Global health security: the wider lessons from the west African Ebola virus disease epidemic

From the Frontline: Strengthening Surveillance and Response Capacities of the Rural Workforce in the Asia-Pacific Region. How Can Grass-Roots Implementation Research Help?

Health systems in the Asia-Pacific region are poorly prepared for pandemic threats, particularly in rural/provincial areas. Yet future emerging infectious diseases are highly likely to emerge in these rural/provincial areas, due to high levels of contact between animals and humans (domestically and through agricultural activities), over-stretched and under-resourced health systems, notably within the health workforce, and a diverse array of socio-cultural determinants of health. In order to optimally implement health security measures at the frontline of health services where the people are served, it is vital to build capacity at the local district and facility level to adapt national and global guidelines to local contexts, including health systems, and community and socio-cultural realities. During 2017/18 James Cook University (JCU) facilitated an implementation research training program (funded by Australian Department of Foreign Affairs and Trade) for rural/provincial and regional health and biosecurity workers and managers from Fiji, Indonesia, Papua New Guinea (PNG), Solomon Islands and Timor-Leste. This training was designed so frontline health workers could learn research in their workplace, with no funding other than workplace resources, on topics relevant to health security in their local setting. The program, based upon the WHO-TDR Structured Operational Research and Training IniTiative (SORT-IT) consists of three blocks of teaching and a small, workplace-based research project. Over 50 projects by health workers including surveillance staff, laboratory managers, disease control officers, and border security staff included: analysis and mapping of surveillance data, infection control, IHR readiness, prevention/response and outbreak investigation. Policy briefs written by participants have informed local, provincial and national health managers, policy makers and development partners and provided on-the-ground recommendations for improved practice and training. These policy briefs reflected the socio-cultural, health system and disease-specific realities of each context. The information in the policy briefs can be used collectively to assess and strengthen health workforce capacity in rural/provincial areas. The capacity to use robust but simple research tools for formative and evaluative purposes provides sustainable capacity in the health system, particularly the rural health workforce. This capacity improves responses to infectious diseases threats and builds resilience into fragile health systems.

The Urgent Need for Transparent and Accountable Procurement of Medicine and Medical Supplies in Times of COVID-19 Pandemic

The COVID-19 pandemic has unleashed unprecedented and complex public policy issues. One that has emerged as a challenge for many countries globally is how to ensure the efficient and effective procurement of quality medical supplies. Existing corruption pressures on procurement-everything from undue influence to the outright bribery of public officials-has been amplified by the pandemic, and thus demands commensurate policy responses. We argue that transparency and accountability in procurement are essential to preventing the corruption risks that threaten the health and well-being of populations.

The cost of insecurity: from flare-up to control of a major Ebola virus disease hotspot during the outbreak in the Democratic Republic of the Congo, 2019

The ongoing Ebola outbreak in the eastern Democratic Republic of the Congo is facing unprecedented levels of insecurity and violence. We evaluate the likely impact in terms of added transmissibility and cases of major security incidents in the Butembo coordination hub. We also show that despite this additional burden, an adapted response strategy involving enlarged ring vaccination around clusters of cases and enhanced community engagement managed to bring this main hotspot under control.

COVID-19: The World Community Expects the World Health Organization to Play a Stronger Leadership and Coordination Role in Pandemics Control

The coronavirus disease 2019 (COVID-19) pandemic has been accompanied by the return of the concept of national state and exhibited signs of crisis of globalism and liberalism. The pandemic affected most aspects of society and human activity, including socioeconomic impact. Economic problems, shortages of medical supplies and personnel, xenophobic sentiments, and misinformation led to the use of unethical practices and human rights violations. To navigate through this crisis, many countries resorted to traditional diplomacy in the absence of effective international instruments. Thus, the world faced the urgent need in functioning global governance. The pandemic also manifested the increasing importance of international organizations as sources of technical expertise, providing scientific basis for politicians to legitimize their decisions and actions. The article addresses the topic of implications of the pandemic for governance and forecasting a post-pandemic future. The research focus of this paper, therefore, is the assessment of the role of the World Health Organization (WHO) in prevention and response to pandemics. The work is aimed at identifying the functions of the WHO and assessing its activities in prevention and control of pandemics and response to the COVID-19 pandemic in particular. Furthermore, the objective of this article is to identify gaps in the WHO pandemic control efforts and formulate recommendations on addressing them.

Public perception of COVID-19’s global health crisis on Twitter until 14 weeks after the outbreak

Because language represents advanced aspects of human cognition, studying linguistic styles and figurative meaning have proven effective in measuring embodied cognition about the external world. This article defines the most worrisome topics people discussed from Weeks 1 to 14 after the outbreak and compares the message delivered by the literal use of words to the figurative use of metaphoric expressions. We bootstrapped representative data from Twitter over 14 weeks since the inception of the outbreak to be analyzed thematically using the Linguistic Inquiry and Word Count (LIWC) 2015 software as well as corpus tools. The MetaNet database, corpus tools, and manual annotation were used to detect expressions that can be linguistically mapped to the formalized list of conceptual metaphors. The most frequently tagged themes included ‘the outbreak of the pandemic, its epidemiology, its prophylaxis measures, national and world economies, media’, as well as the ‘signs and symptoms of COVID-19’. Although LIWC-based analysis showed English-speaking tweeters maintained high levels of analytical thinking, elevated levels of anger, anxiety, and doubtfulness, there were discrepancies and improper conceptualization of the clinical picture of the pandemic.

Moving health to the heart of agri-food policies; mitigating risk from our food systems

Our food systems are progressively more industrialized and consolidated with many modern food value chains involving multiple countries and continents, and as such being associated with changes in risk profile and impacts of emerging and re-emerging diseases. Disease outbreaks that sweep through a single region can have massive impacts on food supply, while severe outbreaks of human pathogens can disrupt agricultural labor supply or demand for products perceived as 'unsafe'. Market pressures have generally rewarded production of cash crops for fuel and energy dense, low nutrient processed foods over production of fruits and vegetables for local consumption. Climbing rates of food-related NCDs and pre-existing conditions leave the population increasingly susceptible to infectious diseases that are often driven by or arise from the food system. Therefore disease and diet from our food systems cause impacts on human health, and human health issues can impact on the functioning of the food system. The COVID-19 outbreak is the most recent example of food system driven disease emergence and of massive supply and demand shocks in the food system, experienced as a direct and indirect result of this disease. The effects of the food system on disease spread (and vice versa) must be addressed in future plans to prevent and mitigate large scale outbreaks. Health policies must acknowledge the food system as the base of our health system, as must agri-food policy recognize the pre-eminence of human health (directly and indirectly) in decision making.

