Pandemic preparedness improves national-level SARS-CoV-2 infection and mortality data completeness: a cross-country ecologic analysis

BACKGROUND

Heterogeneity in national SARS-CoV-2 infection surveillance capabilities may compromise global enumeration and tracking of COVID-19 cases and deaths and bias analyses of the pandemic's tolls. Taking account of heterogeneity in data completeness may thus help clarify analyses of the relationship between COVID-19 outcomes and standard preparedness measures.

METHODS

We examined country-level associations of pandemic preparedness capacities inventories, from the Global Health Security (GHS) Index and Joint External Evaluation (JEE), on SARS-CoV-2 infection and COVID-19 death data completion rates adjusted for income. Analyses were stratified by 100, 100-300, 300-500, and 500-700 days after the first reported case in each country. We subsequently reevaluated the relationship of pandemic preparedness on SARS-CoV-2 infection and age-standardized COVID-19 death rates adjusted for cross-country differentials in data completeness during the pre-vaccine era.

RESULTS

Every 10% increase in the GHS Index was associated with a 14.9% (95% confidence interval 8.34-21.8%) increase in SARS-CoV-2 infection completion rate and a 10.6% (5.91-15.4%) increase in the death completion rate during the entire observation period. Disease prevention (infections: β = 1.08 [1.05-1.10], deaths: β = 1.05 [1.04-1.07]), detection (infections: β = 1.04 [1.01-1.06], deaths: β = 1.03 [1.01-1.05]), response (infections: β = 1.06 [1.00-1.13], deaths: β = 1.05 [1.00-1.10]), health system (infections: β = 1.06 [1.03-1.10], deaths: β = 1.05 [1.03-1.07]), and risk environment (infections: β = 1.27 [1.15-1.41], deaths: β = 1.15 [1.08-1.23]) were associated with both data completeness outcomes. Effect sizes of GHS Index on infection completion (Low income: β = 1.18 [1.04-1.34], Lower Middle income: β = 1.41 [1.16-1.71]) and death completion rates (Low income: β = 1.19 [1.09-1.31], Lower Middle income: β = 1.25 [1.10-1.43]) were largest in LMICs. After adjustment for cross-country differences in data completeness, each 10% increase in the GHS Index was associated with a 13.5% (4.80-21.4%) decrease in SARS-CoV-2 infection rate at 100 days and a 9.10 (1.07-16.5%) decrease at 300 days. For age-standardized COVID-19 death rates, each 10% increase in the GHS Index was with a 15.7% (5.19-25.0%) decrease at 100 days and a 10.3% (- 0.00-19.5%) decrease at 300 days.

CONCLUSIONS

Results support the pre-pandemic hypothesis that countries with greater pandemic preparedness capacities have larger SARS-CoV-2 infection and mortality data completeness rates and lower COVID-19 disease burdens. More high-quality data of COVID-19 impact based on direct measurement are needed.

The United States Needs A Better Testing Playbook For Future Public Health Emergencies

The absence of a comprehensive national playbook for developing and deploying testing has hindered the United States' ability to rapidly suppress recent biological emergencies (for example, the COVID-19 pandemic and outbreaks of mpox). We describe here the Testing Playbook for Biological Emergencies, a national testing playbook we developed. It includes a set of decisions and actions for US officials to take at specific times during infectious disease emergencies to implement testing rapidly and to ensure that available testing meets clinical and public health needs. Although the United States had multiple plans at the federal level for responding to pandemic threats, US leaders were unable to quickly and efficiently operationalize those plans to deploy different types of tests during the COVID-19 pandemic in 2020-21, and again during the US mpox outbreak in 2022. The playbook fills a critical gap by providing the necessary specific and adaptable guidance for decision makers to meet this need.

