies on evidence drawn from published material wherever possible and maintained up to date. It allows efficient use of expertise, as maintained disease profiles reduce the need for on call, reactive, expert input for policy development and enables rapid simultaneous access to the same information by multiple parties, for example during exotic disease outbreaks. The experience in developing D2R2 has been shared internationally to assist others with their development of disease prioritisation and categorisation systems.

Prioritizing Zoonotic Diseases: Differences in Perspectives Between Human and Animal Health Professionals in North America

Zoonoses pose a significant burden of illness in North America. Zoonoses represent an additional threat to public health because the natural reservoirs are often animals, particularly wildlife, thus eluding control efforts such as quarantine, vaccination and social distancing. As there are limited resources available, it is necessary to prioritize diseases in order to allocate resources to those posing the greatest public health threat. Many studies have attempted to prioritize zoonoses, but challenges exist. This study uses a quantitative approach, conjoint analysis (CA), to overcome some limitations of traditional disease prioritization exercises. We used CA to conduct a zoonoses prioritization study involving a range of human and animal health professionals across North America; these included epidemiologists, public health practitioners, research scientists, physicians, veterinarians, laboratory technicians and nurses. A total of 699 human health professionals (HHP) and 585 animal health professionals (AHP) participated in this study. We used CA to prioritize 62 zoonotic diseases using 21 criteria. Our findings suggest CA can be used to produce reasonable criteria scores for disease prioritization. The fitted models were satisfactory for both groups with a slightly better fit for AHP compared to HHP (84.4% certainty fit versus 83.6%). Human-related criteria were more influential for HHP in their decision to prioritize zoonoses, while animal-related criteria were more influential for AHP resulting in different disease priority lists. While the differences were not statistically significant, a difference of one or two ranks could be considered important for some individuals. A potential solution to address the varying opinions is discussed. The scientific framework for disease prioritization presented can be revised on a regular basis by updating disease criteria to reflect diseases as they evolve over time; such a framework is of value allowing diseases of highest impact to be identified routinely for resource allocation.

Multi-Stakeholder Decision Aid for Improved Prioritization of the Public Health Impact of Climate Sensitive Infectious Diseases

The effects of climate change on infectious diseases are an important global health concern and necessitate decisions for allocation of resources. Economic tools have been used previously; however, how prioritization results might differ when done using broader considerations identified by local stakeholders has yet to be assessed. A multicriteria decision analysis (MCDA) approach was used to assess multi-stakeholder expressed concerns around disease prioritization via focus groups held in Quebec and Burkina Faso. Stakeholders weighted criteria and comparisons were made across study sites. A pilot disease prioritization was done to examine effects on disease rankings. A majority of identified criteria were common to both sites. The effect of context specific criteria and weights resulted in similar yet distinct prioritizations of diseases. The presence of consistent criteria between sites suggests that common concerns exist for prioritization; however, context-specific adjustments reveal much regarding resource availability, capacity and concerns that should be considered as this impacts disease ranking. Participatory decision aid approaches facilitate rich knowledge exchange and problem structuring. Furthermore, given multiple actors in low- and middle-income countries settings, multi-actor collaborations across non-governmental organizations, local government and community are important. Formal mechanisms such as MCDA provide means to foster consensus, shared awareness and collaboration.

Weighting of Criteria for Disease Prioritization Using Conjoint Analysis and Based on Health Professional and Student Opinion

Disease prioritization exercises have been used by several organizations to inform surveillance and control measures. Though most methodologies for disease prioritization are based on expert opinion, it is becoming more common to include different stakeholders in the prioritization exercise. This study was performed to compare the weighting of disease criteria, and the consequent prioritization of zoonoses, by both health professionals and students in Switzerland using a Conjoint Analysis questionnaire. The health professionals comprised public health and food safety experts, cantonal physicians and cantonal veterinarians, while the student group comprised first-year veterinary and agronomy students. Eight criteria were selected for this prioritization based on expert elicitation and literature review. These criteria, described on a 3-tiered scale, were evaluated through a choice-based Conjoint Analysis questionnaire with 25 choice tasks. Questionnaire results were analyzed to obtain importance scores (for each criterion) and mean utility values (for each criterion level), and the latter were then used to rank 16 zoonoses. While the most important criterion for both groups was “Severity of the disease in humans”, the second ranked criteria by the health professionals and students were “Economy” and “Treatment in humans”, respectively. Regarding the criterion “Control and Prevention”, health professionals tended to prioritize a disease when the control and preventive measures were described to be 95% effective, while students prioritized a disease if there were almost no control and preventive measures available. Bovine Spongiform Encephalopathy was the top-ranked disease by both groups. Health professionals and students agreed on the weighting of certain criteria such as “Severity” and “Treatment of disease in humans”, but disagreed on others such as “Economy” or “Control and Prevention”. Nonetheless, the overall disease ranking lists were similar, and these may be taken into consideration when making future decisions regarding resource allocation for disease control and prevention in Switzerland.