Operationalizing the One Health Approach in Uganda: Challenges and Opportunities

Uganda is considered as a ‘hot spot’ for emerging and re-emerging infectious disease epidemics. The country has experienced several epidemics including; Ebola, Marburg, plague, Rift Valley fever, yellow fever and Crimean Congo haemorrhagic fever. Epidemics overwhelm health systems, devastate economies and cause global health insecurity. These public health challenges arising from the interaction of humans-animals-environment link require a holistic approach referred to as One Health (OH). OH is the collaborative effort of multiple disciplines working locally, nationally, and globally, to attain optimal health for people, animals, and the environment. Given its situation, Uganda has embraced the OH approach in order to be able to predict, prepare and respond to these public health challenges effectively, though still in infancy stages. In this paper, we present major achievements and challenges of OH implementation, and make recommendations for systematic and sustainable OH implementation. Achievements include: formation of the National One Health (NOH) platform with a Memorandum of Understanding between sectors; a national priority list of zoonotic diseases, the NOH Strategic Plan and a One Health communication strategy to strengthen engagement across sectors and stakeholders. There have also been efforts to integrate OH in academia. The challenges are related to inadequate; coordination across sectors, government commitment, advocacy and awareness creation and research. For systematic and sustainable OH engagements, urgent efforts should be made through government support to address current and related future challenges.

Using routine health information data for research in low- and middle-income countries: a systematic review

BACKGROUND

Routine health information systems (RHISs) support resource allocation and management decisions at all levels of the health system, as well as strategy development and policy-making in many low- and middle-income countries (LMICs). Although RHIS data represent a rich source of information, such data are currently underused for research purposes, largely due to concerns over data quality. Given that substantial investments have been made in strengthening RHISs in LMICs in recent years, and that there is a growing demand for more real-time data from researchers, this systematic review builds upon the existing literature to summarize the extent to which RHIS data have been used in peer-reviewed research publications.

METHODS

Using terms 'routine health information system', 'health information system', or 'health management information system' and a list of LMICs, four electronic peer-review literature databases were searched from inception to February 202,019: PubMed, Scopus, EMBASE, and EconLit. Articles were assessed for inclusion based on pre-determined eligibility criteria and study characteristics were extracted from included articles using a piloted data extraction form.

RESULTS

We identified 132 studies that met our inclusion criteria, originating in 37 different countries. Overall, the majority of the studies identified were from Sub-Saharan Africa and were published within the last 5 years. Malaria and maternal health were the most commonly studied health conditions, although a number of other health conditions and health services were also explored.

CONCLUSIONS

Our study identified an increasing use of RHIS data for research purposes, with many studies applying rigorous study designs and analytic methods to advance program evaluation, monitoring and assessing services, and epidemiological studies in LMICs. RHIS data represent an underused source of data and should be made more available and further embraced by the research community in LMIC health systems.

Field evaluation of a mobile biosafety laboratory in Senegal to strengthen rapid disease outbreak response and monitoring

Background

Past and recent outbreaks have highlighted the vulnerability of humans to infectious diseases, which represent serious economic and health security threats. A paradigm shift in the management of sanitary crises is urgently needed. Based on lessons from the 2014 Ebola outbreak, the Praesens Foundation has developed an all-terrain mobile biosafety laboratory (MBS-Lab) for effective field diagnostics capabilities.

Objective

The aim of the study was to train African teams and run a field evaluation of the MBS-Lab, including robustness, technical and operational sustainability, biosafety, connectivity, turn-around times for testing and result delivery.

Methods

The MBS-Lab was deployed in Senegal in October 2017 for a six-month field assessment under various ecological conditions and was mobilised during the dengue outbreaks in 2017 and 2018.

Results

The MBS-Lab can be considered an off-grid solution that addresses field challenges with regard to working conditions, mobility, deployment, environment and personnel safety. Blood (n = 398) and nasal swab (n = 113) samples were collected from 460 study participants for molecular screening for acute febrile illnesses and respiratory infections. The results showed that malaria (particularly in Kédougou) and upper respiratory tract infections remain problematic. Suspected dengue samples were tested on board during the dengue outbreaks in 2017 (882 tests; 128 confirmed cases) and 2018 (1736 tests; 202 confirmed cases).

Conclusion

The MBS-Lab is an innovative solution for outbreak response, even in remote areas. The study demonstrated successful local ownership and community engagement. The MBS-Lab can also be considered an open mobile healthcare platform that offers various opportunities for field-deployable, point-of-care technologies for surveillance programmes.

National reporting of deaths after enhanced Ebola surveillance in Sierra Leone

Background

Sierra Leone experienced the largest documented epidemic of Ebola Virus Disease in 2014–2015. The government implemented a national tollfree telephone line (1-1-7) for public reporting of illness and deaths to improve the detection of Ebola cases. Reporting of deaths declined substantially after the epidemic ended. To inform routine mortality surveillance, we aimed to describe the trends in deaths reported to the 1-1-7 system and to quantify people’s motivations to continue reporting deaths after the epidemic.

Methods

First, we described the monthly trends in the number of deaths reported to the 1-1-7 system between September 2014 and September 2019. Second, we conducted a telephone survey in April 2017 with a national sample of individuals who reported a death to the 1-1-7 system between December 2016 and April 2017. We described the reported deaths and used ordered logistic regression modeling to examine the potential drivers of reporting motivations.

Findings

Analysis of the number of deaths reported to the 1-1-7 system showed that 12% of the expected deaths were captured in 2017 compared to approximately 34% in 2016 and over 100% in 2015. We interviewed 1,291 death reporters in the survey. Family members reported 56% of the deaths. Nearly every respondent (94%) expressed that they wanted the 1-1-7 system to continue. The most common motivation to report was to obey the government’s mandate (82%). Respondents felt more motivated to report if the decedent exhibited Ebola-like symptoms (adjusted odds ratio 2.3; 95% confidence interval 1.8–2.9).

Conclusions

Motivation to report deaths that resembled Ebola in the post-outbreak setting may have been influenced by knowledge and experiences from the prolonged epidemic. Transitioning the system to a routine mortality surveillance tool may require a robust social mobilization component to match the high reporting levels during the epidemic, which exceeded more than 100% of expected deaths in 2015.

By November 2015 when the World Health Organization declared the Ebola epidemic in Sierra Leone to be over, approximately 95% of the population had become aware of the risk of Ebola transmission linked to physical contact with infected corpses, especially during traditional burials. Enhanced Ebola surveillance was implemented between November 2015 and June 2016, i.e. after the epidemic had officially ended to improve detection of possible new cases. Reporting to the 1-1-7 system declined nationally after enhanced Ebola surveillance ended even though the Government of Sierra Leone continued to mandate that all deaths must be reported. Based on a request from the Sierra Leone Ministry of Health and Sanitation, we conducted a telephone survey with a national sample of people who had reported a death in 2017 after the end of enhanced surveillance to understand their motivations for reporting and describe the deaths that they reported. In addition, we analyzed the five-year trends (2014–2019) in the number of deaths reported through the system. Analysis of monthly summary data of deaths reported showed that on the last month of enhanced surveillance, 3,851 deaths were reported compared to 2,456 deaths in the month immediately after (July 2016). The monthly numbers of reported deaths continued to plummet and reached as low as 1,550 in January 2017, 673 in January 2018, and 586 in January 2019. In the survey, we uncovered that people who reported deaths were mainly motivated to do so in order to comply with the Government’s mandate. After adjusting for potential confounders, motivations to report were strongly associated with the presence of Ebola-like symptoms in the decedent. Additional investigations are needed to unveil reporting barriers among people who failed to report household deaths to the 1-1-7 system to optimize reporting levels. It has been shown that during the Ebola epidemic that it is possible to reach high levels of death reporting in Sierra Leone as exemplified by the fact that in 2015 more than 100% of the expected deaths nationally were reported; albeit not counting potential duplicates. The post-Ebola-outbreak setting provides a unique opportunity to improve future overall mortality surveillance in Sierra Leone and contribute to the establishment of civil registration of vital statistics.