Evaluation of the Global Health Security Index as a predictor of COVID-19 excess mortality standardised for under-reporting and age structure

BACKGROUND

Previous studies have observed that countries with the strongest levels of pandemic preparedness capacities experience the greatest levels of COVID-19 burden. However, these analyses have been limited by cross-country differentials in surveillance system quality and demographics. Here, we address limitations of previous comparisons by exploring country-level relationships between pandemic preparedness measures and comparative mortality ratios (CMRs), a form of indirect age standardisation, of excess COVID-19 mortality.

METHODS

We indirectly age standardised excess COVID-19 mortality, from the Institute for Health Metrics and Evaluation modelling database, by comparing observed total excess mortality to an expected age-specific COVID-19 mortality rate from a reference country to derive CMRs. We then linked CMRs with data on country-level measures of pandemic preparedness from the Global Health Security (GHS) Index. These data were used as input into multivariable linear regression analyses that included income as a covariate and adjusted for multiple comparisons. We conducted a sensitivity analysis using excess mortality estimates from WHO and The Economist.

RESULTS

The GHS Index was negatively associated with excess COVID-19 CMRs (table 2; β= -0.21, 95% CI= -0.35 to -0.08). Greater capacities related to prevention (β= -0.11, 95% CI= -0.22 to -0.00), detection (β= -0.09, 95% CI= -0.19 to -0.00), response (β = -0.19, 95% CI= -0.36 to -0.01), international commitments (β= -0.17, 95% CI= -0.33 to -0.01) and risk environments (β= -0.30, 95% CI= -0.46 to -0.15) were each associated with lower CMRs. Results were not replicated using excess mortality models that rely more heavily on reported COVID-19 deaths (eg, WHO and The Economist).

CONCLUSION

The first direct comparison of COVID-19 excess mortality rates across countries accounting for under-reporting and age structure confirms that greater levels of preparedness were associated with lower excess COVID-19 mortality. Additional research is needed to confirm these relationships as more robust national-level data on COVID-19 impact become available.

Identifying Operational Challenges and Solutions During the COVID-19 Response Among US Public Health Laboratories

CONTEXT

The ability to diagnose and screen for infection is an important component of the US COVID-19 response and is facilitated by public health laboratories (PHLs). Anecdotal media reports and limited case studies have described some of the challenges faced by PHLs during the pandemic, particularly initial challenges related to developing and deploying tests to PHLs, but there has not been a systematic evaluation of the experience of PHLs during the pandemic.

OBJECTIVE

To document challenges and lessons learned experienced by local and state PHLs during the COVID-19 pandemic to support generation of best practices for current and future similar emergencies.

DESIGN, SETTING, AND PARTICIPANTS

From February to June 2021, researchers conducted 24 interviews with 68 leaders and staff representing 28 local and state PHLs across 27 states. Thematic analysis of interview content documented operational challenges and any identified solutions or preventive measures used or proposed.

MAIN OUTCOME MEASURES

Analysis identified the following themes regarding challenges faced among PHLs: strategic decision making and determining the mandate of the PHL; political interference by jurisdictional leadership; federal mismanagement of the emergency; regulatory challenges; managing partnerships with other laboratories; acquisition of appropriate supplies; insufficient information systems; acquiring and retaining workforce; and difficulty accessing sufficient funding.

RESULTS

Within the identified themes, key informants provided further elaboration regarding how PHLs experienced, evaded, or solved these challenges. In addition, PHLs described how challenges evolved throughout the course of the COVID-19 pandemic and made proposals regarding how challenges could be prevented or further addressed in the future by laboratories or other decision makers and stakeholders.

CONCLUSIONS

While fellow laboratories and political leadership may gain inspiration from creative solutions employed by PHLs, recognition of long-standing gaps related to funding, laboratory workforce, and consideration of laboratory needs in preparedness policies must be addressed for future large-scale outbreaks.

The WHO Declaration of Monkeypox as a Global Public Health Emergency

This Viewpoint examines the ongoing monkeypox outbreak and the recent decision by the director-general of the World Health Organization to declare a Public Health Emergency of International Concern.

