Lessons learnt from implementation of the International Health Regulations: a systematic review

A closer look at the international health regulations capacities in Lebanon: a mixed method study

BACKGROUND

Lebanon ratified the International Health Regulations (IHR) (2005) in 2007, and since then, it has been facing complex political deadlocks, financial deterioration, and infectious disease emergencies. We aimed to understand the IHR capacities' scores of Lebanon in comparison to other countries, the IHR milestones and activities in Lebanon, the challenges of maintaining the IHR capacities, the refugee crisis's impact on the development of these capacities; and the possible recommendations to support the IHR performance in Lebanon.

METHODS

We used a mixed-method design. The study combined the use of secondary data analysis of the 2020 State Party Self-Assessment Annual Report (SPAR) submissions and qualitative design using semi-structured interviews with key informants. Semi-structured interviews were conducted with nine key informants. The analysis of the data generated was based on inductive thematic analysis.

RESULTS

According to SPAR, Lebanon had levels of 4 out of 5 (≤ 80%) in 2020 in the prevention, detection, response, enabling functions, and operational readiness capacities, pertaining that the country was functionally capable of dealing with various events at the national and subnational levels. Lebanon scored more than its neighboring countries, Syria, and Jordan, which have similar contexts of economic crises, emergencies, and refugee waves. Despite this high level of commitment to meeting IHR capacities, the qualitative findings demonstrated several gaps in IHR performance as resource shortage, governance, and political challenges. The study also showed contradictory results regarding the impact of refugees on IHR capacities. Some key informants agreed that the Syrian crisis had a positive impact, while others suggested the opposite. Whether refugees interfere with IHR development is still an area that needs further investigation.

CONCLUSION

The study shows that urgent interventions are needed to strengthen the implementation of the IHR capacities in Lebanon. The study recommends 1) reconsidering the weight given to IHR capacities; 2) promoting governance to strengthen IHR compliance; 3) strengthening the multisectoral coordination mechanisms; 4) reinforcing risk communication strategies constantly; 5) mobilizing and advancing human resources at the central and sub-national levels; 6) ensuring sustainable financing; 7) integrating refugees and displaced persons in IHR framework and its assessment tools; 8) acknowledging risk mapping as a pre-requisite to a successful response; and 9) strengthening research on IHR capacities in Lebanon.

Rapid response teams in the Eastern Mediterranean Region: Results from the baseline survey of country-level capacities, operations and outbreak response capabilities

The aim of this study is to assess WHO/Eastern Mediterranean region (WHO/EMR) countries capacities, operations and outbreak response capabilities. Cross-sectional study was conducted targeting 22 WHO/EMR countries from May to June 2021. The survey covers 8 domains related to 15 milstones and key performance indicators (KPIs) for RRT. Responses were received from 14 countries. RRTs are adequately organised in 9 countries (64.3%). The mean retention rate of RRT members was 85.5% ± 22.6. Eight countries (57.1%) reported having standard operating procedures, but only three countries (21.4%) reported an established mechanism of operational fund allocation. In the last 6 months, 10,462 (81.9%) alerts were verified during the first 24 h. Outbreak response was completed by the submission of final RRT response reports in 75% of analysed outbreaks. Risk Communication and Community Engagement (RCCE) activities were part of the interventional response in 59.5% of recent outbreaks. Four countries (28.6%) reported an adequate system to assess RRTs operations. The baseline data highlights four areas to focus on: developing and maintaining the multidisciplinary nature of RRTs through training, adequate financing and timely release of funds, capacity and system building for implementing interventions, for instance, RCCE, and establishing national monitoring and evaluation systems for outbreak response.

Parents' perspectives of anorexia nervosa treatment in adolescents: a systematic review and metasynthesis of qualitative data

BACKGROUND

Studies have established the central role of the family in the recognition, treatment, and recovery of anorexia nervosa. The objective of this study was to review, synthesize, and critically appraise the literature on parents' views on the treatment and recovery process of anorexia nervosa in their adolescent child.