The United Kingdom Field Epidemiology Training Programme: meeting programme objectives

Introduction

Most evaluations of field epidemiology training programmes (FETP) are limited to process measures, but stakeholders may need evidence of impact.

Objective

To ascertain if the United Kingdom (UK) FETP met its objectives to: (i) strengthen capacity and provision of national epidemiology services, (ii) develop a network of highly skilled field epidemiologists with a shared sense of purpose working to common standards and (iii) raise the profile of field epidemiology through embedding it into everyday health protection practice.

Methods

The evaluation consisted of: (i) focus groups with training site staff, (ii) individual interviews with stakeholders and (iii) an online survey of FETP fellows and graduates. Findings were synthesised and triangulated across the three evaluation components to identify cross-cutting themes and subthemes.

Findings

Eight focus groups were undertaken with 38 staff, ten stakeholders were interviewed and 28 (76%) graduates and fellows responded to the survey. Three themes emerged: confidence, application and rigour. FETP was perceived to have contributed to the development, directly and indirectly, of a skilled workforce in field epidemiology, increasing stakeholders’ confidence in the service. Graduates applied their learning in practice, collaborating with a wide range of disciplines. Fellows and graduates demonstrated rigour by introducing innovations, supporting service improvements and helping supervisors maintain their skills and share good practice.

Conclusion

The UK FETP appears to have met its three key objectives, and also had wider organisational impact. FETPs should systematically and prospectively collect information on how they have influenced changes to field epidemiology practice.

Systemic Solutions for Addressing Non-Communicable Diseases in Low- and Middle-Income Countries

Non-communicable diseases (NCDs) have been on the rise in low- and middle-income countries (LMICs) over the last few decades and represent a significant healthcare concern. Over 85% of "premature" deaths worldwide due to NCDs occur in the LMICs. NCDs are an economic burden on these countries, increasing their healthcare expenditure. However, targeting NCDs in LMICs is challenging due to evolving health systems and an emphasis on acute illness. The major issues include limitations with universal health coverage, regulations, funding, distribution and availability of the healthcare workforce, and availability of health data. Experts from across the health sector in LMICs formed a Think Tank to understand and examine the issues, and to offer potential opportunities that may address the rising burden of NCDs in these countries. This review presents the evidence and posits pragmatic solutions to combat NCDs.

Learning from the Epidemiological Response to the 2014/15 Ebola Virus Disease Outbreak

A large international response was needed to bring the 2014/15 West African Ebola virus disease outbreak under control. This study sought to learn lessons from this epidemic to strengthen the response to future outbreaks of international significance by identifying priorities for future epidemiology training and response. Epidemiologists who were deployed to West Africa were recruited through a snowball sampling method and surveyed using an online anonymous questionnaire. Associations between demographics, training, qualifications, and role while in-country were explored alongside respondents’ experience during deployment. Of 128 responses, 105 met the inclusion criteria. Respondents originated from 25 countries worldwide, for many (62%), this was their first deployment abroad. The most common tasks carried out while deployed were surveillance, training, contact tracing, and cluster investigation. Epidemiologists would value more detailed predeployment briefings including organizational aspects of the response. Gaps in technical skills reported were mostly about geographical information systems; however, epidemiologists identified the need for those deployed in future to have greater knowledge about roles and responsibilities of organizations involved in the response, better cultural awareness, and leadership and management skills. Respondents felt that the public health community must improve the timeliness of the response in future outbreaks and strengthen collaboration and coordination between organizations.

The COVID-19 Pandemic: Effects on Low- and Middle-Income Countries

Coronavirus disease 2019 (COVID-19) is spreading rapidly around the world with devastating consequences on patients, health care workers, health systems, and economies. As it reaches low- and middle-income countries, its effects could be even more dire, because it will be difficult for them to respond aggressively to the pandemic. There is a great shortage of all health care providers, who will be at risk due to a lack of personal protection equipment. Social distancing will be almost impossible. The necessary resources to treat patients will be in short supply. The end result could be a catastrophic loss of life. A global effort will be required to support faltering economies and health care systems.

Ebola vaccine? Family first! Evidence from using a brief measure on Ebola vaccine demand in a national household survey during the outbreak in Sierra Leone

BACKGROUND

Vaccination against Ebolavirus is an emerging public health tool during Ebola Virus Disease outbreaks. We examined demand issues related to deployment of Ebolavirus vaccine during the 2014-2015 outbreak in Sierra Leone.

METHODS

A cluster survey was administered to a population-based sample in December 2014 (N = 3540), before any Ebola vaccine was available to the general public in Sierra Leone. Ebola vaccine demand was captured in this survey by three Likert-scale items that were used to develop a composite score and dichotomized into a binary outcome to define high demand. A multilevel logistic regression model was fitted to assess the associations between perceptions of who should be first to receive an Ebola vaccine and the expression of high demand for an Ebola vaccine.

RESULTS

The largest proportion of respondents reported that health workers (35.1%) or their own families (29.5%) should receive the vaccine first if it became available, rather than politicians (13.8%), vaccination teams (9.8%), or people in high risk areas (8.2%). High demand for an Ebola vaccine was expressed by 74.2% of respondents nationally. The odds of expressing high demand were 13 times greater among those who said they or their families should be the first to take the vaccine compared to those who said politicians should be the first recipients (adjusted odds ratio [aOR] 13.0 [95% confidence interval [CI] 7.8-21.6]). The ultra-brief measure of the Ebola vaccine demand demonstrated acceptable scale reliability (Cronbach's α = 0.79) and construct validity (single-factor loadings > 0.50).

CONCLUSION

Perceptions of who should be the first to get the vaccine was associated with high demand for Ebola vaccine around the peak of the outbreak in Sierra Leone. Using an ultra-brief measure of Ebola vaccine demand is a feasible solution in outbreak settings and can help inform development of future rapid assessment tools.

Recent setbacks in measles elimination: the importance of investing in innovations for immunizations

The recent setbacks in efforts to achieve measles elimination goals are alarming. To reverse the current trends, it is imperative that the global health community urgently intensify efforts and make resource commitments to implement evidence-based elimination strategies fully, including supporting research and innovations. The Immunization Agenda 2030: A Global Strategy to Leave No One Behind (IA2030) is the new global guidance document that builds on lessons learned and progress made toward the GVAP goals, includes research and innovation as a core strategic priority, and identifies measles as a “tracer” for improving immunisation services and strengthening primary health care systems. To achieve vaccination coverage and equity targets that leave no one behind, and accelerate progress toward disease eradication and elimination goals, sustained and predictable investments are needed for the identified research and innovations priorities for the new decade.

Ebola, Zika, Corona…What Is Next for Our World?

In the past century, there have been several pandemics. Within the context of global health, these pandemics have often been viewed from the lens of determinants such as population, poverty, and pollution. With an ever-changing world and the COVID-19 pandemic, the current global determinants of public health need to be expanded. In this editorial, we explore and redefine the major determinants of global public health to prevent future pandemics. Policymakers and global leaders should keep at heart the determinants suggested hereby in any planning, implementation, and evaluation of efforts to improve global public health and prevent pandemics.

