Assessing health systems in Guinea for prevention and control of priority zoonotic diseases: A One Health approach

To guide One Health capacity building efforts in the Republic of Guinea in the wake of the 2014-2016 Ebola virus disease (EVD) outbreak, we sought to identify and assess the existing systems and structures for zoonotic disease detection and control. We partnered with the government ministries responsible for human, animal, and environmental health to identify a list of zoonotic diseases - rabies, anthrax, brucellosis, viral hemorrhagic fevers, trypanosomiasis and highly pathogenic avian influenza - as the country's top priorities. We used each priority disease as a case study to identify existing processes for prevention, surveillance, diagnosis, laboratory confirmation, reporting and response across the three ministries. Results were used to produce disease-specific systems "maps" emphasizing linkages across the systems, as well as opportunities for improvement. We identified brucellosis as a particularly neglected condition. Past efforts to build avian influenza capabilities, which had degraded substantially in less than a decade, highlighted the challenge of sustainability. We observed a keen interest across sectors to reinvigorate national rabies control, and given the regional and global support for One Health approaches to rabies elimination, rabies could serve as an ideal disease to test incipient One Health coordination mechanisms and procedures. Overall, we identified five major categories of gaps and challenges: (1) Coordination; (2) Training; (3) Infrastructure; (4) Public Awareness; and (5) Research. We developed and prioritized recommendations to address the gaps, estimated the level of resource investment needed, and estimated a timeline for implementation. These prioritized recommendations can be used by the Government of Guinea to plan strategically for future One Health efforts, ideally under the auspices of the national One Health Platform. This work demonstrates an effective methodology for mapping systems and structures for zoonotic diseases, and the benefit of conducting a baseline review of systemic capabilities prior to embarking on capacity building efforts.

Community Health Workers and Pandemic Preparedness: Current and Prospective Roles

Despite the importance of community health workers (CHWs) to health systems in resource-constrained environments, relatively little has been written about their contributions to pandemic preparedness. In this perspective piece, we draw from the response to the 2014 Ebola and 2015 Zika epidemics to review examples whereby CHWs contributed to health security and pandemic preparedness. CHWs promoted pandemic preparedness prior to the epidemics by increasing the access to health services and products within communities, communicating health concepts in a culturally appropriate fashion, and reducing the burdens felt by formal healthcare systems. During the epidemics, CHWs promoted pandemic preparedness by acting as community-level educators and mobilizers, contributing to surveillance systems, and filling health service gaps. Acknowledging the success CHWs have had in these roles and in previous interventions, we propose that the cadre may be better engaged in pandemic preparedness in the future. Some practical strategies for achieving this include training and using CHWs to communicate One Health information to at-risk communities prior to outbreaks, pooling them into a reserve health corps to be used during public health emergencies, and formalizing agreements and strategies to promote the early engagement of CHWs in response actions. Recognizing that CHWs already play a role in pandemic preparedness, we feel that expanding the roles and responsibilities of CHWs represents a practical means of improving pandemic and community-level resilience.

Local Decision Making for Implementing Social Distancing in Response to Outbreaks

OBJECTIVES

Social distancing is the practice of restricting contact among persons to prevent the spread of infection. This study sought to (1) identify key features of preparedness and the primary concerns of local public health officials in deciding to implement social distancing measures and (2) determine whether any particular factor could explain the widespread variation among health departments in responses to past outbreaks.

METHODS

We conducted an online survey of health departments in the United States in 2015 to understand factors influencing health departments' decision making when choosing whether to implement social distancing measures. We paired survey results with data on area population demographic characteristics and analyzed them with a focus on broad trends.

RESULTS

Of 600 health departments contacted, 150 (25%) responded. Of these 150 health departments, 63 (42%) indicated that they had implemented social distancing in the past 10 years. Only 10 (7%) health departments had a line-item budget for isolation or quarantine. The most common concern about social distancing was public health impact (n = 62, 41%). Concerns about law, politics, finances, vulnerable populations, and sociocultural issues were each identified by 7% to 10% of health departments. We were unable to clearly predict which factors would influence these decisions.