Can the EVIDEM Framework Tackle Issues Raised by Evaluating Treatments for Rare Diseases: Analysis of Issues and Policies, and Context-Specific Adaptation

BACKGROUND

The multiplicity of issues, including uncertainty and ethical dilemmas, and policies involved in appraising interventions for rare diseases suggests that multicriteria decision analysis (MCDA) based on a holistic definition of value is uniquely suited for this purpose. The objective of this study was to analyze and further develop a comprehensive MCDA framework (EVIDEM) to address rare disease issues and policies, while maintaining its applicability across disease areas.

METHODS

Specific issues and policies for rare diseases were identified through literature review. Ethical and methodological foundations of the EVIDEM framework v3.0 were systematically analyzed from the perspective of these issues, and policies and modifications of the framework were performed accordingly to ensure their integration.

RESULTS

Analysis showed that the framework integrates ethical dilemmas and issues inherent to appraising interventions for rare diseases but required further integration of specific aspects. Modification thus included the addition of subcriteria to further differentiate disease severity, disease-specific treatment outcomes, and economic consequences of interventions for rare diseases. Scoring scales were further developed to include negative scales for all comparative criteria. A methodology was established to incorporate context-specific population priorities and policies, such as those for rare diseases, into the quantitative part of the framework. This design allows making more explicit trade-offs between competing ethical positions of fairness (prioritization of those who are worst off), the goal of benefiting as many people as possible, the imperative to help, and wise use of knowledge and resources. It also allows addressing variability in institutional policies regarding prioritization of specific disease areas, in addition to existing uncertainty analysis available from EVIDEM.

CONCLUSION

The adapted framework measures value in its widest sense, while being responsive to rare disease issues and policies. It provides an operationalizable platform to integrate values, competing ethical dilemmas, and uncertainty in appraising healthcare interventions.

To notify or not to notify: decision aid for policy makers on whether to make an infectious disease mandatorily notifiable

Mandatory notification can be a useful tool to support infectious disease prevention and control. Guidelines are needed to help policymakers decide whether mandatory notification of an infectious disease is appropriate. We developed a decision aid, based on a range of criteria previously used in the Netherlands or in other regions to help decide whether to make a disease notifiable. Criteria were categorised as being effective, feasible and necessary with regard to the relevance of mandatory notification. Expert panels piloted the decision aid. Here we illustrate its use for three diseases (Vibrio vulnificus infection, chronic Q fever and dengue fever) for which mandatory notification was requested. For dengue fever, the expert panel advised mandatory notification; for V. vulnificus infection and chronic Q fever, the expert panel concluded that mandatory notification was not (yet) justified. Use of the decision aid led to a structured, transparent decision making process and a thorough assessment of the advantages and disadvantages of mandatory notification of these diseases. It also helped identify knowledge gaps that required further research before a decision could be made. We therefore recommend use of this aid for public health policy making.

Preparedness for emerging infectious diseases: pathways from anticipation to action

Emerging and re-emerging infectious disease (EID) events can have devastating human, animal and environmental health impacts. The emergence of EIDs has been associated with interconnected economic, social and environmental changes. Understanding these changes is crucial for EID preparedness and subsequent prevention and control of EID events. The aim of this review is to describe tools currently available for identification, prioritization and investigation of EIDs impacting human and animal health, and how these might be integrated into a systematic approach for directing EID preparedness. Environmental scanning, foresight programmes, horizon scanning and surveillance are used to collect and assess information for rapidly responding to EIDs and to anticipate drivers of emergence for mitigating future EID impacts. Prioritization of EIDs - using transparent and repeatable methods - based on disease impacts and the importance of those impacts to decision-makers can then be used for more efficient resource allocation for prevention and control. Risk assessment and simulation modelling methods assess the likelihood of EIDs occurring, define impact and identify mitigation strategies. Each of these tools has a role to play individually; however, we propose integration of these tools into a framework that enhances the development of tactical and strategic plans for emerging risk preparedness.

A review and classification of approaches for dealing with uncertainty in multi-criteria decision analysis for healthcare decisions

Multi-criteria decision analysis (MCDA) is increasingly used to support decisions in healthcare involving multiple and conflicting criteria. Although uncertainty is usually carefully addressed in health economic evaluations, whether and how the different sources of uncertainty are dealt with and with what methods in MCDA is less known. The objective of this study is to review how uncertainty can be explicitly taken into account in MCDA and to discuss which approach may be appropriate for healthcare decision makers. A literature review was conducted in the Scopus and PubMed databases. Two reviewers independently categorized studies according to research areas, the type of MCDA used, and the approach used to quantify uncertainty. Selected full text articles were read for methodological details. The search strategy identified 569 studies. The five approaches most identified were fuzzy set theory (45% of studies), probabilistic sensitivity analysis (15%), deterministic sensitivity analysis (31%), Bayesian framework (6%), and grey theory (3%). A large number of papers considered the analytic hierarchy process in combination with fuzzy set theory (31%). Only 3% of studies were published in healthcare-related journals. In conclusion, our review identified five different approaches to take uncertainty into account in MCDA. The deterministic approach is most likely sufficient for most healthcare policy decisions because of its low complexity and straightforward implementation. However, more complex approaches may be needed when multiple sources of uncertainty must be considered simultaneously.