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Readiness for Microbial Threats 2030: Exploring Lessons Learned Since the 1918 Influenza Pandemic

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Abstract

The world has made dramatic strides in tackling infectious diseases over the past century, including smallpox eradication, significant progress on polio eradication, and widespread vaccination. However, new threats have emerged—including 30 new zoonotic diseases in the past two decades alone. This uptick in new diseases may be the result of many factors, including economic growth, global travel, the proximity of humans to animals, or climate change, and the trend does not appear to be slowing. One hundred years after the 1918 pandemic influenza, we remain at risk of pandemic spread—perhaps more so than ever before. This continued risk highlights the need to be globally prepared. While many lessons on preparedness were gleaned following the 2014 Ebola outbreak in West Africa, we still lack a more comprehensive summary of lessons from different outbreak and pandemic events over the course of the past century. To address this gap, we reviewed reports outlining recommendations and lessons from major epidemics that have occurred since the 1918 influenza pandemic. Six major types of outbreaks were chosen by the Forum on Microbial Threats (FMT) to survey. We conducted a unique review of the literature for each outbreak to capture reports or studies published during, or in the years following, that pandemic (see reference list at the end of the commissioned paper). The subject of the review was what needs to be accomplished to make progress in epidemic and pandemic preparedness moving forward—or globally relevant lessons learned from each event. Where possible, we focused on global lessons (for more than one country) from each specific outbreak. This ultimately included global lessons abstracted from 16 peer-reviewed papers or reports. The process was not meant to be exhaustive but rather representative of different periods, disease types, and authorship (e.g., academic, practitioner, multilateral).
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http://nap.edu/25391
Exploring Lessons Learned from a Century of Outbreaks:
Readiness for 2030: Proceedings of a Workshop (2019)
230 pages | 6 x 9 | PAPERBACK
ISBN 978-0-309-49032-0 | DOI 10.17226/25391
V. Ayano Ogawa, Cecilia Mundaca Shah, and Anna Nicholson, Rapporteurs; Forum on
Microbial Threats; Board on Global Health; Health and Medicine Division;
National Academies of Sciences, Engineering, and Medicine
National Academies of Sciences, Engineering, and Medicine 2019. Exploring
Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of
a Workshop. Washington, DC: The National Academies Press.
https://doi.org/10.17226/25391.
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
Copyright National Academy of Sciences. All rights reserved.
Appendix A
Commissioned Paper
Readiness for Microbial Threats 2030: Exploring Lessons Learned Since
the 1918 Influenza Pandemic
Elvis Garcia, M.P.H., M.P.A., M.Eng.
Harvard T.H. Chan School of Public Health
Liana Rosenkrantz Woskie, M.Sc.
Harvard Global Health Institute
149
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
Copyright National Academy of Sciences. All rights reserved.
150 LESSONS LEARNED FROM A CENTURY OF OUTBREAKS
ACRONYMS AND ABBREVIATIONS
DG Director-General
DON disease outbreak news
DORS disease outbreak response system
ED executive director
EIS epidemic intelligence service
EOC emergency operations centers
ERF emergency response framework
FAO Food and Agriculture Organization of the United Nations
GHSA Global Health Security Agenda
GOARN Global Outbreak Alert and Response Network
HSS health systems strengthening
IHR International Health Regulations
ILAR Institute for Laboratory Animal Research
IMF International Monetary Fund
MERS-CoV Middle East respiratory syndrome coronavirus
MOH Ministry of Health
OIE World Organisation for Animal Health
PHEIC public health emergency of international concern
R&D research and development
SARS severe acute respiratory syndrome
SDG Sustainable Development Goal
UHC universal health coverage
UN United Nations
UNGA United Nations General Assembly
UNSG United Nations Secretary-General
WHA World Health Assembly
WHO World Health Organization
WTO World Trade Organization
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
Copyright National Academy of Sciences. All rights reserved.
APPENDIX A 151
BACKGROUND
The world has made dramatic strides in tackling infectious diseases
over the past century, including smallpox eradication, significant progress
on polio eradication, and widespread vaccination. However, new threats
have emerged—including 30 new zoonotic diseases in the past two decades
alone. This uptick in new diseases may be the result of many factors, includ-
ing economic growth, global travel, the proximity of humans to animals, or
climate change, and the trend does not appear to be slowing. One hundred
years after the 1918 pandemic influenza, we remain at risk of pandemic
spread—perhaps more so than ever before. This continued risk highlights
the need to be globally prepared. While many lessons on preparedness were
gleaned following the 2014 Ebola outbreak in West Africa, we still lack a
more comprehensive summary of lessons from different outbreak and pan-
demic events over the course of the past century.
To address this gap, we reviewed reports outlining recommendations
and lessons from major epidemics that have occurred since the 1918 influ-
enza pandemic. Six major types of outbreaks were chosen by the Forum
on Microbial Threats (FMT) to survey.1 We conducted a unique review of
the literature for each outbreak to capture reports or studies published dur-
ing, or in the years following, that pandemic (see reference list at the end
of the commissioned paper). The subject of the review was what needs to
be accomplished to make progress in epidemic and pandemic preparedness
moving forward—or globally relevant lessons learned from each event.
Where possible, we focused on global lessons (for more than one coun-
try) from each specific outbreak. This ultimately included global lessons
abstracted from 16 peer-reviewed papers or reports. The process was not
meant to be exhaustive but rather representative of different periods, dis-
ease types, and authorship (e.g., academic, practitioner, multilateral).
We found significant overlap in content across the reports. This finding
was consistent with themes summarized by both Gostin (2016) and Moon
et al. (2017) in Toward a Common Secure Future: Four Global Commis-
sions in the Wake of Ebola and Post-Ebola Reforms: Ample Analysis,
Inadequate Action, respectively. Moon et al. (2017) categorized recommen-
dations from the 2014 Ebola outbreak in West Africa as follows:
1. Bolster country-level core capacities and compliance with the
International Health Regulations (IHR).