CONCLUSIONS

Variations in the decision to implement social distancing are likely the result of differences in organizational authority and resources and in the primary concerns about implementing social distancing. Research and current social distancing guidelines for health departments should address these factors.

Global health security and universal health coverage: from a marriage of convenience to a strategic, effective partnership

Global health security and universal health coverage have been frequently considered as "two sides of the same coin". Yet, greater analysis is required as to whether and where these two ideals converge, and what important differences exist. A consequence of ignoring their individual characteristics is to distort global and local health priorities in an effort to streamline policymaking and funding activities. This paper examines the areas of convergence and divergence between global health security and universal health coverage, both conceptually and empirically. We consider analytical concepts of risk and human rights as fundamental to both goals, but also identify differences in priorities between the two ideals. We support the argument that the process of health system strengthening provides the most promising mechanism of benefiting both goals.

Mapping stakeholders and policies in response to deliberate biological events

Background

Recent infectious disease outbreaks have brought increased attention to the need to strengthen global capacity to prevent, detect, and respond to natural biological threats. However, deliberate biological events also represent a significant global threat, but have received relatively little attention. While the Biological Weapons Convention provides a foundation for the response to deliberate biological events, the political mechanisms to respond to and recover from such an event are poorly defined.

Methods

We performed an analysis of the epidemiological timeline, the international policies triggered as a notional deliberate biological event unfolds, and the corresponding stakeholders and mandates assigned by each policy.

Findings

The results of this analysis identify a significant gap in both policy and stakeholder mandates: there is no single policy nor stakeholder mandate for leading and coordinating response activities associated with a deliberate biological event. These results were visualized using an open source web-based tool published at https://dbe.talusanalytics.com.

Interpretation

While there are organizations and stakeholders responsible for leading security or public health response, these roles are non-overlapping and are led by organizations not with limited interaction outside such events. The lack of mandates highlights a gap in the mechanisms available to coordinate response and a gap in guidance for managing the response. The results of the analysis corroborate anecdotal evidence from stakeholder meetings and highlight a critical need and gap in deliberate biological response policy.

Analysis of results from the Joint External Evaluation: examining its strength and assessing for trends among participating countries

Background

The Joint External Evaluation (JEE) is part of the World Health Organization’s (WHO) new process to help countries assess their ability to prevent, detect and respond to public health threats such as infectious disease outbreaks, as specified by the International Health Regulations (IHR). How countries are faring on these evaluations is not well known and neither is there any previous assessment of the performance characteristics of the JEE process itself.

Methods

We obtained JEE data for 48 indicators collectively across 19 technical areas of preparedness for 55 countries. The indicators are scored on a 1 to 5 scale with 4 indicating demonstrated capacity. We created a standardized JEE index score representing cumulative performance across indicators using principal components analysis. We examined the state of performance across all indicators and then examined the relationship between this index score and select demographic and health variables to better understand potential drivers of performance.

Results

Among our study cohort, the median performance on 43 of the 48 (89.6%) indicators was less than 4, suggesting that countries were failing to meet demonstrated capacity on these measures. The two weakest indicators were related to antimicrobial resistance (median score = 1.0, interquartile range = 1.0-2.0) and biosecurity response (median score = 2.0, interquartile range = 2.0-3.0). JEE index scores correlated with various metrics of health outcomes (life expectancy, under-five year mortality rate, disability-adjusted life years lost to communicable diseases) and with standard measures of social and economic development that enable public health system performance in the total sample, but in stratified analyses, these relationships were much weaker in the AFRO region.

Conclusions

We find large variations in JEE scores among countries and WHO regions with many nations still unprepared for the next disease outbreak with pandemic potential The strong correlations between JEE performance and metrics of both health outcomes and health systems’ performance suggests that the JEE is likely accurately measuring the strength of IHR-specific, public health capabilities.

