A checklist to improve health system resilience to infectious disease outbreaks and natural hazards

Recent infectious disease outbreaks, including the ongoing global COVID-19 pandemic and Ebola in the Democratic Republic of the Congo, have demonstrated the critical importance of resilient health systems in safeguarding global health security. Importantly, the human, economic and political tolls of these crises are being amplified by health systems’ inabilities to respond quickly and effectively. Improving resilience within health systems can build on pre-existing strengths to enhance the readiness of health system actors to respond to crises, while also maintaining core functions. Using data gathered from a scoping literature review, interviews with key informants and from stakeholders who attended a workshop held in Dhaka, Bangladesh, we developed a Health System Resilience Checklist (‘the checklist’). The aim of the checklist is to measure the specific capacities, capabilities and processes that health systems need in order to ensure resilience in the face of both infectious disease outbreaks and natural hazards. The checklist is intended to be adapted and used in a broad set of countries as a component of ongoing processes to ensure that health actors, institutions and populations can mount an effective response to infectious disease outbreaks and natural hazards while also maintaining core healthcare services. The checklist is an important first step in improving health system resilience to these threats, but additional research and resources will be necessary to further refine and prioritise the checklist items and to pilot the checklist with the frontline health facilities that would be using it. This will help ensure its feasibility and durability for the long-term within the health systems strengthening and health security fields.

Operational stresses on New York City Health+Hospitals Health System frontline hospitals during the 2017-18 influenza season

OBJECTIVE

Identify operational lessons to support hospital and health system preparedness and response for sea-sonal and pandemic influenza based on firsthand experiences from the 2017-2018 influenza season.

DESIGN

We conducted semistructured, retrospective interviews with New York City Health+Hospitals (NYCH+H) personnel to gather firsthand experiences from the 2017-2018 influenza season and evaluated stress data across four operational domains reported by NYCH+H hospitals during the 2017-2018 influenza season.

SETTING

Frontline hospitals in the NYCH+H health system during and after the 2017-2018 influenza season.

PARTICIPANTS

Interviews conducted with personnel from 5 NYCH+H frontline hospitals. Operational stress data re-ported by 11 NYCH+H hospitals during the 2017-2018 influenza season.

MAIN OUTCOME MEASURES

Operational challenges and lessons from frontline hospitals responding to severe sea-sonal influenza.

RESULTS

Operational stresses during the 2017-2018 influenza season varied over the influenza season, between facilities, and across operational domains. Patient surge and staff absenteeism pushed some facilities to their limits, and supply shortages highlighted shortcomings in existing procurement systems. Resources tied to pandemic influ-enza were unavailable without a pandemic declaration.

CONCLUSION

Seasonal influenza poses dynamic operational stresses across health systems and cities, potentially causing major impacts outside of declared pandemics. Lessons from NYCH+H can help other hospitals and health systems anticipate operational challenges, but novel solutions are needed to mitigate effects of patient surge and per-sonnel and supply shortages during severe influenza seasons and pandemics. Improved data collection can help health systems better understand operational stresses and challenges across their facilities.

An analysis of International Health Regulations Emergency Committees and Public Health Emergency of International Concern Designations

INTRODUCTION

Nine events have been assessed for potential declaration of a Public Health Emergency of International Concern (PHEIC). A PHEIC is defined as an extraordinary event that constitutes a public health risk to other states through international spread and requires a coordinated international response. The WHO Director-General convenes Emergency Committees (ECs) to provide their advice on whether an event constitutes a PHEIC. The EC rationales have been criticised for being non-transparent and contradictory to the International Health Regulations (IHR). This first comprehensive analysis of EC rationale provides recommendations to increase clarity of EC decisions which will strengthen the IHR and WHO's legitimacy in future outbreaks.

METHODS

66 EC statements were reviewed from nine public health outbreaks of influenza A, Middle East respiratory syndrome coronavirus, polio, Ebola virus disease, Zika, yellow fever and coronavirus disease-2019. Statements were analysed to determine which of the three IHR criteria were noted as contributing towards the EC's justification on whether to declare a PHEIC and what language was used to explain the decision.

RESULTS

Interpretation of the criteria were often vague and applied inconsistently. ECs often failed to describe and justify which criteria had been satisfied.

DISCUSSION

Guidelines must be developed for the standardised interpretation of IHR core criteria. The ECs must clearly identify and justify which criteria have contributed to their rationale for or against PHEIC declaration.

CONCLUSION

Striving for more consistency and transparency in EC justifications would benefit future deliberations and provide more understanding and support for the process.