METHOD

A systematic search of Medline, PsychINFO, CINHAL, EMBASE, Cochrane library, and SSCI was conducted for qualitative studies published regarding parents' views about the treatment of anorexia nervosa. The quality of articles was assessed using the critical appraisal skills program (CASP) and findings were analysed using thematic synthesis.

RESULTS

A total of 25 studies from nine countries reporting the views of 357 parents met the inclusion criteria. Four major themes were developed from the analysis: understanding the child and the disease, experience of services and treatment modalities, the role of professionals, and the experience of recovery.

CONCLUSION

Parents report struggles with delays in finding help, judgmental attitudes of professionals, and uncertainty about the future. Recognition of the challenges faced by parents and families empowers clinicians to build stronger therapeutic relationships essential for long-term recovery from anorexia nervosa.

Lessons learned from identifying clusters of severe acute respiratory infections with influenza sentinel surveillance, Bangladesh, 2009-2020

Background

We explored whether hospital-based surveillance is useful in detecting severe acute respiratory infection (SARI) clusters and how often these events result in outbreak investigation and community mitigation.

Methods

During May 2009-December 2020, physicians at 14 sentinel hospitals prospectively identified SARI clusters (i.e., ≥2 SARI cases who developed symptoms ≤10 days of each other and lived <30 min walk or <3 km from each other). Oropharyngeal and nasopharyngeal swabs were tested for influenza and other respiratory viruses by real-time reverse transcriptase-polymerase chain reaction (rRT-PCR). We describe the demographic of persons within clusters, laboratory results, and outbreak investigations.

Results

Field staff identified 464 clusters comprising 1427 SARI cases (range 0-13 clusters per month). Sixty percent of clusters had three, 23% had two, and 17% had ≥4 cases. Their median age was 2 years (inter-quartile range [IQR] 0.4-25) and 63% were male. Laboratory results were available for the 464 clusters with a median of 9 days (IQR = 6-13 days) after cluster identification. Less than one in five clusters had cases that tested positive for the same virus: respiratory syncytial virus (RSV) in 58 (13%), influenza viruses in 24 (5%), human metapneumovirus (HMPV) in five (1%), human parainfluenza virus (HPIV) in three (0.6%), adenovirus in two (0.4%). While 102/464 (22%) had poultry exposure, none tested positive for influenza A (H5N1) or A (H7N9). None of the 464 clusters led to field deployments for outbreak response.

Conclusions

For 11 years, none of the hundreds of identified clusters led to an emergency response. The value of this event-based surveillance might be improved by seeking larger clusters, with stronger epidemiologic ties or decedents.

Communicating risk during early phases of COVID-19: Comparing governing structures for emergency risk communication across four contexts

Background

Emergency risk communication (ERC) is key to achieving compliance with public health measures during pandemics. Yet, the factors that facilitated ERC during COVID-19 have not been analyzed. We compare ERC in the early stages of the pandemic across four socio-economic settings to identify how risk communication can be improved in public health emergencies (PHE).

Methods

To map and assess the content, process, actors, and context of ERC in Germany, Guinea, Nigeria, and Singapore, we performed a qualitative document review, and thematically analyzed semi-structured key informant interviews with 155 stakeholders involved in ERC at national and sub-national levels. We applied Walt and Gilson's health policy triangle as a framework to structure the results.

Results

We identified distinct ERC strategies in each of the four countries. Various actors, including governmental leads, experts, and organizations with close contact to the public, collaborated closely to implement ERC strategies. Early integration of ERC into preparedness and response plans, lessons from previous experiences, existing structures and networks, and clear leadership were identified as crucial for ensuring message clarity, consistency, relevance, and an efficient use of resources. Areas of improvement primarily included two-way communication, community engagement, and monitoring and evaluation. Countries with recurrent experiences of pandemics appeared to be more prepared and equipped to implement ERC strategies.