Anaesthetic management for caesarean section of a parturient with a known difficult airway and closed spinal dysraphism

Many anaesthetists consider patients with existing neurological deficits, untreated spinal pathology or those having undergone major spinal intervention to be precluded from undergoing neuraxial anaesthesia. While this is partly rooted in fears of litigation there is also a lack of consensus of the best practice in the anaesthetic management of these patients. We present our management of a parturient who attended our institution, having a number of anaesthetic complexities including a known difficult airway, spinal fusion and persistent spinal cord tethering. She successfully underwent delivery under neuraxial blockade for the delivery of her fourth child. We believe that by undergoing a thorough multidisciplinary clinical evaluation, including the extensive use of neuroimaging and ultrasound, it may be possible to plan and perform safe neuraxial anaesthesia.

Organization of oversight for integrated control of neglected tropical diseases within Ministries of Health

BACKGROUND

Neglected tropical diseases (NTDs) are communicable diseases that impact approximately 1 billion people, but receive relatively little research, funding, and attention. Many NTDs have similar treatments, epidemiology, and geographic distribution, and as a result, the integration of control efforts can improve accountability, efficiency, and cost-effectiveness of programs. Here, we examine the landscape of efforts towards NTD integration across countries with the highest burden of disease, and review the administrative management of integration in order to identify approaches and pathways for integration.

METHODOLOGY AND PRINCIPAL FINDINGS

We utilized a standardized system to score countries for NTD endemnicity to create a list of 25 countries with the highest overall burden of NTDs. We then conducted a literature review to characterize the NTD control programs in the focus countries. Six countries were selected for key informant interviews to validate literature review results and gather additional data on opportunities and obstacles to NTD integration, from an administrative perspective. The majority of countries included in the study were located in Africa, with the remainder from Asia, North America, and South America. Multiple models and pathways were observed for the integration of NTD programs, in combination with other NTD programs, other diseases, or other health programs. Substantial heterogeneity existed with respect to the NTD control programs, and no country had integrated all of their NTD control efforts into a single program. NTDs that can be treated with preventative chemotherapy were frequently integrated into a single program. Leprosy control was also frequently integrated with those of other communicable diseases, and notably tuberculosis. Barriers to NTD integration may result from internal administrative obstacles or external obstacles.

CONCLUSIONS

Although many countries have begun to integrate NTD control efforts, additional work will be required to realize the full benefits of integration in most of the countries examined here. Moving forward, NTD integration efforts must ensure that administrative structures are designed to maximize the potential success of integrated programs and account for existing administrative processes.

Strengthening health security: an intuitive and user-friendly tool to estimate country-level costs

Member States of the WHO working to build capacity under the International Health Regulations (IHR) are advised to develop prioritised, costed plans to implement improvements based on the results of voluntary external assessments. Defining the costs associated with capacity building under the IHR, however, has challenged nations, funders and supporting organisations. Most current efforts to develop costed national action plans involve long-term engagements that may take weeks or months to complete. While these efforts have value in and of themselves, there is an urgent need for a rapid-use tool to provide cost estimates regardless of the level of expertise of the personnel assigned to the task. In this paper, we describe a tool that can—in a matter of hours—provide country-level cost estimates for capacity building under the IHR. This paper also describes how the tool can be used in countries, as well as the challenges inherent in any costing process.

Decision support for evidence-based integration of disease control: A proof of concept for malaria and schistosomiasis

AUTHOR SUMMARY

Designing and implementing effective programs for infectious disease control requires complex decision-making, informed by an understanding of the diseases, the types of disease interventions and control measures available, and the disease-relevant characteristics of the local community. Though disease modeling frameworks have been developed to address these questions and support decision-making, the complexity of current models presents a significant barrier to on-the-ground end users. The picture is further complicated when considering approaches for integration of different disease control programs, where co-infection dynamics, treatment interactions, and other variables must also be taken into account. Here, we describe the development of an application available on the internet with a simple user interface, to support on-the-ground decision-making for integrating disease control, given local conditions and practical constraints. The model upon which the tool is built provides predictive analysis for the effectiveness of integration of schistosomiasis and malaria control, two diseases with extensive geographical and epidemiological overlap. This proof-of-concept method and tool demonstrate significant progress in effectively translating the best available scientific models to support pragmatic decision-making on the ground, with the potential to significantly increase the impact and cost-effectiveness of disease control.