The Missing COVID-19 Demographic Data: A Statewide Analysis of COVID-19-Related Demographic Data From Local Government Sources and a Comparison With Federal Public Surveillance Data

Objectives. To collect and standardize COVID-19 demographic data published by local public-facing Web sites and analyze how this information differs from Centers for Disease Control and Prevention (CDC) public surveillance data. Methods. We aggregated and standardized COVID-19 data on cases and deaths by age, gender, race, and ethnicity from US state and territorial governmental sources between May 24 and June 4, 2021. We describe the standardization process and compare it with the CDC's process for public surveillance data. Results. As of June 2021, the CDC's public demographic data set included 80.9% of total cases and 46.7% of total deaths reported by states, with significant variation across jurisdictions. Relative to state and territorial data sources, the CDC consistently underreports cases and deaths among African American and Hispanic or Latino individuals and overreports deaths among people older than 65 years and White individuals. Conclusions. Differences exist in amounts of data included and demographic composition between the CDC's public surveillance data and state and territory reporting, with large heterogeneity across jurisdictions. A lack of standardization and reporting mechanisms limits the production of complete real-time demographic data.

Disparities in SARS-CoV-2 Testing for Hispanic/Latino Populations: An Analysis of State-Published Demographic Data

Racial and ethnic minorities in the United States have been disproportionately affected by the COVID-19 pandemic, experiencing increased risk of infection, hospitalization, and death. In this study, we sought to examine race- and ethnicity-based differences in SARS-CoV-2 testing. We used publicly available US state dashboards to extract demographic data for COVID-19 cases and tests. Poisson regression models were used to model the effect of race and ethnicity on the number of SARS-CoV-2 tests performed per case. In total, just 8 states reported testing data by race and ethnicity. In regression models, race and ethnicity was a significant predictor of testing rate per case. In all states, Hispanic/Latino patients had a significantly lower testing rate than their non-Hispanic/Latino counterparts, with an incident rate ratio varying from 0.45 to 0.81, depending on the state and referent race category. These results suggest disparities in testing access among Hispanic/Latino individuals, who are already at a disproportionate risk for infection and severe outcomes.

Assessing COVID-19 Pandemic Risk Perception and Response Preparedness in Veterinary and Animal Care Workers

Veterinary and animal care workers perform critical functions in biosecurity and public health, yet little has been done to understand the unique needs and barriers these workers face when responding during a pandemic crisis. In this article, we evaluated the perceived risks and roles of veterinary and animal care workers during the COVID-19 pandemic and explored barriers and facilitators in their readiness, ability, and willingness to respond during a pandemic. We deployed a survey targeting US veterinary medical personnel, animal shelter and control workers, zoo and wildlife workers, and other animal care workers. Data were collected on respondents' self-reported job and demographic factors, perceptions of risk and job efficacy, and readiness, ability, and willingness to respond during the pandemic. We found that leadership roles and older age had the strongest association with decreased perceived risk and improved job efficacy and confidence, and that increased reported contact level with others (both coworkers and the public) was associated with increased perceived risk. We determined that older age and serving in leadership positions were associated with improved readiness, willingness, and ability to respond. Veterinary and animal care workers' dedication to public health response, reflected in our findings, will be imperative if more zoonotic vectors of SARS-CoV-2 arise. Response preparedness in veterinary and animal care workers can be improved by targeting younger workers not in leadership roles through support programs that focus on improving job efficacy and confidence in safety protocols. These findings can be used to target intervention and training efforts to support the most vulnerable within this critical, yet often overlooked, workforce.