Conclusion

We found that considerable potential exists for countries to improve communication during public health emergencies, particularly in the areas of bilateral communication and community engagement as well as monitoring and evaluation. Building adaptive structures and maintaining long-term relationships with at-risk communities reportedly facilitated suitable communication. The findings suggest considerable potential and transferable learning opportunities exist between countries in the global north and countries in the global south with experience of managing outbreaks.

Towards applying the essential public health functions for building health systems resilience: A renewed list and key enablers for operationalization

The COVID-19 pandemic, climate change-related events, protracted conflicts, economic stressors and other health challenges, call for strong public health orientation and leadership in health system strengthening and policies. Applying the essential public health functions (EPHFs) represents a holistic operational approach to public health, which is considered to be an integrated, sustainable, and cost-effective means for supporting universal health coverage, health security and improved population health and wellbeing. As a core component of the Primary Health Care (PHC) Operational Framework, EPHFs also support the continuum of health services from health promotion and protection, disease prevention to treatment, rehabilitation, and palliative services. Comprehensive delivery of EPHFs through PHC-oriented health systems with multisectoral participation is therefore vital to meet population health needs, tackle public health threats and build resilience. In this perspective, we present a renewed EPHF list consisting of twelve functions as a reference to foster country-level operationalisation, based on available authoritative lists and global practices. EPHFs are presented as a conceptual bridge between prevailing siloed efforts in health systems and allied sectors. We also highlight key enablers to support effective implementation of EPHFs, including high-level political commitment, clear national structures for institutional stewardship on EPHFs, multisectoral accountability and systematic assessment. As countries seek to transform health systems in the context of recovery from COVID-19 and other public health emergencies, the renewed EPHF list and enablers can inform public health reform, PHC strengthening, and more integrated recovery efforts to build resilient health systems capable of managing complex health challenges for all people.

Prioritizing Global Public Health Investments for COVID-19 Response in Real Time: Results from a Delphi Exercise

In the first months of the COVID-19 pandemic, there was a lack of guidance on how to channel the unprecedented amount of health financing toward the pandemic response. We employed a multistep, interactive Delphi process to reach consensus on a “menu” of priority COVID-19 response interventions. In all, 27 health security experts—representing national governments, bilateral and multilateral organizations, academia, technical agencies, and nongovernmental organizations—participated in the exercise. The experts rated 11 technical investment areas and 37 interventions on a 5-point scale in terms of their importance to COVID-19 response. Initial findings were discussed at a virtual meeting where experts suggested modifications. A group of 19 experts then rated a revised list of 11 technical areas and 39 interventions. Consensus was defined as at least 80% of experts agreeing on the importance of a technical area or intervention; stability of scores across the rounds was identified using Wilcoxon matched-pairs and unpaired signed rank tests. Between the initial and final menu, 3 technical areas and 7 interventions were slightly modified, 3 interventions were added, and 1 intervention was removed. Consensus was reached on all 11 technical areas and 35 of the final 39 interventions, and between 34 and 37 interventions were stable across rounds depending on the test used. In this exercise, the health security experts agreed that COVID-19 response financing should prioritize interventions that enhance a country's capacity to test, trace, and treat high-risk populations. Simultaneously, supportive systems (eg, risk communication, community engagement, public health infrastructure, information systems, policy and coordination, workforce capacity, other social protections) should be developed to ensure that nonpharmaceutical and medical interventions can maximize the effectiveness of these systems.