1
The following outbreaks were selected: (1) the 1957 and 1968 influenza pandemics,
(2) the 2003 emergence of influenza A (H5N1) and severe acute respiratory syndrome
(SARS), (3) the 2009 H1N1 influenza A pandemic, (4) the 2013 emergence of influenza A
(H7N9), (5) the 2014–2016 Ebola outbreak in West Africa, and (6) the 2012–2015 Middle
East respiratory syndrome coronavirus (MERS-CoV) outbreak in Saudi Arabia and in Korea.
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
Copyright National Academy of Sciences. All rights reserved.
152 LESSONS LEARNED FROM A CENTURY OF OUTBREAKS
2. Improve knowledge sharing and research.
3. Strengthen the World Health Organization (WHO), the United
Nations (UN), and broader global health or humanitarian systems.
Below, we summarize highlights from the review using an adaptation
of this same framework. Additionally, for each category, we provide sum-
maries of recommendations and lessons (see Boxes A-1 to A-5), which are
outlined in more detail in Tables A-1 to A-5.
CATEGORY 1: COUNTRY-LEVEL CORE CAPACITIES
Robust and sustainable health systems are a prerequisite for preventing,
detecting, and responding to pandemics and to pandemic threats. The IHR
are the current framework for country preparedness for infectious disease
outbreaks and require 196 State Parties to develop and maintain core health
system capacities in the face of acute public health risks such as infectious
disease threats of international concern. Core capacities in this framework
are organized into three categories related to prevention, detection, and
response, which include subdomains (e.g., health workforce, laboratories,
data systems, and risk communication), in order to identify and to con-
tain threats before they cross national borders. While this review includes
studies that were released prior to the development of the IHR, we use the
IHR framework to organize recommendations and lessons from reviewed
content (see Box A-1). Additional content was also reviewed on trade and
travel, accountability mechanisms, and other suggestions to support coun-
tries as they work to achieve adequate core capacities.
BOX A-1
Recommendations and Lessons for Bolstering
Country-Level Core Capacities
Strengthening Capacity to PREVENT
1. Response frameworks should include better scenario planning and less
rigidity, considering variation that occurs among diseases. Ministries of
health should be familiar with different suites of measures so that they
can deploy them flexibly. (H1N1)
2. Effective primary care can help alleviate the overloading of emergency
departments. (H1N1)
3. Prevention goals within the International Health Regulations (IHR)
should align with those in the universal health coverage (UHC) agenda,
and accountability should be built into both frameworks. (Ebola)
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
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APPENDIX A 153
Strengthening Capacity to DETECT
1. “Wide net” surveillance often makes sense in situations when there
are nonspecific symptoms (H1N1), and nonhealth entities can support
screening in places such as schools, businesses, and transportation
sites. (SARS, H1N1)
2. National surveillance needs to be paired with rapid international verifica-
tion, especially when a pandemic occurs in low-resource contexts with
limited lab capacity. (H5N1)
3. Web-based search patterns can be used to identify potential risks early.
(H1N1)
4. Surveillance efforts must be tied to animal health and focused on rural
areas. (H1N1, H5N1)
5. “Timeliness of data management and risk assessment is essential for
identifying unusual clusters (e.g., high death rates) and initiating ap-
propriate responses” (Fisher et al., 2011). (H1N1)
6. When the disease is not fully understood, detection systems should
include feedback loops on spread, so clinicians and other people who
treat the disease can understand viral transmission and treatment ef-
fectiveness. (H1N1)
Strengthening Capacity to RESPOND
1. Strong health systems are key: “Underresourced, understaffed, and
fragmented health services are unable to contain outbreaks of serious
infectious diseases or to adequately respond to health emergencies”
(Save the Children, 2015). (Ebola)
2. “Health care workers must be given priority for protection and treatment
to enable them to perform their duties” (Lee et al., 2008). (H1N1)
3. Lack of epidemiological information on the disease hampers effective
treatment. (H1N1)
4. Response plans, even those created for prior diseases, are effective
and provide a blueprint for countries. However, there is need for practi-
cal testing of these plans at both hospital and above hospital levels.
(H1N1)
5. Containment, as a strategy, is highly dependent on the disease. When
containment efforts do not work, the importance of communicating risk
to the public increases. (H1N1)
6. Risk communication and engagement with communities throughout
outbreak events were noted as critical for each outbreak. Specific efforts
featured included dedicated government websites and use of social
media. (Multiple)
BOX A-1 Continued
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154 LESSONS LEARNED FROM A CENTURY OF OUTBREAKS
In this review, we found that 16 out of 16 papers included content
on core national capacities on outbreak reporting (if not specifically those
outlined in the IHR). Some of this content was presented in the form of
lessons for future outbreaks while other content was framed as reflections
(often made by practitioners or policy makers who actively addressed an
outbreak event).
Recommendations and lessons regarding how the broader global health
system could support countries’ efforts to develop core capacities were also
mentioned throughout the reviewed papers but were less common than
lessons aimed at countries themselves. Suggestions for WHO included
content on supporting country preparedness in the absence of a current
pandemic and on what WHO’s role should be during an actual outbreak
(see Box A-2).