Retrospective identification of key activities in Uganda's preparedness measures related to the 2018-2020 EVD outbreak in eastern DRC utilizing a framework evaluation tool

Uganda has engaged in numerous capacity building activities related to outbreak preparedness over the last two decades and initiated additional just-in-time preparedness activities after the declaration of the 2018-2020 Ebola Virus Disease (EVD) outbreak in eastern Democratic Republic of Congo (DRC). When Uganda faced importation events related to the DRC outbreak in June-August 2019, the country's ability to prevent sustained in-country transmission was attributed to these long-term investments in preparedness. In order to help prepare countries for similar future scenarios, this analysis reviewed evidence from Uganda's response to the June-August 2019 importation events to identify preparedness activities and capacities that may have enabled Uganda to identify and isolate infected individuals or otherwise prevent further transmission. Content from 143 grey literature documents gathered via targeted and systematic searches from June 6, 2019 to October 29, 2019 and six interviews of key informants were utilized to inform a framework evaluation tool developed for this study. A conceptual framework of Uganda's preparedness activities was developed and evaluated against timelines of Uganda's response activities to the June-August 2019 EVD importation events based on the applicability of a preparedness activity to a response activity and the contribution of the said response activity to the prevention or interruption of transmission. Preparedness activities related to coordination, health facility preparation, case referral and management, laboratory testing and specimen transport, logistics and resource mobilization, and safe and dignified burials yielded consistent success across both importation events while point of entry screening was successful in one importation event but not another according to the framework evaluation tool. Countries facing similar threats should consider investing in these preparedness areas. Future analyses should validate and expand on the use of the framework evaluation tool.

Analysing COVID-19 outcomes in the context of the 2019 Global Health Security (GHS) Index

Introduction

The Global Health Security Index benchmarks countries’ capacities to carry out the functions necessary to prevent, detect and respond to biological threats. The COVID-19 pandemic served as an opportunity to evaluate whether the Index contained the correct array of variables that influence countries’ abilities to respond to these threats; assess additional variables that may influence preparedness; and examine how the impact of preparedness components change during public health crises.

Methods

Linear regression models were examined to determine the relationship between excess mortality per capita for the first 500 days of countries’ COVID-19 pandemic and internal Index variables, as well as external variables including social cohesion; island status; perceived corruption; elderly population size; previous epidemic experience; stringency of non-pharmaceutical interventions; and social and political polarisation.

Results

COVID-19 outcomes were significantly associated with sociodemographic, political and governance variables external to the 2019 Index: social cohesion, reduction in social polarisation and reduced perceptions of corruption were consistently correlated with reduced excess mortality throughout the pandemic. The association of other variables assessed by the Index, like epidemiological workforce robustness, changed over time. Fixed country features, including geographic connectedness, larger elderly population and lack of prior coronavirus outbreak experience were detrimental to COVID-19 outcomes. Finally, there was evidence that countries that lacked certain capacities were able to develop these over the course of the pandemic.

Conclusions

Additional sociodemographic, political and governance variables should be included in future indices to improve their ability to characterise preparedness. Fixed characteristics, while not directly addressable, are useful for establishing countries’ inherent risk profile and can motivate those at greater risk to invest in preparedness. Particular components of preparedness vary in their impact on outcomes over the course of the pandemic, which may inform resource direction during ongoing crises. Future research should seek to further characterise time-dependent impacts as additional COVID-19 outcome data become available.

Lives and Costs Saved by Expanding and Expediting Coronavirus Disease 2019 Vaccination

BACKGROUND

With multiple coronavirus disease 2019 (COVID-19) vaccines available, understanding the epidemiologic, clinical, and economic value of increasing coverage levels and expediting vaccination is important.

METHODS

We developed a computational model (transmission and age-stratified clinical and economics outcome model) representing the United States population, COVID-19 coronavirus spread (February 2020-December 2022), and vaccination to determine the impact of increasing coverage and expediting time to achieve coverage.