Implementation of DHIS2 for Disease Surveillance in Guinea: 2015–2020

A robust epidemic-prone disease surveillance system is a critical component of public health infrastructure and supports compliance with the International Health Regulations (IHR). One digital health platform that has been implemented in numerous low- and middle-income countries is the District Health Information System Version 2 (DHIS2). In 2015, in the wake of the Ebola epidemic, the Ministry of Health in Guinea established a strategic plan to strengthen its surveillance system, including adoption of DHIS2 as a health information system that could also capture surveillance data. In 2017, the DHIS2 platform for disease surveillance was piloted in two regions, with the aim of ensuring the timely availability of quality surveillance data for better prevention, detection, and response to epidemic-prone diseases. The success of the pilot prompted the national roll-out of DHIS2 for weekly aggregate disease surveillance starting in January 2018. In 2019, the country started to also use the DHIS2 Tracker to capture individual cases of epidemic-prone diseases. As of February 2020, for aggregate data, the national average timeliness of reporting was 72.2%, and average completeness 98.5%; however, the proportion of individual case reports filed was overall low and varied widely between diseases. While substantial progress has been made in implementation of DHIS2 in Guinea for use in surveillance of epidemic-prone diseases, much remains to be done to ensure long-term sustainability of the system. This paper describes the implementation and outcomes of DHIS2 as a digital health platform for disease surveillance in Guinea between 2015 and early 2020, highlighting lessons learned and recommendations related to the processes of planning and adoption, pilot testing in two regions, and scale up to national level.

Coronavirus Disease Case Definitions, Diagnostic Testing Criteria, and Surveillance in 25 Countries with Highest Reported Case Counts

We compared case definitions for suspected, probable, and confirmed coronavirus disease (COVID-19), as well as diagnostic testing criteria, used in the 25 countries with the highest reported case counts as of October 1, 2020. Of the identified countries, 56% followed World Health Organization (WHO) recommendations for using a combination of clinical and epidemiologic criteria as part of the suspected case definition. A total of 75% of identified countries followed WHO recommendations on using clinical, epidemiologic, and diagnostic criteria for probable cases; 72% followed WHO recommendations to use PCR testing to confirm COVID-19. Finally, 64% of countries used testing eligibility criteria at least as permissive as WHO. We observed marked heterogeneity in testing eligibility requirements and in how countries define a COVID-19 case. This heterogeneity affects the ability to compare case counts, transmission, and vaccine effectiveness, as well as estimates derived from case surveillance data across countries.

The Preparedness of Primary Health Care Network in terms of Emergency Risk Communication: A Study in Iran

OBJECTIVE

Emergency Risk Communication (ERC) is known as 1 of the important components of an effective response to public health emergencies. In this study, we aimed to investigate the preparedness of the Primary Health Care Network (PHCN) of Iran in terms of the ERC.

METHODS

This study was conducted in 136 Primary Health Care Facilities (PHCFs) affilated to Shahrekord University of Medical Sciences, Chaharmahal and Bakhtiari Province, Iran. Data in terms of ERC were collected using a checklist developed by the Center of Disease Control and Prevention (CDC).

RESULTS

The findings of the study revealed that 65.9% of the PHCFs had low preparedness in terms of the ERC, 33.3% had a moderate level and 0.8% had high preparedness in this regard. There was a significant difference between the level of ERC and the history of crisis in the past year, PHCF type, and the education level of the responsible employees in the crisis unit in the PHCF.

CONCLUSIONS

The results showed that the PHCFs studied need to increase their capacity and capability in the field of ERC. Further efforts to provide ERC components may increase the preparedness of PHCN in Iran in terms of the ERC.

Addressing the double burden of the COVID-19 and noncommunicable disease pandemics: a new global governance challenge

Purpose

As the coronavirus disease 2019 (COVID-19) continues to spread across countries, it is becoming increasingly clear that the presence of pre-existing noncommunicable diseases (NCDs) dramatically increases the risk of aggravation in persons who contract the virus. The neglect in managing NCDs during emergencies may result in fatal consequences for individuals living with comorbidities. This paper aims to highlight the need for a paradigm shift in the governance of public health emergencies to simultaneously address NCD and noncommunicable disease (CD) pandemics while taking into account the needs of high-risk populations, underlying etiological factors, and the social, economic, and environmental determinants that are relevant for both CDs and NCDs.

Design/methodology/approach

The paper reviews the available global frameworks for pandemic preparedness to highlight the governance challenges of addressing the dual agenda of NCDs and CDs during a public health emergency. It proposes key strategies to strengthen multilevel governance in support of countries to better prepare for public health emergencies through the engagement of a wide range of stakeholders across sectors.