State by state implementation of Zika virus testing guidance in the United States in 2017 and 2018

In 2015 and 2016, outbreaks of the Zika virus began occurring in the Americas and the Caribbean. Following the introduction of this new threat, the United States’ Centers for Disease Control and Prevention (CDC) issued testing guidance for the nation’s state public health laboratories. We collected and analyzed testing guidance for all fifty states and the District of Columbia for both 2017 and 2018. In both years, state testing guidance was consistent for men and non-pregnant women, but there was notable variation in guidance for pregnant women. In addition, there were changes between the two years as testing algorithms shifted toward guidance that recommended testing in more limited circumstances. States adopted large, or complete, portions of CDC testing guidance, but were not required to conform completely, 33% of states had identical guidance in 2017 and 49% in 2018. Some of these trends, such as specifying that testing be contingent on travel, or sexual contact with an individual who has recently traveled, to an area where the Zika virus was circulating, presents a potential deficiency in the United States surveillance capacity. Understanding variations in state testing guidance enables public health professionals to better understand ongoing surveillance. This analysis provides insight into the testing practices for the various states across the country. Better understanding of how states approach Zika testing, and how that testing changes over time, will increase the public health community’s ability to interpret future Zika case counts.

Operational stresses on New York City Health+Hospitals Health System frontline hospitals during the 2017-18 influenza season

OBJECTIVE

Identify operational lessons to support hospital and health system preparedness and response for sea-sonal and pandemic influenza based on firsthand experiences from the 2017-2018 influenza season.

DESIGN

We conducted semistructured, retrospective interviews with New York City Health+Hospitals (NYCH+H) personnel to gather firsthand experiences from the 2017-2018 influenza season and evaluated stress data across four operational domains reported by NYCH+H hospitals during the 2017-2018 influenza season.

SETTING

Frontline hospitals in the NYCH+H health system during and after the 2017-2018 influenza season.

PARTICIPANTS

Interviews conducted with personnel from 5 NYCH+H frontline hospitals. Operational stress data reported by 11 NYCH+H hospitals during the 2017-2018 influenza season.

MAIN OUTCOME MEASURES

Operational challenges and lessons from frontline hospitals responding to severe seasonal influenza.

RESULTS

Operational stresses during the 2017-2018 influenza season varied over the influenza season, between facilities, and across operational domains. Patient surge and staff absenteeism pushed some facilities to their limits, and supply shortages highlighted shortcomings in existing procurement systems. Resources tied to pandemic influ-enza were unavailable without a pandemic declaration.

CONCLUSION

Seasonal influenza poses dynamic operational stresses across health systems and cities, poten-tially causing major impacts outside of declared pandemics. Lessons from NYCH+H can help other hospitals and health systems anticipate operational challenges, but novel solutions are needed to mitigate effects of patient surge and personnel and supply shortages during severe influenza seasons and pandemics. Improved data collection can help health systems better understand operational stresses and challenges across their facilities.

Outbreaks of Hepatitis A in US Communities, 2017-2018: Firsthand Experiences and Operational Lessons From Public Health Responses

Objectives. To identify and analyze common challenges from multiple US communities affected by the hepatitis A epidemic beginning in March 2017, and to identify operational lessons to support preparedness for similar future public health emergencies.Methods. We conducted semistructured interviews with health officials from 9 city or county health departments to collect the firsthand experience of public health responders. We collected data from January to October 2018 via teleconference. Key informants, whom we purposefully sampled, were senior public health officials who were directly involved in outbreak response or in preparing for potential hepatitis A outbreaks in their communities.Results. Several themes emerged during these discussions, including common challenges and solutions pertaining to sanitation and hygiene infrastructure, hepatitis A vaccination, health workforce availability and surge capacity, communication and stigma, and partnerships and coordination with local law enforcement and other stakeholders.Conclusions. By generating key, evidence-based operational lessons, this study can inform response activities in localities currently experiencing outbreaks as well as community preparedness for possible future outbreaks due to the presence of similar at-risk populations.

What makes health systems resilient against infectious disease outbreaks and natural hazards? Results from a scoping review

Background

The 2014–2016 Ebola outbreak was a wake-up call regarding the critical importance of resilient health systems. Fragile health systems can become overwhelmed during public health crises, further exacerbating the human, economic, and political toll. Important work has been done to describe the general attributes of a health system resilient to these crises, and the next step will be to identify the specific capacities that health systems need to develop and maintain to achieve resiliency.

Methods

We conducted a scoping review of the literature to identify recurring themes and capacities needed for health system resiliency to infectious disease outbreaks and natural hazards and any existing implementation frameworks that highlight these capacities. We also sought to identify the overlap of the identified themes and capacities with those highlighted in the World Health Organization’s Joint External Evaluation. Sources of evidence included PubMed, Web of Science, OAIster, and the websites of relevant major public health organizations.