Tracking Japan's development assistance for health, 2012-2016

Background

Development assistance for health (DAH) is one of the most important means for Japan to promote diplomacy with developing countries and contribute to the international community. This study, for the first time, estimated the gross disbursement of Japan’s DAH from 2012 to 2016 and clarified its flows, including source, aid type, channel, target region, and target health focus area.

Methods

Data on Japan Tracker, the first data platform of Japan’s DAH, were used. The DAH definition was based on the Organisation for Economic Co-operation and Development’s (OECD) sector classification. Regarding core funding to non-health-specific multilateral agencies, we estimated DAH and its flows based on the OECD methodology for calculating imputed multilateral official development assistance (ODA).

Results

Japan’s DAH was estimated at 1472.94 (2012), 823.15 (2013), 832.06 (2014), 701.98 (2015), and 894.57 million USD (2016) in constant prices of 2016. Multilateral agencies received the largest DAH share of 44.96–57.01% in these periods, followed by bilateral grants (34.59–53.08%) and bilateral loans (1.96–15.04%). Ministry of Foreign Affairs (MOFA) was the largest contributors to the DAH (76.26–82.68%), followed by Ministry of Finance (MOF) (10.86–16.25%). Japan’s DAH was most heavily distributed in the African region with 41.64–53.48% share. The channel through which the most DAH went was Global Fund to Fight AIDS, Tuberculosis, and Malaria (20.04–34.89%). Between 2012 and 2016, approximately 70% was allocated to primary health care and the rest to health system strengthening.

Conclusions

With many major high-level health related meetings ahead, coming years will play a powerful opportunity to reevaluate DAH and shape the future of DAH for Japan. We hope that the results of this study will enhance the social debate for and contribute to the implementation of Japan’s DAH with a more efficient and effective strategy.

Global shifts in mammalian population trends reveal key predictors of virus spillover risk

Emerging infectious diseases in humans are frequently caused by pathogens originating from animal hosts, and zoonotic disease outbreaks present a major challenge to global health. To investigate drivers of virus spillover, we evaluated the number of viruses mammalian species have shared with humans. We discovered that the number of zoonotic viruses detected in mammalian species scales positively with global species abundance, suggesting that virus transmission risk has been highest from animal species that have increased in abundance and even expanded their range by adapting to human-dominated landscapes. Domesticated species, primates and bats were identified as having more zoonotic viruses than other species. Among threatened wildlife species, those with population reductions owing to exploitation and loss of habitat shared more viruses with humans. Exploitation of wildlife through hunting and trade facilitates close contact between wildlife and humans, and our findings provide further evidence that exploitation, as well as anthropogenic activities that have caused losses in wildlife habitat quality, have increased opportunities for animal–human interactions and facilitated zoonotic disease transmission. Our study provides new evidence for assessing spillover risk from mammalian species and highlights convergent processes whereby the causes of wildlife population declines have facilitated the transmission of animal viruses to humans.

Adaptation of the National Plan for the Prevention and Fight Against Pandemic Influenza to the 2020 COVID-19 Epidemic in France

On Tuesday, March 17, 2020, at noon, France became the third European country to impose a nationwide containment policy in the fight against epidemic coronavirus disease 2019 (COVID-19) viral infection. Announcing that the country was at “war,” President Macron called upon all to play a role in mitigating against further development of contagion. This extreme measure never seen before during peace time was the result of adapting not only the French Pandemic Influenza Plan (PIP) being applied to the national context but also real-time clinical, epidemiological, and scientific information about the evolution of COVID-19 infection in the country. The situation was further complicated by local municipal elections and political agendas by populist opinions. Despite mass communication about the importance of individual behavioral attitudes to counter disease propagation, few heeded government advice. Consequently, the situation rapidly deteriorated with increasing number of cases that started to overwhelm health services. As a result, decisive and immediate action was taken by the State for the national public health interest. This report from the field details the timely events that contributed to this extreme policy decision taken by France. A policy decision that other Western democracies have since applied as the pandemic disseminated across the globe.

Mind your Language: Discursive Practices Produce Unequal Power and Control Over Infectious Disease: A Critical Discourse Analysis

BACKGROUND

Power, socioeconomic inequalities, and poverty are recognized as some of the fundamental determinants of differences in vulnerability of societies to infectious disease threats. The economic south is carrying a higher burden than those in the economic north. This raises questions about whether social preventions and biomedical preventions for infectious disease are given equal consideration, and about social institutions and structures that frame the debate about infectious disease. This article examines how institutionalized ways of talking about infectious disease reinforces, creates, and sustains health inequalities.

METHODS

Critical discourse analysis was considered to be epistemologically and ontologically consistent with the aims and context of this study.

RESULTS

The study examined three types of infectious disease: • Emerging infectious diseases/pathogens • Neglected tropical diseases • Vector-borne infections. Examination revealed that poverty is the most common determinant of all three.

CONCLUSIONS

A sustainable reduction in infectious disease in the southern countries is most likely to be achieved through tackling socioeconomic determinants. There is a need for a change in the discourse on infectious disease, and adopt a discourse that promotes self-determination, rather than one that reinforces the hero-victim scenario and power inequalities.

Infectious Disease Emergency Specialist (IDES) Training Program in Japan: an innovative governmental challenge to respond to global public health emergencies

In 2015, Japan created a unique governmental program to train experts in health emergencies called Infectious Disease Emergency Specialist (IDES). This is a concept paper to set out the goal and structure of the program, and to describe the achievement and the way forward to further contribute to global health security. The IDES program background, mission, structure, achievement, and future directions were reviewed and discussed by the IDES trainees, graduates, and program coordinators/supervisors. Since 2015, thirteen Japanese medical doctors have graduated from the program while five are currently in training. The IDES core competencies were identified in the context of a wide range of skillsets required for health emergencies. A large national and global network has been created through the training. Coordinated work with surge capacity of experts is of paramount importance to prepare for and respond to public health emergencies. The IDES program can be a good model to many other governments, and contribute to global health security.

Simulation and Modeling Applications in Global Health Security

Global health security (GHS) is dependent upon having an adequate and prepared health security workforce. There are currently numerous challenges in establishing and maintaining a health security workforce. The frequency and magnitude of disasters have increased significantly over the past 30 years. Current and future GHS threats, both manmade and natural, require a prepared and flexible healthcare provider workforce ready to respond to current or emerging GHS threats. Developing and maintaining GHS -specific skills in the healthcare workforce is a tremendous logistical challenge. Innovative education technologies, including simulation and digital learning, can be leveraged to achieve preparedness for GHS threats.

This chapter focuses on the application of modeling and simulation to support Global Health Security planning, preparedness and operations.

How Cities Cope in Outbreak Events?

An outbreak can cause more problems than just the spread of disease. It can be an antagonistic nemesis to our cities and communities, particularly if we lack preparedness and resilience. Its progress is usually unclear as it can be completely different from case to case, and can react differently in different contexts and with different groups of people. Such reactions may purely relate to climatic conditions, hygienic status, and environmental attributes of the context. Those reactions can also differ from one group of people to another, while the disease has to find its correct host as well the way it can transmit and evolve. Consequently, the magnitude of impacts would depend on many factors, of which the nature of the disease is very important during the whole outbreak progress.