Findings

Addressing both CD and NCD pandemics during public health emergencies requires (1) a new framework that unites the narratives and overcomes service and system fragmentations; (2) a multisectoral and multistakeholder governance mechanism empowered and resourced to include stakeholders across sectors and (3) a prioritized research agenda to understand the political economy of pandemics, the role played by different political systems and actors and implementation challenges, and to identify combined strategies to address the converging agendas of CDs and NCDs.

Research limitations/implications

The article is based on the review of available published evidence.

Practical implications

The uptake of the strategies proposed will better prepare countries to respond to NCD and CD pandemics during public health emergencies.

Originality/value

The article is the first of its kind addressing the governance challenges of the dual pandemic of NCDs and CDs in emergencies.

Challenges Associated With the Response to the Coronavirus Disease (COVID-19) Pandemic in Africa-An African Diaspora Perspective

The 2014-2016 Ebola outbreak in West Africa extracted huge health, social, and economic costs. How can lessons learnt during the 2014-2016 Ebola outbreak in West Africa help to mitigate the likelihood of a long-term devastating effect of the coronavirus disease (COVID-19) outbreak on the African continent? Despite COVID-19 spreading quickly across the globe after being first reported in Wuhan, China on December 31, 2019, African countries remained relatively unaffected until the second week of March 2020. The majority of Africa countries have been at low to moderate risk. However, they have experienced many sociocultural, economic, political, and structural challenges. These have included laboratory capacity and logistical challenges; ill-equipped public health systems; land border permeability, and delayed preparedness to transnational threats; and abject economic deprivation, lack of basic infrastructure, and associated sociocultural implications. There needs to be a strong country-level leadership to coordinate and own all aspects of the responses to the COVID-19 pandemic in a collaborative, transparent, and accountable way. Strategic and sustained response plans to fight the pandemic should incorporate culturally competent strategies that harness different cultural practices and strengthen cultural security. They should also promote and strengthen the implementation of the International Health Regulations.

A survey of International Health Regulations National Focal Points experiences in carrying out their functions

Background

The 2005 International Health Regulations (IHR (2005)) require States Parties to establish National Focal Points (NFPs) responsible for notifying the World Health Organization (WHO) of potential events that might constitute public health emergencies of international concern (PHEICs), such as outbreaks of novel infectious diseases. Given the critical role of NFPs in the global surveillance and response system supported by the IHR, we sought to assess their experiences in carrying out their functions.

Methods

In collaboration with WHO officials, we administered a voluntary online survey to all 196 States Parties to the IHR (2005) in Africa, Asia, Europe, and South and North America, from October to November 2019. The survey was available in six languages via a secure internet-based system.

Results

In total, 121 NFP representatives answered the 56-question survey; 105 in full, and an additional 16 in part, resulting in a response rate of 62% (121 responses to 196 invitations to participate). The majority of NFPs knew how to notify the WHO of a potential PHEIC, and believed they have the content expertise to carry out their functions. Respondents found training workshops organized by WHO Regional Offices helpful on how to report PHEICs. NFPs experienced challenges in four critical areas: 1) insufficient intersectoral collaboration within their countries, including limited access to, or a lack of cooperation from, key relevant ministries; 2) inadequate communications, such as deficient information technology systems in place to carry out their functions in a timely fashion; 3) lack of authority to report potential PHEICs; and 4) inadequacies in some resources made available by the WHO, including a key tool – the NFP Guide. Finally, many NFP representatives expressed concern about how WHO uses the information they receive from NFPs.

Conclusion

Our study, conducted just prior to the COVID-19 pandemic, illustrates key challenges experienced by NFPs that can affect States Parties and WHO performance when outbreaks occur. In order for NFPs to be able to rapidly and successfully communicate potential PHEICs such as COVID-19 in the future, continued measures need to be taken by both WHO and States Parties to ensure NFPs have the necessary authority, capacity, training, and resources to effectively carry out their functions as described in the IHR.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-021-00675-7.