Results

We identified 16 themes of health system resilience, including: the need to develop plans for altered standards of care during emergencies, the need to develop plans for post-event recovery, and a commitment to quality improvement. Most of the literature described the general attributes of a resilient health system; no implementation frameworks were identified that could translate these elements into specific capacities that health system actors can employ to improve resilience to outbreaks and natural hazards in a variety of settings.

Conclusions

An implementation-oriented health system resilience framework could help translate the important components of a health system identified in this review into specific capacities that actors in the health system could work to develop to improve resilience to public health crises. However, there remains a need to further refine the concept of resilience so that health systems can simultaneously achieve sustainable transformations in healthcare practice and health service delivery as well as improve their preparedness for emergencies.

Taiwan's Annual Seasonal Influenza Mass Vaccination Program-Lessons for Pandemic Planning

Rapid medical countermeasure (MCM) dispensing is an important intervention during a public health emergency. In the United States, MCM planning and exercising efforts have largely focused on dispensing therapeutics, with less emphasis on mass vaccination operations that would require additional specialized staff and infrastructure. Difficulties in distributing vaccines during the 2009 H1N1 influenza pandemic highlighted the need for enhanced planning and exercising of plans for conducting mass vaccination campaigns. In Taiwan, seasonal influenza mass vaccination campaigns are conducted annually, which both mitigate the effects of seasonal influenza and serve as functional exercises for mass vaccination operations during a pandemic. To identify lessons that can be applied to mass vaccination planning in the United States and elsewhere, we conducted an in-person observation and data review of Taiwan's annual seasonal influenza mass vaccination efforts in October 2017. We offer findings and recommendations for enhancing preparedness for seasonal and pandemic influenza and other public health emergencies that would require mass vaccination.

Establishing a theoretical foundation for measuring global health security: a scoping review

Background

Since the 2014–2016 West Africa Ebola epidemic, the concept of measuring health security capacity has become increasingly important within the broader context of health systems-strengthening, enhancing responses to public health emergencies, and reducing global catastrophic biological risks. Efforts to regularly and sustainably track the evolution of health security capabilities and capacities over time – while also accounting for political, social, and environmental risks – could help countries progress toward eliminating sources of health insecurity. We sought to aggregate evidence-based principles that capture a country’s baseline public health and healthcare capabilities, its health security system performance before and during infectious disease crises, and its broader social, political, security, and ecological risk environments.

Methods

We conducted a scoping review of English-language scholarly and gray literature to identify evidence- and practice-based indicators and proxies for measuring health security at the country level over time. We then used a qualitative coding framework to identify recurrent themes in the literature and synthesize foundational principles for measuring global health security. Documents reviewed included English-language literature published after 2001 until the end of the research period—September 2017—to ensure relevance to the current global health security landscape; literature examining acute infectious disease threats with potential for transnational spread; and literature addressing global health security efforts at the country level.

Results

We synthesized four foundational principles for measuring global health security: measurement requires assessment of existing capacities, as well as efforts to build core public health, healthcare, and biosecurity capabilities; assessments of national programs and efforts to mitigate a critical subset of priority threats could inform efforts to generate useful metrics for global health security; there are measurable enabling factors facilitating health security-strengthening efforts; and finally, measurement requires consideration of social, political, and ecological risk environments.

Conclusion

The themes identified in this review could inform efforts to systematically assess the impacts and effectiveness of activities undertaken to strengthen global health security.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7216-0) contains supplementary material, which is available to authorized users.

Evaluating the frequency of operational research conducted during the 2014-2016 West Africa Ebola epidemic

INTRODUCTION

The West Africa Ebola epidemic of 2014-2016 was the largest Ebola outbreak on record, and thousands of individuals were involved in the response, including local and national governments, as well as numerous philanthropic and other non-governmental organizations. A number of after-action reports and other reviews of the global response to the epidemic routinely pointed out key challenges, including gaps in operational research.

METHODS

To determine the extent to which operational research studies were conducted during the 2014-2016 West Africa Ebola epidemic, a quantitative analysis of the literature published during and immediately after the epidemic was conducted. The goal was to identify the proportion of all Ebola-related publications released regarding the epidemic that addressed operational aspects of the response. It was also sought to describe, at a general level, the sorts of studies that were published during the epidemic, with the goal of increasing understanding of whether additional efforts are needed to encourage the conduct and dissemination of operational studies during future public health crises.