BOX A-2
Recommendations and Lessons for Bolstering the Global
System Support for Country-Level Core Capacities
Role of the World Health Organization (WHO) in Supporting Country Capacity
1. WHO should prepare a template pandemic preparedness plan for coun-
tries. (H5N1)
2. WHO should develop benchmarks for core capabilities and support
countries’ efforts to achieve them. (Ebola)
3. WHO needs to “establish a more extensive public health reserve work-
force” (WHO, 2005). (H5N1)
4. WHO is mandated to serve as the guardian of the International Health
Regulations, and it may require involvement from multiple levels of the
organization to accomplish this mandate (e.g., national country offices,
regional offices, and headquarters). (H7N9)
5. WHO needs to “work with existing regional and sub-regional networks
to strengthen linkages and coordination; the ultimate goal is to enhance
mutual support and trust” (Sands et al., 2016). (Ebola)
6. WHO and other international guidelines cannot adapt as fast as local
knowledge and should not eclipse clinical judgment. Adequate feedback
loops are required so that guidelines are dynamic and respond to on-
the-ground realities. (MERS-CoV)
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
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APPENDIX A 155
Roles of Other Global Actors in Supporting Country Capacity
1. The UN Secretary-General should ensure a minimum level of health-
system functionality in fragile and failed states. (H7N9)
2. “The International Monetary Fund (IMF) should include pandemic pre-
paredness in countries’ economic and policy assessments” (Sands et
al., 2016). (Ebola)
3. All development assistance for health should be contingent on pan-
demic preparedness at the national level. (Ebola)
Public Health Emergency of International Concern (PHEIC)a Reporting
1. The PHEIC reporting mechanisms should be used for the duration of a
pandemic to communicate updates throughout the event. (H7N9)
2. An intermediate level prior to a formal PHEIC would incentivize coun-
tries to express risk at earlier stages—without the risks associated with
communicating a full PHEIC. (Ebola)
a“A PHEIC is an extraordinary event that constitutes a public health risk to other
State Parties through the international spread of disease and that potentially
requires a coordinated international response” (WHO, 2016a).
BOX A-2 Continued
CATEGORY 2: RESEARCH, DEVELOPMENT,
AND KNOWLEDGE SHARING
There has been a persistent failure of timely vaccine deployment and
lack of global knowledge/data sharing over time. The papers reviewed, con-
sistent with prior work, recognize that for both effectively preventing and
mitigating outbreaks timely sharing of information of research and health
technology efforts is critical. While this topic was less well explored than
national core capacities or global governance, several papers have outlined
problems with vaccine readiness, sample sharing, and other issues related
to the handling of epidemiological, genomic, or clinical data both during
as well as after pandemics.
In this review, we found that 8 out of the 16 papers contained content
that addressed pharmaceutical research and development (R&D) or sample
sharing and information sharing (see Box A-3).
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156 LESSONS LEARNED FROM A CENTURY OF OUTBREAKS
BOX A-3
Recommendations and Lessons for Improving
Research, Development, and Knowledge Sharing
Vaccine, Diagnostic, and Therapeutic Readiness
1. “Public health measures such as antivirals, vaccination, and
nonpharmaceutical interventions must be performed in concert to
reduce the impact of a future pandemic” (Lee et al., 2008). (H1N1
1957–1968)
2. Very rapid and highly sensitive tests, which “substantially reduce the
number of individuals that need to be quarantined without decreasing
the effectiveness of the measure, need to be developed” (Tan, 2006).
(SARS)
3. The development of a pandemic vaccine should be expedited: “Shorten
the time between the emergence of a pandemic virus and the start of
commercial production” (Behrens et al., 2006). (H5N1)
4. Scientific understanding and technical capacity need to be improved,
because both are currently fundamental constraints on pandemic
preparedness. (H1N1)
5. A comprehensive influenza research and evaluation program should be
pursued. (H1N1)
6. “Investment in medical research and development (R&D) for diseases
that largely affect the poor is deeply inadequate. Of the $214 billion
invested in health R&D globally in 2010, less than 2 percent was
allocated to neglected diseases” (UN High-level Panel on the Global
Response to Health Crises, 2016). (Ebola)
7. Research and development (R&D) should not be left to market forces:
The Ebola outbreak exemplified “how ill-suited the medical research
and development model is for addressing the world’s health priorities”
(Heymann et al., 2015). (Ebola)
8. Drug quality issues should be addressed: They pose “social, economic,
and political challenges to health security by undermining capabilities
to curb both infectious and noncommunicable diseases while eroding
public confidence in governments and international institutions”
(Heymann et al., 2015). (Ebola)
9. R&D “armory” should be built. It currently has “many gaps, which Ebola
and other outbreaks have revealed, that span vaccine development
and capacity, diagnostic tools, therapeutics, protective equipment, and
anthropological research” (Sands et al., 2016). (Ebola)
10. Resources should be dedicated to “R&D on prioritized pathogens to
ensure the greater availability of critical vaccines and treatments when
they are most needed” (UN, 2016). (Ebola)
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
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APPENDIX A 157
Delivery Capacity for Pharmaceutical and Medical Goods
1. An outbreak should be contained or delayed at the source. An
international stockpile of antiviral drugs should be established, and
mass delivery mechanisms for antiviral drugs should be developed.
(H5N1)
2. There is a worldwide need for greater production capacity and for faster
throughput. (H1N1)
3. Advanced agreements for vaccine distribution and delivery should be
encouraged. (H1N1)
4. Significantly greater resources for medical products should be
prioritized, mobilized, and deployed, and development and regulatory
approval processes should be harmonized. (Ebola)
Sample and Knowledge Sharing
1. “The exchange of epidemiological information on infectious diseases,
especially the emergence of new infections, should be strengthened
between the health authorities in Mainland China and Hong Kong”
(Hung, 2003). (SARS)
2. It is important to reach an agreement on the sharing of viruses. (H1N1,
Ebola)
Synergies with One Health
1. Feedback loops should be developed between human and animal
health. (Multiple)
2. “Most of the affected countries could not adequately compensate
farmers for culled poultry, thus discouraging the reporting of outbreaks
in rural areas where the vast majority of human cases have occurred”
(WHO, 2005). (H5N1)
3. “Domestic ducks were able to excrete large quantities of a highly
pathogenic virus without showing signs of illness. Their silent role
in maintaining transmission further complicated control in poultry
and made human avoidance of risky behaviors more difficult” (WHO
Communicable Disease Surveillance and Response Global Influenza
Programme, 2005). (H5N1)
4. More investment in “One Health research should be requested to
enhance understanding of the emergence, prevention, detection, and
control of pandemic influenza viruses” (Monath et al., 2010). (H1N1)
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158 LESSONS LEARNED FROM A CENTURY OF OUTBREAKS
CATEGORY 3: WHO AND THE GLOBAL SYSTEM
Following the 2014 Ebola outbreak in West Africa, seven major reports
agreed that reforms needed to be put in place to improve the global gov-
ernance mechanisms within WHO and the broader UN and humanitarian
systems to strengthen the global response capacity to these type of events.