Travel time to health facilities in areas of outbreak potential: maps for guiding local preparedness and response

BACKGROUND

Repeated outbreaks of emerging pathogens underscore the need for preparedness plans to prevent, detect, and respond. As countries develop and improve National Action Plans for Health Security, addressing subnational variation in preparedness is increasingly important. One facet of preparedness and mitigating disease transmission is health facility accessibility, linking infected persons with health systems and vice versa. Where potential patients can access care, local facilities must ensure they can appropriately diagnose, treat, and contain disease spread to prevent secondary transmission; where patients cannot readily access facilities, alternate plans must be developed. Here, we use travel time to link facilities and populations at risk of viral hemorrhagic fevers (VHFs) and identify spatial variation in these respective preparedness demands.

METHODS AND FINDINGS

We used geospatial resources of travel friction, pathogen environmental suitability, and health facilities to determine facility accessibility of any at-risk location within a country. We considered in-country and cross-border movements of exposed populations and highlighted vulnerable populations where current facilities are inaccessible and new infrastructure would reduce travel times. We developed profiles for 43 African countries. Resulting maps demonstrate gaps in health facility accessibility and highlight facilities closest to areas at risk for VHF spillover. For instance, in the Central African Republic, we identified travel times of over 24 h to access a health facility. Some countries had more uniformly short travel times, such as Nigeria, although regional disparities exist. For some populations, including many in Botswana, access to areas at risk for VHF nationally was low but proximity to suitable spillover areas in bordering countries was high. Additional analyses provide insights for considering future resource allocation. We provide a contemporary use case for these analyses for the ongoing Ebola outbreak.

CONCLUSIONS

These maps demonstrate the use of geospatial analytics for subnational preparedness, identifying facilities close to at-risk populations for prioritizing readiness to detect, treat, and respond to cases and highlighting where gaps in health facility accessibility exist. We identified cross-border threats for VHF exposure and demonstrate an opportunity to improve preparedness activities through the use of precision public health methods and data-driven insights for resource allocation as part of a country's preparedness plans.

Emergent threats: lessons learnt from Ebola

Recent disease outbreaks have demonstrated the severe health, economic and political crises that epidemics can trigger. The rate of emergence of infectious diseases is accelerating and, with deepening globalisation, pathogens are increasingly mobile. Yet the 2014-2015 West African Ebola epidemic exposed major gaps in the world's capacity to prevent and respond to epidemics. In the midst of the world's second largest ever recorded Ebola outbreak in the Democratic Republic of the Congo, we reflect on six of the many lessons learnt from the epidemic in West Africa, focusing on progress made and the challenges ahead in preparing for future threats. While Ebola and other emerging epidemics will remain a challenge in the years to come, by working in partnership with affected communities and across sectors, and by investing in robust health systems, it is within our power to be better prepared when they strike.

'Never let a crisis go to waste': post-Ebola agenda-setting for health system strengthening in Guinea

Introduction

Guinea is a country with a critical deficit and maldistribution of healthcare workers along with a high risk of epidemics' occurrence. However, actors in the health sector have missed opportunities for more than a decade to attract political attention. This article aims to explain why this situation exists and what were the roles of actors in the agenda-setting process of the post-Ebola health system strengthening programme. It also assesses threats and opportunities for this programme's sustainability.

Methods

We used Kingdon’s agenda-setting methodological framework to explain why actors promptly focused on the health sector reform after the Ebola outbreak. We conducted a qualitative explanatory study using a literature review and key informant interviews.

Results

We found that, in the problem stream, the Ebola epidemic caused considerable fear among national as well as international actors, a social crisis and an economic system failure. This social crisis was entertained by communities’ suspicion of an 'Ebola-business'. In response to these problems, policy actors identified three sets of solutions: the temporary external funds generated by the Ebola response; the availability of experienced health workers in the Ebola control team; and the overproduction of health graduates in the labour market. We also found that the politics agenda was dominated by two major factors: the global health security agenda and the political and financial interests of national policy actors. Although the opening of the policy window has improved human resources, finance and logistics, and infrastructures pillars of the health system, it, however, disproportionally focuses on epidemic preparedness and response. and neglects patients’ financial affordability of essential health services.

Conclusion

Domestic policy entrepreneurs must realise that agenda-setting of health issues in the Guinean context strongly depends on the construction of the problem definition and how this is influenced by international actors.

[Epidemic and emerging prone-infectious diseases: Lessons learned and ways forward]

Africa along side with south-east Asia are the epicentres of emerging and epidemic prone-infectious diseases and megacity biosecurity threat scenarios. Massive mobility and reluctance in the populations exposed to epidemic and emerging prone-infectious diseases coupled by a weak health system made disease alert and control measures difficult to implement. The investigation of virus detection and persistence in semen across a range of emerging viruses is useful for clinical and public health reasons, in particular for viruses that lead to high mortality or morbidity rates or to epidemics. Innovating built facility to safely treat patients with highly pathogenic infectious diseases is urgently need, not only to prevent the spread of infection from patients to healthcare workers but also to offer provision of relatively invasive organ support, whenever considered appropriate, without posing additional risk to staff. Despite multiple challenges, the need to conduct research during epidemics is inevitable, and candidate products must continue undergoing rigorous trials. Preparedness including management of complex humanitarian crises with community distrust is a cornerstone in response to high consequence emerging infectious disease outbreaks and imposes strengthening of the public health response infrastructure and emergency outbreak systems in high-risk regions.

Establishing National Multisectoral Coordination and collaboration mechanisms to prevent, detect, and respond to public health threats in Guinea, Liberia, and Sierra Leone 2016-2018

BACKGROUND

The governments of Guinea, Liberia, and Sierra Leone have acknowledged that weak health systems and poor coordination of efforts hampered effectiveness of the 2014-2016 Ebola outbreak response. The bitter experience of the Ebola outbreak response served as an important catalyst for increased efforts to comply with World Health Organization (WHO) International Health Regulations (IHR 2005), Performance of Veterinary Services (PVS) Pathway capacities, and Global Health Security Agenda (GHSA) goals. In November 2016, an interministerial meeting held in Dakar, Senegal, resulted in formalized commitments from the three nations to strengthen resilience to health threats by establishing a Regional Strategic Roadmap to institutionalize the One Health approach. Since then, each country has made significant progress towards establishing National One Health Platforms to coordinate health security interventions, in collaboration with international partners. This paper outlines the methodology and results of these efforts for the period June 2016-January 2019, with a specific focus on activities supported by the US Agency for International Development (USAID)-funded Preparedness & Response (P&R) project.

OBJECTIVES

In support of the West African Health Organization's November 2016 Regional Strategic Roadmap for institutionalization of the One Health approach, the Preparedness & Response (P&R) project worked in coordination with national partners in Guinea, Liberia, and Sierra Leone to establish multisectoral, One Health coordinating mechanisms.

METHODOLOGY

The global USAID-funded P&R project was launched in 2014 to support the achievement of this objective, and began coordinating with partners in Guinea, Liberia, and Sierra Leone in 2016 to tailor its multi-step conceptual framework to fit the priorities and operating constraints of national stakeholders. Organized in phases of Collaboration (building key relationships), Formalization (defining and establishing a coordination structure), and Implementation (using newfound coordination to produce better health security outcomes), the framework features steps such as One Health sensitizations for multisectoral national stakeholders, development of One Health platform terms of reference and other operating guidelines, and application of these tools to coordination of technical assistance during outbreaks.