Trust, risk, and the challenge of information sharing during a health emergency

Information sharing is a critical element of an effective response to infectious disease outbreaks. The international system of coordination established through the World Health Organization via the International Health Regulations largely relies on governments to communicate timely and accurate information about health risk during an outbreak. This information supports WHO's decision making process for declaring a public health emergency of international concern. It also aides the WHO to work with governments to coordinate efforts to contain cross-border outbreaks.Given the importance of information sharing by governments, it is not surprising that governments that withhold or delay sharing information about outbreaks within their borders are often condemned by the international community for non-compliance with the International Health Regulations. The barriers to rapid and transparent information sharing are numerous. While governments must be held accountable for delaying or withholding information, in many cases non-compliance may be a rational response to real and perceived risks rather than a problem of technical incapacity or a lack of political commitment. Improving adherence to the International Health Regulations will require a long-term process to build trust that incorporates recognizing and mitigating the potential and perceived risks of information sharing.

Toward Human Rights-Consistent Responses to Health Emergencies: What Is the Overlap between Core Right to Health Obligations and Core International Health Regulation Capacities?

COVID-19 has highlighted the responsibilities of states under the International Health Regulations (IHR), as well as state accountability in case of a breach. These approaches and dimensions are valuable, as many COVID responses have breached human rights. We should also look beyond this crisis and address country preparedness for effective and equitable responses to future infectious disease outbreaks. This paper assesses countries' international legal obligations to be prepared to respond to this and future public health emergencies. It does so from the perspective of the right to health, in interaction with the IHR. We analyze the functional relationship between the right to health and the IHR, focusing in particular on "core obligations" under the right to health and "core capacities" under the IHR. We find considerable parallels between the two regimes and argue in favor of more cross-fertilization between them. This regime interaction may enrich both frameworks from a normative perspective while also enhancing accountability and public health and human rights outcomes.

Preparedness of African Palliative Care Services to Respond to the COVID-19 Pandemic: A Rapid Assessment

CONTEXT

Palliative care is an essential component of the coronavirus disease 2019 (COVID-19) pandemic response but is overlooked in national and international preparedness plans. The preparedness and capacity of African palliative care services to respond to COVID-19 is unknown.

OBJECTIVES

To evaluate the preparedness and capacity of African palliative care services to respond to the COVID-19 pandemic.

METHODS

We developed, piloted, and conducted a cross-sectional online survey guided by the 2005 International Health Regulations. It was electronically mailed to the 166 African Palliative Care Association's members and partners. Descriptive analyses were conducted.

RESULTS

About 83 participants from 21 countries completed the survey. Most services had at least one procedure for the case management of COVID-19 or another infectious disease (63%). Respondents reported concerns over accessing running water, soap, and disinfectant products (43%, 42%, and 59%, respectively) and security concerns for themselves or their staff (52%). Two in five services (41%) did not have any or make available additional personal protective equipment. Most services (80%) reported having the capacity to use technology instead of face-to-face appointment, and half (52%) reported having palliative care protocols for symptom management and psychological support that could be shared with nonspecialist staff in other health care settings.

CONCLUSION

Our survey suggests that African palliative care services could support the wider health system's response to the COVID-19 pandemic with greater resources such as basic infection control materials. It identified specific and systemic weaknesses impeding their preparedness to respond to outbreaks. The findings call for urgent measures to ensure staff and patient safety.

Thinking differently: lessons learned by international public health specialists while supporting the Integrated Disease Surveillance and Response system in Pakistan

Internationally supported activities to build public health capacity and improve compliance with International Health Regulations (2005) so that countries are better able to ‘prevent, protect against, control and provide a public health response to the international spread of disease’ have had a positive impact in recent years. However, despite the proliferation of technical guidance, tools and roadmaps, as the recent COVID-19 emergency demonstrates, a significant challenge still remains. The unique and complex environment within countries is increasingly being recognised as a factor which needs greater consideration if system strengthening activities are to be successful.