While the reports also agreed on maintaining the global preparedness and
response functions for global disease outbreaks within WHO, they did not
agree on how best to do this. Since Ebola, WHO has undergone a number
of reforms—which we do not fully cover here. Rather, in this review, we
look at what postpandemic reports have suggested as necessary changes.
In line with prior work on this topic, we use sub-themes—for example,
WHO’s specific role in outbreaks, as well as internal suggestions regard-
ing leadership and human resources (see Box A-4). This includes issues
related to WHO’s operational capacity to respond to disease outbreaks
on the ground as well as broader institutional reforms to all multilateral
organizations, such as financing, that may not be limited to emergencies
or outbreaks (see Box A-5). There is some overlap with the category on
national core capacities, but in that category we had focused on the role
of WHO in supporting countries, while in this category, we take a systems
view of the global governance mechanisms in place.
We found that 7 of the 16 papers addressed broader issues of the global
governance system (items that might be addressed by cross-national bodies,
such as WHO or the UN). The inclusion of this topic, recommendations
related to the global system (UN, WHO, or other multilateral organiza-
tions), increased during and after the 2014 Ebola outbreak. Therefore, the
majority of recommendations are from reports on, or following, the 2014
Ebola outbreak. Prior to this time, many reports were produced by agencies
themselves with minimal inward-looking recommendations or critiques of
the global health system, however defined.
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
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APPENDIX A 159
BOX A-4
Recommendations and Lessons for Strengthening
World Health Organization’s (WHO’s) Capacity
WHO Actions and Internal Capacity for Future Outbreaks
1. WHO needs to develop operational capacity. (Ebola)
2. WHO should build capacity to support low- and middle-income countries
in the development of their own vaccine manufacturing capacity, and
national pandemics preparedness plans. (H5N1)
3. Greater resources are needed to be able to improve WHO capacities,
and this would require a profound organizational transformation. (Ebola)
4. WHO should establish a Program/Center for Health Emergency
Preparedness and Response that is governed by an independent
technical governing board. (H5N1, Ebola)
5. The role of WHO as a broker of knowledge—with the ability to
respond more effectively when at odds with local, quickly developing
knowledge—should be reinforced. (Ebola)
6. WHO should enhance cooperation with non-state actors while
recalibrating relationships with member states and recognizing the
distinct roles that each actor plays. (Ebola)
WHO Leadership and Human Resources
1. The new Director-General’s critical role should be to refocus WHO’s
purpose and structure, and remain accountable for incident management
within WHO. (Ebola)
2. WHO should revise how elections are conducted for WHO officials and
should specifically improve transparency and the democratic nature of
elections. (Ebola)
3. WHO should invest in training health professionals, especially
community health workers. (Ebola)
4. WHO staff need to be qualified to manage outbreaks and emergencies.
Health workforces should include a broad range of actors from multiple
sectors working at different levels, rather than a single global workforce
of “white helmets.” (Ebola)
5. WHO should increase its staff. (Ebola)
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160 LESSONS LEARNED FROM A CENTURY OF OUTBREAKS
BOX A-5
Recommendations and Lessons for
Strengthening System-Wide Capacity
Operations (Internal and External to World Health Organization [WHO])
1. Existing institutions should be leveraged rather than creating new ones.
(Ebola)
2. Actors need to coordinate more effectively with each other and to
establish clear lines of command. (Ebola)
3. During health crises, humanitarian actors should have access to
guidelines and standard operating procedures. (Ebola)
4. Health cluster capacities and integration need to be developed along
with the overall humanitarian system. (Ebola)
Accountability
1. Regular independent assessments should be commissioned. (Ebola)
2. Sustainable Development Goals (SDGs) should be used to target
indicators as a baseline for accountability. (Ebola)
3. WHO should be required to use existing resources more efficiently,
report against specific outcomes, develop indicators to assess progress,
and rigorously track expenditures. (Ebola)
Financing and Aid
1. Investments need to increase for building robust health systems.
(Ebola)
2. WHO should mobilize international financial support for IHR core
capacities strengthening. (Ebola)
3. Contributions should increase for WHO, and WHO should establish a
contingency fund for these type of emergencies. (Ebola)
4. Funding for WHO’s Emergency Program’s baseline capacity should be
secured through predictable and reliable financing streams, including
assessed contribution and different from funding for specific responses.
(Ebola)
5. Effective mechanisms are needed to help countries in need through
institutions like the IMF and World Bank. Initiatives need to provide
budgetary support and rapid credit availability. (Ebola)
6. The creation of World Bank’s Pandemic Emergency Finance Facility
should be supported. (Ebola)
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
Copyright National Academy of Sciences. All rights reserved.
APPENDIX A 161
CONCLUSION
We found that country-level core capacities were the most common
subject covered by the reports in this review. In earlier reports, recommen-
dations on core capacities were more thoroughly explored, and targeted
advice was provided at the country level. Later reports, particularly those
following the 2005 IHR, focused on the effective implementation of IHR as
opposed to its component parts. However, domains across the reports were
similar (e.g., preparedness, detection, and response), which may reflect the
incorporation of earlier recommendations into the IHR in 2005. Another
notable difference in later reports was a shift toward taking a wider lens
view (e.g., recommendations to strengthen capacities across countries) and
examining the need to tie together global health agendas, such as the IHR
and universal health coverage (UHC), as a primary component of the SDGs.