RESULTS

Among the 3681 publications on Ebola published between the World Health Organization announcement of the Ebola outbreak in March 2014 and the end of 2017, 109 (3%) were determined to be operational research publications. Among these, 64 (58%) were published after the World Health Organization initially declared the outbreak over on January 14, 2016, reflecting the time delay of sharing operational lessons with the broader preparedness and response community.

DISCUSSION

Improved sharing of firsthand, operational knowledge from practitioners who respond to outbreaks is critical for improving preparedness activities and informing the development of sound, effective policies that support ongoing and future preparedness efforts. Based on the results from this review, we propose several policy and programmatic innovations that could facilitate knowledge sharing during future outbreaks.

Global Catastrophic Biological Risks: Toward a Working Definition

The Johns Hopkins Center for Health Security is working to analyze and deepen scientific dialogue regarding potential global catastrophic biological risks (GCBRs), in a continuation of its mission to reduce the consequences of epidemics and disasters. Because GCBRs constitute an emerging policy concern and area of practice, we have developed a framework to guide our work. We invited experts from a variety of disciplines to engage with our underlying concepts and assumptions to refine collective thinking on GCBRs and thus advance protections against them.

Public Health Surveillance: At the Core of the Global Health Security Agenda

Global health security involves developing the infrastructure and capacity to protect the health of people and societies worldwide. The acceleration of global travel and trade poses greater opportunities for infectious diseases to emerge and spread. The International Health Regulations (IHR) were adopted in 2005 with the intent of proactively developing public health systems that could react to the spread of infectious disease and provide better containment. Various challenges delayed adherence to the IHR. The Global Health Security Agenda came about as an international collaborative effort, working multilaterally among governments and across sectors, seeking to implement the IHR and develop the capacities to prevent, detect, and respond to public health emergencies of international concern. When examining the recent West African Ebola epidemic as a case study for global health security, both strengths and weaknesses in the public health response are evident. The central role of public health surveillance is a lesson reiterated by Ebola. Through further implementation of the Global Health Security Agenda, identified gaps in surveillance can be filled and global health security strengthened.

The Joint External Evaluation of Taiwan: The External Evaluators' Perspective

A team of experts from the Johns Hopkins Center for Health Security conducted an independent external assessment of Taiwan's capabilities under the International Health Regulations 2005 (IHR), using the IHR Joint External Evaluation (JEE) tool adopted by the World Health Organization and the Global Health Security Agenda. In this article we describe the methods and process of the assessment, identify lessons learned, and make recommendations for the government of Taiwan, the JEE process, and the JEE tool.

Enhancing the Diagnosis, Treatment, Surveillance, and Control of Infectious Diseases in the ACA Era

As US public health faces increasing threats from outbreaks, impending changes to the healthcare landscape in the United States may alter the way that health departments are able to detect and control some of the most common infectious diseases. The Patient Protection and Affordable Care Act (ACA) has made significant changes in the way health care is provided in the United States. While many of the clinical, economic, and policy implications of the ACA are well described, there has been limited analysis of changes, if any, in the surveillance and control of infectious diseases of public health importance-such as tuberculosis, sexually transmitted infections, and HIV-that are anticipated or occurring as the ACA is implemented across the United States. To address these questions, we reviewed the literature for evidence of changing trends and conducted 66 semi-structured, not-for-attribution interviews with 82 participants from healthcare systems; academia; federal, state, and local public health agencies; and professional and nongovernmental organizations across the United States. This analysis identifies several ways in which ACA implementation has not fully addressed the public health needs associated with diagnosis, treatment, surveillance, and control of infectious diseases of public health importance.

Analysis of latent tuberculosis infection treatment adherence among refugees and other patient groups referred to the Baltimore City Health Department TB clinic, February 2009-March 2011

We sought to determine the proportion of refugee patients at the Baltimore City Health Department Tuberculosis program (BCHD-TB) successfully completing latent tuberculosis infection (LTBI) treatment, as compared to other referral groups, and to identify factors associated with treatment completion. We completed a retrospective cohort analysis of individuals referred to BCHD-TB program for LTBI care between February 1, 2009 and March 31, 2011. Among 841 patients evaluated by BCHD-TB and diagnosed with LTBI, 81% of refugees, 50% of non-refugee foreign-born, and 35% of US-born patients completed LTBI treatment. In multivariate analysis, refugees had greater odds of LTBI treatment completion (Adjusted Odds Ratio 7.2; 95% CI 4.2-12.4, p < 0.001) compared to US-born individuals adjusting for age, gender, and treatment regimen. Overall, LTBI treatment completion remains suboptimal. At BCHD-TB, LTBI treatment completion was significantly higher among refugees than other referral groups. Additional efforts are needed to optimize LTBI care, and future efforts may need to be tailored for different risk groups.