RESULTS

In Guinea, Liberia, and Sierra Leone, in less than 3 yrs there has been a marked improvement in cross-sectoral coordination on health security actions. All three countries have passed legislation establishing permanent multisectoral coordination mechanisms referred to in this document as National One Health Platforms, or simply Platforms; instituted an annual mechanism for assessing capacity and performance of these platforms to lead health security actions; and have undertaken key steps towards developing and updating National Preparedness & Response Plans which truly reflect the multisectoral nature of emerging disease threats. However, multisectoral coordination is a work in progress: government stakeholders and their international partners continue to work together to further strengthen national ownership and investment in the newly established Platforms.

CONCLUSION AND NEXT STEPS

Newly established Platforms in Guinea, Liberia, and Sierra Leone offer a long-term structure for coordinating health security actions. However, given the short period of time since their formalization, they depend on continued national, regional, and international resources to build from recent progress and further improve capacity and performance. Regional programs such as the World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) project are of critical importance in keeping the momentum going. The highlighted progress and outputs to date provide reasons and motivation for continued, longer-term investment in the Platforms.

Consensus building around nutrition lessons from the 2014-16 Ebola virus disease outbreak in Guinea and Sierra Leone

There are important lessons learned from the 2014-16 Ebola virus disease outbreak in West Africa. However, there has not been a systematic documentation of nutrition lessons specifically. Therefore, this study sought to generate multiple stakeholder perspectives for understanding the nutrition challenges faced during the Ebola virus disease outbreak, as well as for consensus building around improved response strategies. Participatory workshops with 17 and 19 participants in Guinea and Sierra Leone, respectively, were conducted in February 2017. Workshops followed the Nominal Group Technique, which is a methodological approach for idea generation and consensus building among diverse participants. Those findings were triangulated with qualitative interview data from participants representing government, United Nations bodies, civil society, non-governmental organizations and local communities in both Guinea (n = 27) and Sierra Leone (n = 42). (1) Reduced health system access and utilization, Poor caretaking and infant and young child feeding practices, Implementation challenges during nutrition response, Household food insecurity and Changing breastfeeding practices were five nutrition challenges identified in both Guinea and Sierra Leone. (2) Between settings, 14 distinct and 11 shared organizational factors emerged as facilitators to this response. In Sierra Leone, participants identified the Use of Standard Operating Procedures and Psychosocial counselling, whereas in Guinea, Hygiene assistance was distinctly important. Political will, Increased funding, Food assistance and to a lesser extent, Enhanced coordination, were deemed 'most important' response factors. (3) The top nutrition lessons learned were diverse, reflecting those of nutrition policy, programme implementation, community activity and household behaviours. Disease outbreaks pose widespread nutrition challenges to populations in resource-constrained settings where global health security is not a guarantee. These findings should be considered for emergency nutrition preparedness and inform evidence-based priority setting in the post-Ebola virus context of Guinea and Sierra Leone.

Infectious disease outbreaks in the African region: overview of events reported to the World Health Organization in 2018

The WHO African region is characterised by the largest infectious disease burden in the world. We conducted a retrospective descriptive analysis using records of all infectious disease outbreaks formally reported to the WHO in 2018 by Member States of the African region. We analysed the spatio-temporal distribution, the notification delay as well as the morbidity and mortality associated with these outbreaks. In 2018, 96 new disease outbreaks were reported across 36 of the 47 Member States. The most commonly reported disease outbreak was cholera which accounted for 20.8% (n = 20) of all events, followed by measles (n = 11, 11.5%) and Yellow fever (n = 7, 7.3%). About a quarter of the outbreaks (n = 23) were reported following signals detected through media monitoring conducted at the WHO regional office for Africa. The median delay between the disease onset and WHO notification was 16 days (range: 0-184). A total of 107 167 people were directly affected including 1221 deaths (mean case fatality ratio (CFR): 1.14% (95% confidence interval (CI) 1.07%-1.20%)). The highest CFR was observed for diseases targeted for eradication or elimination: 3.45% (95% CI 0.89%-10.45%). The African region remains prone to outbreaks of infectious diseases. It is therefore critical that Member States improve their capacities to rapidly detect, report and respond to public health events.

Joint external evaluation of the International Health Regulation (2005) capacities: current status and lessons learnt in the WHO African region

The International Health Regulations (IHR, 2005) are an essential vehicle for addressing global health security. Here, we report the IHR capacities in the WHO African from independent joint external evaluation (JEE). The JEE is a voluntary component of the IHR monitoring and evaluation framework. It evaluates IHR capacities in 19 technical areas in four broad themes: ‘Prevent’ (7 technical areas, 15 indicators); ‘Detect’ (4 technical areas, 13 indicators); ‘Respond’ (5 technical areas, 14 indicators), points of entry (PoE) and other IHR hazards (chemical and radiation) (3 technical areas, 6 indicators). The IHR capacity scores are graded from level 1 (no capacity) to level 5 (sustainable capacity). From February 2016 to March 2019, 40 of 47 WHO African region countries (81% coverage) evaluated their IHR capacities using the JEE tool. No country had the required IHR capacities. Under the theme ‘Prevent’, no country scored level 5 for 12 of 15 indicators. Over 80% of them scored level 1 or 2 for most indicators. For ‘Detect’, none scored level 5 for 12 of 13 indicators. However, many scored level 3 or 4 for several indicators. For ‘Respond’, none scored level 5 for 13 of 14 indicators, and less than 10% had a national multihazard public health emergency preparedness and response plan. For PoE and other IHR hazards, most countries scored level 1 or 2 and none scored level 5. Countries in the WHO African region are commended for embracing the JEE to assess their IHR capacities. However, major gaps have been identified. Urgent collective action is needed now to protect the WHO African region from health security threats.

Lessons Learned from the CORE Group Polio Project and Their Relevance for Other Global Health Priorities

Despite numerous setbacks, the Global Polio Eradication Initiative has implemented various community strategies with potential application for other global health issues. This article reviews strategies implemented by the CORE Group Polio Project (CGPP), including pursuit of the missed child, microplanning, independent campaign monitoring, using community health workers and community mobilizers to build community engagement, community-based surveillance, development of the capacity to respond to other health needs, targeting geographic areas at high risk, the secretariat model for non-governmental organization collaboration, and registration of vital events. These strategies have the potential for contributing to the reduction of child and maternal mortality in hard-to-reach, underserved populations around the world. Community-based surveillance as developed by the CGPP also has potential for improving global health security, now a global health priority.

Towards Resilient Health Systems in Sub-Saharan Africa: A Systematic Review of the English Language Literature on Health Workforce, Surveillance, and Health Governance Issues for Health Systems Strengthening

Background:

Meeting health security capacity in sub-Saharan Africa will require strengthening existing health systems to prevent, detect, and respond to any threats to health. The purpose of this review was to examine the literature on health workforce, surveillance, and health governance issues for health systems strengthening.

Methods:

We searched PubMed, Science Direct, Cochrane library, CINAHL, Web of Science, EMBASE, EBSCO, Google scholar, and the WHO depository library databases for English-language publications between January 2007 and February 2017. Electronic searches for selected articles were supplemented by manual reference screening. The review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.