This trend aligns with an increase in the number of global health actors over
time, which, in turn, likely increases the relevance of dialogue on global
coordination and accountability for country preparedness.
While some reports covered issues such as health technologies, phar-
maceutical readiness, deployment, or knowledge sharing (e.g., biological
samples or results from trials), several others provided recommendations
focused primarily on vaccine readiness. Specifically, many of the reports
discussed the persistent failure of timely vaccine deployment and the lack of
global knowledge-sharing norms around vaccines. Unlike their suggestions
around country-level core capacities, recommendations on vaccine readiness
resulting from outbreaks over time were generally consistent, which suggests
broader challenges have yet to be addressed in this domain. There have, how-
ever, been notable efforts to address these recommendations more recently
(e.g., the Coalition for Epidemic Preparedness Innovations, the WHO’s
R&D “Blueprint,” and other efforts summarized by Leigh et al. [2018]).
Additionally, across reports, systems for the delivery of pharmaceuticals
and other medical technologies were noted as impediments to effective
response. However, authors offered few recommendations to improve deliv-
ery capacity or to engage other actors, such as the private sector or military,
in doing so. Content on R&D differed among reports depending on disease
context. For example, following influenza outbreaks, discussions included
a focus on One Health and on the need to better align human and animal
R&D strategies. This was not true for Ebola reports, where the zoonotic
nature of the disease was less well understood. In line with country-level
capacity recommendations, this category may benefit from a more dynamic
approach to readiness given the diversity of medical technologies needed.
Such an approach could include familiarizing ministries of health and other
key actors with multiple scenarios so that outbreak responses are adaptive
to disease types.
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162 LESSONS LEARNED FROM A CENTURY OF OUTBREAKS
For reports following the 2014 Ebola outbreak, there was a notable
increase in discussion of and recommendations regarding global governance
mechanisms for health. As noted above, this may stem from diversification
of the global health landscape over time and from the empowerment of
additional global actors, such as those in academia, civil society, and the
private sector, to assess and to comment on global performance—includ-
ing WHO’s performance. This category, which addresses accountability at
a multinational level, is particularly relevant given the current Ebola out-
break in the Democratic Republic of the Congo. When faced with fragile
or failed states, a focus on national core capacities alone becomes starkly
inadequate. The global system should help countries as they develop and
maintain core capacities on the ground but also should oversee global
accountability, ensure clear and accurate knowledge transfer, and assume
other roles that a single country cannot fill. This can be a delicate balance,
and report recommendations highlighted the importance of ensuring that
global guidelines do not eclipse local, real-time understandings of disease.
This has been a consistent challenge to effective global and local response.
Common recommendations included the need to better delineate roles and
responsibilities, improve coordination, ensure accountability mechanisms,
and consider drivers of trust in the relevant institutions.
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Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
Copyright National Academy of Sciences. All rights reserved.
164
TABLE A-1 Category 1a: Country-Level Core
Capacities—National Core Capacities
National Core Capacities
Publication Disease
Year of
Outbreak Outlet Prevent/Prepare D
etect Respond (Treat and Control)
Twentieth Century
Influenza Pandemics
in Singapore
H1N1 1957–
1968
Annals
Academy of
Medicine
Singapore
(R) Identify the onset of the
pandemic for early
intervention (however,
influenza remains a difficult
surveillance target because it
manifests in a variety of non-
specific symptoms)
(R) Collect viral samples in a
routine way. If a pandemic
originates in less developed
regions with high baseline
mortality rates, the signal may
be missed
(R) Focus global surveillance
efforts on frontline efforts in
East Asian farms
(R) Give protection and treatment priority to
health care workers to enable them to
perform their duties
The SARS Epidemic
in Hong Kong: What
Lessons Have We
Learned?
SARS 2003 Journal of the
Royal Society
of Medicine
(B) Inadequate epidemiological information
about the disease hampered the prompt
application of effective control measures
(B) Lack of specified infectious disease
hospitals led to difficulties in designating
hospitals for the isolation and treatment of
SARS patients
(B) Deficient communication between the
secretary (ministry) level responsible for
health policy and the management level
responsible for operation of hospitals
SARS in
Singapore—Key
Lessons from an
Epidemic
SARS 2003 Annals
Academy of
Medicine
Singapore
(F) MOH adopted wide-net
surveillance, isolation, and
quarantine policy to detect all
suspicious cases as early as
possible and to isolate them
(F) Temperature screening in
hospitals and in the
community (e.g., preventing
the importation and
exportation of SARS through
temperature screening at the
airport and sea ports)
(F) Major containment efforts were
concentrated on hospitals (SARS was
predominantly a nosocomial infection)
(F) Early separation of potentially infectious
patients
(F) Enforced use of personal protective
equipment for all hospital staff and the
adoption of strict infection-control measures,
including temperature monitoring of all
hospital staff
(F) Designation of one SARS hospital
allowed the clinicians at that site to develop
strong clinical expertise
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
Copyright National Academy of Sciences. All rights reserved.
165
continued
(R) Contain public anxiety and re-direct this
energy into positive community bonding and
action
(R) Enact a strong and effective command,
control, and coordination of responses
Responding to the
Avian Influenza
Pandemic Threat
H5N1 2003 WHO
Communicable
Disease
Surveillance
and Response
Global
Influenza
Programme
(R) Use WHO, FAO, and OIE
jointly established Global
Early Warning and Response
System for trans-boundary
animal diseases
(R) Develop infrastructure to
complement national testing
with rapid international
verification in WHO-certified
laboratories, especially as
each confirmed human case
yields information essential to
risk assessment
(R) Prioritize interventions in the backyard
rural farming system “wet markets” where
live poultry are sold in overcrowded and
often unsanitary conditions
(R) Strengthen risk communication to rural
residents
(R) Generate better knowledge on animal
and human disease through WHO, in
collaboration with FAO and OIE, to make
risk communication more precise and better
able to prevent risky behavior
(R) Identify risk groups to guide preventive
measures and early interventions
(R) Health authorities should start a
continuous process of risk communication to
the public as soon as pandemic is declared
(R) Monitor the effectiveness of health and
nonhealth interventions in real time
Pandemic
Preparedness and
Response—Lessons
from the H1N1
Influenza of 2009
H1N1 2009 New England
Journal of
Medicine
(R) Accelerate the implementation of the
IHR (2005) core capacities
(F) Web-
b
ased search patterns
can yield valuable intelligence
that can give the world a head
start on the next emerging
pandemic
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
Copyright National Academy of Sciences. All rights reserved.