RESULTS

When achieving a given vaccination coverage in 270 days (70% vaccine efficacy), every 1% increase in coverage can avert an average of 876 800 (217 000-2 398 000) cases, varying with the number of people already vaccinated. For example, each 1% increase between 40% and 50% coverage can prevent 1.5 million cases, 56 240 hospitalizations, and 6660 deaths; gain 77 590 quality-adjusted life-years (QALYs); and save $602.8 million in direct medical costs and $1.3 billion in productivity losses. Expediting to 180 days could save an additional 5.8 million cases, 215 790 hospitalizations, 26 370 deaths, 206 520 QALYs, $3.5 billion in direct medical costs, and $4.3 billion in productivity losses.

CONCLUSIONS

Our study quantifies the potential value of decreasing vaccine hesitancy and increasing vaccination coverage and how this value may decrease with the time it takes to achieve coverage, emphasizing the need to reach high coverage levels as soon as possible, especially before the fall/winter.

Utility of Rapid Antigen Tests in Nursing Homes

In their article, McKay and colleagues show that rapid antigen tests have utility in nursing home settings to screen nursing home residents and staff. The editorialists discuss how these findings provide additional support to the idea that antigen testing could be useful to identify people who are likely to be contagious and may transmit SARS-CoV-2, and that rapid antigen tests can be a useful screening tool to limit infectious outbreaks.

Outbreak response operations during the US measles epidemic, 2017-19

BACKGROUND

To understand operational challenges involved with responding to US measles outbreaks in 2017-19 and identify applicable lessons in order to inform preparedness and response operations for future outbreaks, particularly with respect to specific operational barriers and recommendations for outbreak responses among insular communities.

METHODS

From August 2019 to January 2020, we conducted 11 telephone interviews with 18 participants representing state and local health departments and community health centers that responded to US measles outbreaks in 2017-19, with a focus on outbreaks among insular communities. We conducted qualitative, thematic coding to identify and characterize key operational challenges and lessons identified by the interviewees.

RESULTS

We categorized principal insights into 5 topic areas: scale of the response, vaccination operations, exclusion policies, community engagement, and countering anti-vaccine efforts. These topics address resource-intensive aspects of these outbreak responses, including personnel demands; guidance needed to support response operations and reduce transmission, such as excluding exposed or at-risk individuals from public spaces; operational challenges and barriers to vaccination and other response activities; and effectively engaging and educating affected populations, particularly with respect to insular and vulnerable communities.

CONCLUSIONS

Measles outbreak responses are resource intensive, which can quickly overwhelm existing public health capacities. Early and effective coordination with trusted leaders and organizations in affected communities, including to provide vaccination capacity and facilitate community engagement, can promote efficient response operations. The firsthand experiences of public health and healthcare personnel who responded to measles outbreaks, including among insular communities, provide evidence-based operational lessons that can inform future preparedness and response operations for outbreaks of highly transmissible diseases.

A US metropolitan county health department's response to a measles outbreak in a childcare facility - challenges faced and lessons learned

AIMS

In June 2018, the Multnomah County Health Department located in Portland, Oregon, US, responded to a measles exposure in a local childcare facility. This analysis describes lessons learned and challenges encountered during this measles response that may inform public health policy and help other local public health authorities prepare for measles outbreaks. These lessons will become increasingly important as measles cases continue to increase in both the US and abroad.

METHODS

A semi-structured videoconference interview was conducted with nine health department staff who were directly involved in the health department's response to the measles outbreak. Interview notes were iteratively discussed between all authors to identify those outbreak response challenges and lessons learned that were generalizable to the broader public health community.

RESULTS

Some of the key challenges and lessons learned included the need for increased provider recognition and reporting of measles cases, difficulty in determining which staff and children to exclude from attending daycare during the 21-day postexposure monitoring period, determining who would be prioritized to receive immunoglobulin, and the need for childcare staff vaccine status requirements.

CONCLUSION

Lessons from this response highlight important considerations for public health practitioners and policy makers. Given the relative severity of measles and the potential for spread in facilities that serve infants and young children, the public health community must continue to address key gaps through planning and policy.