Results:

Out of 1,548 citations retrieved from the electronic searches, 31 articles were included in the review. Any country health system that trains a cadre of health professionals on the job, reduces health workforce attrition levels, and builds local capacity for health care workers to apply innovative mHealth technologies improves health sector performance. Building novel surveillance systems can improve clinical care and improve health system preparedness for health threats. Effective governance processes build strong partnerships for health and create accountability mechanisms for responding to health emergencies.

Conclusions:

Overall, policy shifts in African countries’ health systems that prioritize training a cadre of willing and able workforce, invest in robust and cost-effective surveillance capacity, and create financial accountability and good governance are vital in health strengthening efforts.

Mobile phone-based surveillance for animal disease in rural communities: implications for detection of zoonoses spillover

Improving the speed of outbreak detection and reporting at the community level are critical in managing the threat of emerging infectious diseases, many of which are zoonotic. The widespread use of mobile phones, including in rural areas, constitutes a potentially effective tool for real-time surveillance of infectious diseases. Using longitudinal data from a disease surveillance system implemented in 1500 households in rural Kenya, we test the effectiveness of mobile phone animal syndromic surveillance by comparing it with routine household animal health surveys, determine the individual and household correlates of its use and examine the broader implications for surveillance of zoonotic diseases. A total of 20 340 animal and death events were reported from the community through the two surveillance systems, half of which were confirmed as valid disease events. The probability of an event being valid was 2.1 times greater for the phone-based system, compared with the household visits. Illness events were 15 times (95% CI 12.8, 17.1) more likely to be reported through the phone system compared to routine household visits, but not death events (OR 0.1 (95% CI 0.09, 0.11)). Disease syndromes with severe presentations were more likely to be reported through the phone system. While controlling for herd and flock sizes owned, phone ownership was not a determinant of using the phone-based surveillance system, but the lack of a formal education, and having additional sources of income besides farming were associated with decreased likelihood of reporting through the phone system. Our study suggests that a phone-based surveillance system will be effective at detecting outbreaks of diseases such as Rift Valley fever that present with severe clinical signs in animal populations, but in the absence of additional reporting incentives, it may miss early outbreaks of diseases such as avian influenza that present primarily with mortality.

This article is part of the theme issue ‘Dynamic and integrative approaches to understanding pathogen spillover’.

Emergency care research as a global health priority: key scientific opportunities and challenges

Quality emergency medical care is critical to reducing the burden of disease in low-income and middle-income countries (LMICs) and protecting the health of populations during disasters and epidemics. However, conducting research in emergency care settings in LMIC settings entails unique methodological and operational challenges. Therefore, new approaches and strategies that address these challenges need to be developed and will require increased attention from scientists, academic institutions and the global health research funding community. Research priorities to address emergency care in LMICs have also not been well defined, resulting in limited research output from LMICs. This manuscript frames the efforts of four multidisciplinary working groups, which were established under the auspices of the Fogarty International Center as part of the Collaborative on Enhancing Emergency Care Research in LMICs and serves as an introduction to this series, which identifies challenges and solutions in the context of emergency care research in LMICs. The objective of this introductory paper is to articulate the need for emergency care research in LMICs and underscore its future promise. We present public health arguments for greater investment in emergency care research, identify barriers to develop and conduct research, and present a list of research priorities for community organizations, academic institutions and funding agencies. We conclude that advances in emergency care research will be critical to achieve national and global health targets, such as the Sustainable Development Goals (SDGs), and to ensure that evidence informs how such research is best conducted.

Integrated Disease Surveillance and Response (IDSR) strategy: current status, challenges and perspectives for the future in Africa

In 1998, the WHO African region adopted a strategy called Integrated Disease Surveillance and Response (IDSR). Here, we present the current status of IDSR implementation; and provide some future perspectives for enhancing the IDSR strategy in Africa. In 2017, we used two data sources to compile information on the status of IDSR implementation: a pretested rapid assessment questionnaire sent out biannually to all countries and quarterly compilation of data for two IDSR key performance indicators (KPI). The first KPI measures country IDSR performance and the second KPI tracks the number of countries that the WHO secretariat supports to scale up IDSR. The KPI data for 2017 were compared with a retrospective baseline for 2014. By December 2017, 44 of 47 African countries (94%) were implementing IDSR. Of the 44 countries implementing IDSR, 40 (85%) had initiated IDSR training at subnational level; 32 (68%) had commenced community-based surveillance; 35 (74%) had event-based surveillance; 33 (70%) had electronic IDSR; and 32 (68%) had a weekly/monthly bulletin for sharing IDSR data. Thirty-two countries (68%) had achieved the timeliness and completeness threshold of at least 80% of the reporting units. However, only 12 countries (26%) had the desired target of at least 90% IDSR implementation coverage at the peripheral level. After 20 years of implementing IDSR, there are major achievements in the indicator-based surveillance systems. However, major gaps were identified in event-based surveillance. All African countries should enhance IDSR everywhere.

Implementing a quality management system using good clinical laboratory practice guidelines at KEMRI-CMR to support medical research

Background: Good Clinical Laboratory Practice (GCLP) is a standard that helps ensure the quality and reliability of research data through principles of Good Laboratory Practice (GLP) and Good Clinical Practice (GCP). The implementation of GCLP includes careful documentation of procedures, competencies and safety measures. Implementation of GCLP is influenced by existing resources and quality systems, thus laboratories in low- and middle-income countries may face additional challenges. Methods: This paper describes implementation of GCLP at the Kenya Medical Research Institute-Center for Microbiology Research (KEMRI-CMR) as part of a quality system to support medical research. This study employed assessment, twinning (institutional mentorship) model, conducting relevant training workshops and Kaizen 5S approaches to implement an effective quality management system using GCLP standard. This was achieved through a collaboration between the KEMRI/Wellcome Trust Research Programme (KWTRP) and KEMRI-CMR. The aim was compliance and continuous monitoring to meet international GCLP standards in a way that could be replicated in other research organizations. Results: Following a baseline assessment in March 2017, training, mentorship and a cycle of quality audit and corrective action using a Kaizen 5S approach (sorting, setting in order, shining, standardizing and sustaining) was established. Laboratory personnel were trained in writing standard operating procedures and analytical plans, microbiological techniques, and good documentation practice. Mid-term and exit assessments demonstrated significant declines in non-conformances across all GCLP elements. KEMRI-CMR achieved GCLP accreditation in May 2018 by Qualogy Ltd (UK). Conclusions: Involving all the laboratory personnel in implementation of quality management system processes is critical to success. An institutional mentorship (twinning) approach shows potential for future collaborations between accredited and non-accredited organizations to accelerate the implementation of high-quality management systems and continuous improvement.