166
Influenza A (H1N1-
2009) Pandemic in
Singapore—Public
Health Control
Measures
Implemented and
Lessons Learnt
H1N1 2009 Annals
Academy of
Medicine
Singapore
(F) When previous DORS framework
was not applicable to H1N1-2009, both
MOH and its stakeholders had to reframe
and relearn the context of public health
control measures mid-response
(F) Stakeholders benefited from the
flexibility to assess and take appropriate
measures locally
(R) Ensure better planning for multiple
scenarios and less rigidity in plans
(R) MOHs should familiarize themselves
with different suites of measures, which
could be implemented in a modular
fashion
(R) Invest in an effective primary care
response, which can prevent the
overloading of emergency departments in
times of acute need
(F) Local disease surveillance
systems are critically
important to informing
pandemic situations (e.g.,
monitoring the progression of
the pandemic in the
community, identifying the
start of sustained community
transmission, and guiding the
step-down of containment
measures)
(F) At-home learning or work-
from-home options helped
decrease risk when
transmission was high
(R) Work with clinics and
community, not only large
hospitals, to assess true
prevalence of disease
(R) Nonhealth care
establishments (e.g., schools
and businesses) should be
involved in temperature and
symptom screenings
(F) National Influenza Pandemic Readiness
and Response Plan developed for SARS was
useful in responding to H1N1
(F) Framework for organizing/coordinating
“whole of government” strategy and creation
of crisis management groups
(F) Dedicated ambulance service created for
suspected patients
(F) A dedicated government website on
influenza also facilitated the public’s easy
access to information
(R) Consider DORS as a guide for increasing
or scaling down response
(R) Have a core group of clinicians
(comprising public health, infectious disease,
microbiology, and respiratory medicine
specialists) meet regularly to review
epidemiological and clinical information to
make decisions
(R) Develop real-time, targeted public health
“operational” research to determine the
effectiveness of specific public health
policies and control measures
(R) Work toward building trust among
stakeholders, as well as a degree of system
discipline. This must be developed and built
in peacetime
(R) Generate creative personnel strategies
that will help to build and maintain health
care surge capacity in peacetime
Lessons from
Pandemic H1N1
2009 to Improve
Prevention,
Detection, and
Response to
Influenza Pandemics
from a One Health
Perspective
H1N1 2009 ILAR Journal
(R) Develop an effective
global, strategic, integrated
surveillance and response
system (which requires
human, animal, and
environmental health
professionals to work together
for earlier detection and
disease control)
(R) Establish more
comprehensive surveillance
for infection and disease in
occupational groups that work
most closely with animals
(i.e., poultry and swine
workers, live market workers
(B) Misunderstandings of the relationship
between pigs and H1N1 led to unnecessary
confusion and policy action, such as trade
bans on the sale of meat
(R) Move away from naming flu strains
based on potential animal hosts
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
Copyright National Academy of Sciences. All rights reserved.
167
continued
and vendors, abattoir workers,
veterinarians, and animal
health technicians)
Pandemic Response
Lessons from
I
nfluenza H1N1
2009 in Asia
H1N1 2009 Respirology (R) Develop integrated analyses that
combine microbiological/virological,
immunological, clinical, epidemiological,
and genetic data for comprehensive
assessment of host–emerging pathogen
interactions
(R) Strengthen timeliness of
data management and risk
assessments for identifying
unusual clusters (e.g., high
death rates) and initiating
appropriate responses
(B) Planning and hierarchy of intensive care
and high dependency units across Asia were
inadequate and slowed the response
(R) Need for practical and tested hospital
and inter-hospital level response plans for
public health emergencies and mass casualty
events
(R) Need for systems above the hospital
level that allow for coordinated management
of beds and other finite resources including
equipment and manpower
(R) Focus on risk communication when
containment measures do not work
(R) Establish a two-way communication
system between administration and clinical
providers to coordinate protocol
dissemination and resources
(R) Improve preexisting infection control
practices
Early Response to
the Emergence of
Influenza A (H7N9)
Virus in Humans in
China: The Central
Role of Prompt
Information Sharing
and Public
Communication
H7N9 2013 Bulletin of the
World Health
Organization
(R) Strengthen coordination between
public health and veterinary services
during an emergency by engaging in joint
preparedness planning beforehand
(R) Strengthen the relevant
infrastructures, surveillance
systems, and response
capacity in preparation for
future emergencies caused by
emerging or existing disease
threats
Avian Influenza A
(H7N9) Response:
An Investment in
Public Health
Preparedness
H7N9 2013 WHO
Publication
(F) Notable initiatives undertaken by
China included enhancing public health
emergency planning, establishing a Web-
based reporting system, and
strengthening the National Influenza
Center as one of the six WHO
collaborating centers
(R) Leverage surveillance
capacity developed through
previous events (e.g., SARS)
(F) Combined efforts of the human and
animal health sectors through mutual sharing
of information, close and timely
communication, and coordinated response
(F) Rumors spread faster than the virus
itself, so a coordinated social media strategy
was key to keeping the public up to date
(R) Establish country–WHO partnerships,
such as the China–WHO mission, to allow
WHO to learn from people on the frontline
and allow people on the frontline to
communicate information quickly to
regional actors
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
Copyright National Academy of Sciences. All rights reserved.