This paper reflects on the learning from and charts out the journey of the authors’ in their efforts to support the Pakistan government to improve compliance with International Health Regulations, specifically through strengthening its Integrated Disease Surveillance and Response (IDSR) system.

To effect change, public health technical specialists bring their grounded technical and scientific expertise along with their softer public health skills of, among other things, relationship building and multisector working. In the authors’ experience, the importance of taking time throughout to build and maintain strong trusted relationships and peer-to-peer support has been the key to the successes experienced. The nature of this relationship and ongoing reflexive dialogue enabled the co-construction of the reality of the background environment, which, in turn, led to more realistic visioning of the desired system for IDSR, and therefore more appropriate bespoke technical support to be given, leading to the design and initial implementation of a country owned system developed with sustainability in mind.

Rethinking the COVID-19 Pandemic: Back to Public Health

The COVID-19 pandemic has highlighted vast differences across countries in their responses to the emergency and their capacities to implement public health measures that could slow the progression of the disease. As public health systems are the first line of defense during pandemics, it has become clear that sustained investment in strengthening public health infrastructure is a major need in all countries, irrespective of income levels. Drawing on the successful experiences of Switzerland, Georgia, and New Zealand in dealing with COVID-19, we suggest prioritizing core public health capacities with links to the International Health Regulations, improving international cooperation, coordination, and multisectoral action, addressing health inequities by targeting vulnerable groups, and enhancing health literacy, including through sophisticated and sustained communication campaigns to build resilience. These measures will ensure that health systems and communities will be better prepared for the disruptions that future disease outbreaks will inevitably bring.

Lessons Learned from Reinforcing Epidemiologic Surveillance During the 2017 Ebola Outbreak in the Likati District, Democratic Republic of the Congo

On May 12, 2017, the Democratic Republic of Congo (DRC) publicly declared an outbreak of Ebola virus disease (EVD) in the Likati District of the Bas-Uélé Province, 46 days after the index case became symptomatic. The delayed EVD case detection and reporting highlights the importance of establishing real-time surveillance, consistent with the Global Health Security Agenda. We describe lessons learned from implementing improved EVD case detection and reporting strategies at the outbreak epicenter and make recommendations for future response efforts. The strategies included daily coordination meetings to enhance effective and efficient outbreak response activities, assessment and adaptation of case definitions and reporting tools, establishment of a community alert system using context-appropriate technology, training facility and community health workers on adapted case definitions and reporting procedures, development of context-specific plans for outbreak data management, and strengthened operational support for communications and information-sharing networks. Post-outbreak, surveillance officials should preemptively plan for the next outbreak by developing emergency response plans, evaluating the case definitions and reporting tools used, retraining on revised case definitions, and developing responsive strategies for overcoming telecommunications and technology challenges. The ongoing EVD outbreak in the North Kivu and Ituri provinces of DRC, currently the second largest EVD outbreak in history, demonstrates that documentation of successful context-specific strategies and tools are needed to combat the next outbreak. The lessons learned from the rapid containment of the EVD outbreak in Likati can be applied to the DRC and other rural low-resource settings to ensure readiness for future zoonotic disease outbreaks.

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.

Understanding India's urban dengue surveillance: A qualitative policy analysis of Hyderabad district

Dengue's re-emerging epidemiology poses a major global health threat. India contributes significantly to the global communicable disease burden has been declared highly dengue-endemic, exposing public health authorities to severe challenges. Our study aims to provide a deeper understanding of India's urban dengue surveillance policies as well as to explore the organisation, functioning and integration of existing disease control pillars. We conducted a qualitative regional case study, consisting of semi-structured expert interviews and observational data, covering the urban region of Hyderabad in South India. Our findings indicate that Hyderabad's dengue surveillance system predominantly relies on public reporting units, neglecting India's large private health sector. The surveillance system requires further strengthening and additional efforts to efficiently integrate existing governmental initiatives at all geographical levels and administrative boundaries. We concluded with recommendations for improved consistency, accuracy, efficiency and reduction of system fragmentation to enhance the integration of dengue surveillance and improved health information in urban India. Finally, our study underlines India's overall need to increase investment in public health and health infrastructures. That requires coordinated and multi-level action targeting the development of a competent, effective and motivated public health cadre, as well as truly integrated surveillance and epidemic response infrastructure, for dengue and beyond.