Earlier detection of public health risks - Health policy lessons for better compliance with the International Health Regulations (IHR 2005): Insights from low-, mid- and high-income countries

The International Health Regulations (IHR 2005) require all Member States to build and maintain the capacities to prevent, detect and respond to public health emergencies. Early detection of public health risks is one of the core functions. In order to improve surveillance and detection, a better understanding of the health system conditions and their influencing factors are needed. The Israeli Ministry of Health/IHR National Focal Point held a workshop to elucidate health system conditions and their influencing factors that enable earlier detection. The workshop methodology employed a stepwise, small working group analysis approach to elucidate the conditions and their influencing factors affecting each stage of recognition, assessment, and reporting of infectious disease outbreaks, at the local, regional and national levels. In order to detect public health risks earlier, the detection process needs to be moved closer to the local communities and start with building capacity within communities. Building capacity and engaging with local and diverse communities requires significant changes in the governance approach and include information sharing, multi-sectoral communication and coordination across various levels before, during and after public health emergencies. Across the regions, low-, mid- and high-income countries seem to struggle more with governance and information sharing rather than with technical capacities and capabilities.

Quality improvement of health systems in an epidemic context: A framework based on lessons from the Ebola virus disease outbreak in West Africa

Quality improvement (QI) in health generally focuses on the provision of health services with the aim of improving service delivery. Yet QI can be applied not only to health services but also to health systems overall. This is of growing relevance considering that due to deficiencies in health systems, the main countries affected by Ebola virus disease (EVD) outbreak in West Africa (2014-2016) were insufficiently prepared for the epidemic, and according to the WHO, epidemics are increasingly becoming a threat to global health. Our objective is to analyze QI constraints in health systems during that EVD epidemic and to propose a practical framework for QI in health systems for epidemics in developing countries. We applied a framework analysis using experiences shared at the "Second International Quality Forum" organized by the University of Heidelberg and partners in July 2015 and information gathered from a systematic literature review. Empirical results revealed multiple deficiencies in the health systems. We systemized these shortfalls as well as the QI measures taken as a response during the epidemic. On the basis of these findings, we identified six specific "priority intervention areas," which ultimately resulted in the synthesis of a practical QI framework. We deem that this framework that integrates the priority intervention areas with the WHO building blocks is suitable to improve, monitor, and evaluate health system performance in epidemic contexts in developing countries.

Policy and Science for Global Health Security: Shaping the Course of International Health

The global burden of infectious diseases and the increased attention to natural, accidental, and deliberate biological threats has resulted in significant investment in infectious disease research. Translating the results of these studies to inform prevention, detection, and response efforts often can be challenging, especially if prior relationships and communications have not been established with decision-makers. Whatever scientific information is shared with decision-makers before, during, and after public health emergencies is highly dependent on the individuals or organizations who are communicating with policy-makers. This article briefly describes the landscape of stakeholders involved in information-sharing before and during emergencies. We identify critical gaps in translation of scientific expertise and results, and biosafety and biosecurity measures to public health policy and practice with a focus on One Health and zoonotic diseases. Finally, we conclude by exploring ways of improving communication and funding, both of which help to address the identified gaps. By leveraging existing scientific information (from both the natural and social sciences) in the public health decision-making process, large-scale outbreaks may be averted even in low-income countries.

Infectious Disease Threats in the Twenty-First Century: Strengthening the Global Response

The world has developed an elaborate global health system as a bulwark against known and unknown infectious disease threats. The system consists of various formal and informal networks of organizations that serve different stakeholders; have varying goals, modalities, resources, and accountability; operate at different regional levels (i.e., local, national, regional, or global); and cut across the public, private-for-profit, and private-not-for-profit sectors. The evolving global health system has done much to protect and promote human health. However, the world continues to be confronted by longstanding, emerging, and reemerging infectious disease threats. These threats differ widely in terms of severity and probability. They also have varying consequences for morbidity and mortality, as well as for a complex set of social and economic outcomes. To various degrees, they are also amenable to alternative responses, ranging from clean water provision to regulation to biomedical countermeasures. Whether the global health system as currently constituted can provide effective protection against a dynamic array of infectious disease threats has been called into question by recent outbreaks of Ebola, Zika, dengue, Middle East respiratory syndrome, severe acute respiratory syndrome, and influenza and by the looming threat of rising antimicrobial resistance. The concern is magnified by rapid population growth in areas with weak health systems, urbanization, globalization, climate change, civil conflict, and the changing nature of pathogen transmission between human and animal populations. There is also potential for human-originated outbreaks emanating from laboratory accidents or intentional biological attacks. This paper discusses these issues, along with the need for a (possibly self-standing) multi-disciplinary Global Technical Council on Infectious Disease Threats to address emerging global challenges with regard to infectious disease and associated social and economic risks. This Council would strengthen the global health system by improving collaboration and coordination across organizations (e.g., the WHO, Gavi, CEPI, national centers for disease control, pharmaceutical manufacturers, etc.); filling in knowledge gaps with respect to (for example) infectious disease surveillance, research and development needs, financing models, supply chain logistics, and the social and economic impacts of potential threats; and making high-level, evidence-based recommendations for managing global risks associated with infectious disease.

Global Critical Care: Moving Forward in Resource-Limited Settings

Caring for critically ill patients is challenging in resource-limited settings, where the burden of disease and mortality from potentially treatable illnesses is higher than in resource-rich areas. Barriers to delivering quality critical care in these settings include lack of epidemiologic data and context-specific evidence for medical decision-making, deficiencies in health systems organization and resources, and institutional obstacles to implementation of life-saving interventions. Potential solutions include the development of common definitions for intensive care unit (ICU), intensivist, and intensive care to create a universal ICU organization framework; development of educational programs for capacity building of health care professionals working in resource-limited settings; global prioritization of epidemiologic and clinical research in resource-limited settings to conduct timely and ethical studies in response to emerging threats; adaptation of international guidelines to promote implementation of evidence-based care; and strengthening of health systems that integrates these interventions. This manuscript reviews the field of global critical care, barriers to safe high-quality care, and potential solutions to existing challenges. We also suggest a roadmap for improving the treatment of critically ill patients in resource-limited settings.

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.

Post-Ebola Awakening: Urgent Call for Investing in Maintaining Effective Preparedness Capacities at the National and Regional Levels in Sub-Saharan Africa

Background:

The 2014 Ebola outbreak reminded us of the importance of preparedness for addressing health security threats. Learning from this experience, we aim to (1) enhance the understanding of preparedness by policy and decision makers, (2) discuss opportunities for Africa to invest in the prevention of health security threats, (3) highlight the value of investing in preventing health security threats, and (4) propose innovations to enhance investments for the prevention or containment of health security threats at the source.

Methods:

We used observations of governments' attitudes towards investing in preparedness for health security prevention or containment at the source. We conducted a literature review through PubMed, the World Wide Web, and Mendeley using the keywords: “health emergency financing”, “investing in health threats prevention”, and “stopping outbreaks at the source”.

Results:

Countries in sub-Saharan Africa invest inadequately towards building and maintaining critical capacities for preventing, detecting, and containing outbreaks at the source. Global health security emergency funding schemes target responses to outbreaks but neglect their prevention. Governments are not absorbing and maintaining adequately capacity built through GHS, World Bank, and development aid projects – a lost opportunity for building and retaining outbreak prevention capacity.

Recommendations:

Governments should (1) allocate adequate national budgets for health honouring the Abuja and related commitments; (2) own and maintain capacities developed through International Development Aids, OH networks, research consortia and projects; (3) establish a regional health security threats prevention fund. The global community and scientists should (1) consider broadening existing health emergency funds to finance the prevention and containment outbreaks at the source and (2) Strengthen economic analyses and case studies as incentives for governments' budget allocations to prevent health security threats.