168
NOTES: DORS = disease outbreak response system; FAO = Food and
Agriculture Organization of the United Nations; IHR = International Health Regulations; ILAR = Institute for
Laboratory Animal Research; MERS-CoV =
Middle East respiratory syndrome coronavirus; MOH = Ministry of
Health; OIE = World Organisation for Animal Health;
SARS = severe acute respiratory syndrome; WHO = World Health Or
ganization.
13 of 16 publications had relevant findings for this category a
nd were included.
Key:
(B) Barriers to pandemic preparedness and response.
(F) Facilitators to pandemic preparedness and response.
(R) Recommendations for implementation moving forward.
Global Health
Security: The Wider
Lessons from the
West African Ebola
Virus Disease
Epidemic
Ebola 2014 The Lancet (F) Enhanced pharmacovigilance and
quality assurance composed two broad
policy responses that were essential to
coordinate across governments
A Wake Up Call:
Lessons from Ebola
for the World’s
Health Systems
Ebola 2014 Save the
Children
Publication
(R) Make public commitments to
building universal health coverage, with
little or no direct payments at the point of
use, and promote the accountability of
government and of health service
providers
(R) Increase investment in
comprehensive health services, starting
with primary care, and prioritize essential
services, such as infectious disease
outbreaks, and maternal and child health
(R) Increase public finances by raising
fair taxation, and clamping down on tax
avoidance and evasion
(R) Strengthen and invest in national
preparedness plans for possible outbreaks
of infectious diseases. Plans should
comprise public health surveillance, alert
and referral systems, and supply chain
systems that can rapidly procure and/or
distribute medical equipment and drugs
in emergencies
(F) Under-resourced, understaffed, and
fragmented health services are unable to
contain outbreaks of serious infectious
diseases or adequately respond to health
emergencies
Middle East
Respiratory
Syndrome
Coronavirus (MERS-
CoV): What Lessons
Can We Learn?
MERS-
CoV
2013 Journal of
Hospital
Infection
(B) Poor prognosis associated with
MERS-CoV, especially in patients with
multiple comorbidities, and the lack of
effective antiviral therapy make
appropriate infection prevention and
diagnosis challenging
(R) Reinforce dynamics of
continuous vigilance and
perseverance with diagnostic
investigation of undiagnosed
infectious diseases
(R) Update guidelines regularly, and
incorporate local knowledge from the ground
(R) Facilitate the communication of
epidemiological, medical, and scientific
developments in addition to presenting the
public with factual material, timely updates,
and relevant advice
NOTES: DORS = disease outbreak response system; FAO = Food and Agriculture Organization of the United Nations; IHR = International Health Regulations; ILAR = Institute for
Laboratory Animal Research; MERS-CoV = Middle East respiratory syndrome coronavirus; MOH = Ministry of Health; OIE = World Organisation for Animal Health;
SARS = severe acute respiratory syndrome; WHO = World Health Organization.
13 of 16 publications had relevant findings for this category and were included.
Key:
(B) Barriers to pandemic pr
eparedness and response.
(F) Facilitators to pandemic preparedness and response.
(R) Recommendations for implementation moving forward.
Global Health
Security: The Wider
Lessons from the
West African Ebola
Virus Disease
Epidemic
Ebola 2014 The Lancet (F) Enhanced pharmacovigilance and
quality assurance composed two broad
policy responses that were essential to
coordinate across governments
A Wake Up Call:
Lessons from Ebola
for the World’s
Health Systems
Ebola 2014 Save the
Children
Publication
(R) Make public commitments to
building universal health coverage, with
little or no direct payments at the point of
use, and promote the accountability of
government and of health service
providers
(R) Increase investment in
comprehensive health services, starting
with primary care, and prioritize essential
services, such as infectious disease
outbreaks, and maternal and child health
(R) Increase public finances by raising
fair taxation, and clamping down on tax
avoidance and evasion
(R) Strengthen and invest in national
preparedness plans for possible outbreaks
of infectious diseases. Plans should
comprise public health surveillance, alert
and referral systems, and supply chain
systems that can rapidly procure and/or
distribute medical equipment and drugs
in emergencies
(F) Under-resourced, understaffed, and
fragmented health services are unable to
contain outbreaks of serious infectious
diseases or adequately respond to health
emergencies
Middle East
Respiratory
Syndrome
Coronavirus (MERS-
CoV): What Lessons
Can We Learn?
MERS-
CoV
2013 Journal of
Hospital
Infection
(B) Poor prognosis associated with
MERS-CoV, especially in patients with
multiple comorbidities, and the lack of
effective antiviral therapy make
appropriate infection prevention and
diagnosis challenging
(R) Reinforce dynamics of
continuous vigilance and
perseverance with diagnostic
investigation of undiagnosed
infectious diseases
(R) Update guidelines regularly, and
incorporate local knowledge from the ground
(R) Facilitate the communication of
epidemiological, medical, and scientific
developments in addition to presenting the
public with factual material, timely updates,
and relevant advice
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
Copyright National Academy of Sciences. All rights reserved.