Artificial Intelligence (AI) Provided Early Detection of the Coronavirus (COVID-19) in China and Will Influence Future Urban Health Policy Internationally

Predictive computing tools are increasingly being used and have demonstrated successfulness in providing insights that can lead to better health policy and management. However, as these technologies are still in their infancy stages, slow progress is being made in their adoption for serious consideration at national and international policy levels. However, a recent case evidences that the precision of Artificial Intelligence (AI) driven algorithms are gaining in accuracy. AI modelling driven by companies such as BlueDot and Metabiota anticipated the Coronavirus (COVID-19) in China before it caught the world by surprise in late 2019 by both scouting its impact and its spread. From a survey of past viral outbreaks over the last 20 years, this paper explores how early viral detection will reduce in time as computing technology is enhanced and as more data communication and libraries are ensured between varying data information systems. For this enhanced data sharing activity to take place, it is noted that efficient data protocols have to be enforced to ensure that data is shared across networks and systems while ensuring privacy and preventing oversight, especially in the case of medical data. This will render enhanced AI predictive tools which will influence future urban health policy internationally.

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.

Brexit and health security: why we need to protect our global networks

As the United Kingdom (UK) negotiates its separation from the European Union (EU), it is important to remember the public health mechanisms that are directly facilitated via our relationship with the EU. One such mechanism is the UK’s role within the European Centre for Disease Prevention and Control (ECDC). Global health protection is an area that is currently experiencing an unprecedented wave of innovation, both technologically and ideologically, and we must therefore ensure that our future relationship with ECDC is one that facilitates full involvement with the global health security systems of the future.

Systemic resilience to cross-border infectious disease threat events in Europe

Recurrent health emergencies threaten global health security. International Health Regulations (IHR) aim to prevent, detect and respond to such threats, through increase in national public health core capacities, but whether IHR core capacity implementation is necessary and sufficient has been contested. With a longitudinal study we relate changes in national IHR core capacities to changes in cross-border infectious disease threat events (IDTE) between 2010 and 2016, collected through epidemic intelligence at the European Centre for Disease Prevention and Control (ECDC). By combining all IHR core capacities into one composite measure we found that a 10% increase in the mean of this composite IHR core capacity to be associated with a 19% decrease (p = 0.017) in the incidence of cross-border IDTE in the EU. With respect to specific IHR core capacities, an individual increase in national legislation, policy & financing; coordination and communication with relevant sectors; surveillance; response; preparedness; risk communication; human resource capacity; or laboratory capacity was associated with a significant decrease in cross-border IDTE incidence. In contrast, our analysis showed that IHR core capacities relating to point-of-entry, zoonotic events or food safety were not associated with IDTE in the EU. Due to high internal correlations between core capacities, we conducted a principal component analysis which confirmed a 20% decrease in risk of IDTE for every 10% increase in the core capacity score (95% CI: 0.73, 0.88). Globally (EU excluded), a 10% increase in the mean of all IHR core capacities combined was associated with a 14% decrease (p = 0.077) in cross-border IDTE incidence. We provide quantitative evidence that improvements in IHR core capacities at country-level are associated with fewer cross-border IDTE in the EU, which may also hold true for other parts of the world.

The promise and peril of universal health care

Universal health care (UHC) is garnering growing support throughout the world, a reflection of social and economic progress and of the recognition that population health is both an indicator and an instrument of national development. Substantial human and financial resources will be required to achieve UHC in any of the various ways it has been conceived and defined. Progress toward achieving UHC will be aided by new technologies, a willingness to shift medical tasks from highly trained to appropriately well-trained personnel, a judicious balance between the quantity and quality of health care services, and resource allocation decisions that acknowledge the important role of public health interventions and nonmedical influences on population health.