169
continued
TABLE A-2 Category 1b: Country-Level Core Capacities—Core Capacity Enable
rs
Publication Disease
Year of
Outbreak Outlet
Accountability and
PHEIC Reporting Role of WHO and HSS
Regional and Non-WHO
Global Actors Trade and Travel
SARS in
Singapore—Key
Lessons from an
Epidemic
SARS 2003 Annals
Academy of
Medicine
Singapore
(F) Regular audits by
MOH teams,
supplemented by internal
audits by hospitals,
helped ensure a high
level of compliance
Responding to the
Avian Influenza
Pandemic Threat
H5N1 2003 WHO
Communicable
Disease
Surveillance
and Response
Global
Influenza
Programme
(R) Give risk-prone
countries an incentive to
collaborate
internationally
(R) WHO to establish a
surveillance program for
antiviral susceptibility testing,
modeled on a similar program
for anti-tuberculosis drugs
(R) WHO to monitor the
unfolding epidemiological and
clinical behavior of the new
virus in real time
(R) WHO to prepare a template
pandemic plan, which will give
many developing countries a
head start in national pandemic
preparedness planning
Pandemic
Preparedness and
Response—Lessons
from the H1N1
Influenza of 2009
H1N1 2009 New England
Journal of
Medicine
(R) WHO to ensure necessary
authority and resources for all
national focal points
(R) WHO to revise and
streamline the management of
pandemic preparedness
guidance
(R) WHO to establish a more
extensive public health reserve
workforce globally
(R) Reinforce evidence-based
decisions on international travel
and trade
Influenza A (H1N1-
2009) Pandemic in
Singapore—Public
Health Control
Measures
H1N1 2009 Annals
Academy of
Medicine
Singapore
(F) WHO created a model
country plan with the goal of
giving developing countries a
framework to assess their status
(R) Push nonhealth government
sectors involved in mounting a
“whole of government”
response to the H1N1-2009
pandemic to include border
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
Copyright National Academy of Sciences. All rights reserved.
170
Implemented and
Lessons Learnt
of preparedness and to identify
priority needs
(R)WHO to provide support to
countries in rehearsing these
plans during simulation
exercises
control (temperature screening,
health declaration cards, and
health alert notices for
travelers), trade, and industry
Early Response to
the Emergence of
Influenza A (H7N9)
Virus in Humans in
China: The Central
Role of Prompt
Information Sharing
and Public
Communication
H7N9 2013 Bulletin of the
World Health
Organization
(R) Release any results of
risk assessments as well
as other epidemic-related
data promptly and
publicly
(F) WHO and China’s National
Health and Family Planning
Commission jointly coordinated
the response mission by
internationally recognized
influenza experts
(R) WHO to strengthen relevant
infrastructures, surveillance
systems, and response capacity
in preparation for future
emergencies
Avian Influenza A
(H7N9) Response:
An Investment in
Public Health
Preparedness
H7N9 2013 WHO
Publication
(R) Establish transparent
and open channels of
communication with the
global community,
including regular
situation updates
(R) Support the
continued use of IHR
(2005) reporting
mechanisms throughout
the event in order to
provide timely updates
for relevant stakeholders
and the public (e.g., EIS
and DON)
(F) WHO activated an
organization-wide mechanism
involving the three levels of
WHO from the country to
regional to headquarters offices
(F) The ERF provided guidance
in line with emergency
management system and ensured
adequate human resource surge
capacity for monitoring and
assessment
(F) The EOC at the regional
office was the common platform
used to coordinate the response
(R) As a guardian of IHR (2005)
WHO to coordinate and support
the H7N9 response
(F) The Western Pacific
regional office developed
a framework for action
for national health
authorities to highlight
areas of public health
emergency response that
may need specific action
for avian influenza A
(H7N9)
Global Health
Security: The Wider
Lessons from the
West African Ebola
Ebola 2014 The Lancet (R) Use GHSA to make
rapid progress in
strengthening collective
health security through
country and inter-country
(R) Address future threats
to health security
comprehensively based
on deeper understanding
of prevention and
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
Copyright National Academy of Sciences. All rights reserved.
171
continued
Virus Disease
Epidemic
capacities to prevent,
detect, and respond to
infectious disease threats;
independent evaluations
are crucial to accelerate
progress
remediation of human
security
(R) Broaden approach
beyond the IHR (2005);
simply taking the IHR
(2005) to a next step is
too weak and narrow as
an approach
(R) Develop an initiative
to drive better health
within corporations
The Neglected
Dimension of Global
Security: A
Framework for
Countering
Infectious Disease
Crises
Ebola 2014 New England
Journal of
Medicine
(R) Make all
development assistance
for health system
strengthening contingent
on country agreement to
assessment
(R) Countries to develop
and publish plans to
achieve benchmarks by
2020
(R) Create an
intermediate alert level
before declaring a
PHEIC
(R) Develop a daily high-
priority “watch list” of
outbreaks with potential
to become PHEIC,
summary to be published
weekly
(R) Develop benchmarks for
core capabilities and support
countries in achieving them
(R) Work with existing regional
and sub-regional networks to
strengthen linkages and
coordination enhancing mutual
support and trust, sharing of
information and laboratory
resources, and joint outbreak
investigations among
neighboring countries
(R) World Bank to
convene funders to
support lower-middle and
low-income countries to
achieve IHR (2005) core
capacities (these countries
should also develop plans
for eventual financial
self-sufficiency)
(R) IMF to include
p
andemic preparedness in
countries’ Economic and
Policy Assessments
(R) UNSG to ensure
minimal health systems
functioning in fragile and
failed states
(R) The proposed WHO
Emergency Centre should create
protocols to dissuade member
states and the private sector
from implementing unnecessary
restrictions on trade and travel;
WHA to implement
A Wake Up Call:
Lessons from Ebola
for the World’s
Health Systems
Ebola 2014 Save the
Children
Publication
(R) Civil society should
engage with tax
processes and advocate
for progressive tax
reforms and increased
transparency
(R) Civil society should
monitor domestic
(R) Ensure that aid and
global support is
increased and better
aligned to help build
suitable and
comprehensive health
services, and increase
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
Copyright National Academy of Sciences. All rights reserved.
172
budgets to track resource
flows and advocate for
increased and more
equitable revenue and
health expenditure
(R) The SDGs should
commit the world to
support UHC, alongside
priorities such as ending
preventable maternal,
newborn, and child
deaths
(R) The SDGs should
aim (via target
indicators) for universal
coverage of key health
services and for financial
risk protection and
should ensure that targets
apply to all social groups
public financing for
health
(R) Ensure the
multilateral initiatives—
such as the Gavi, the
Vaccine Alliance, the
Global Fund, and the new
proposed Global
Financing Facility for
reproductive, maternal,
and child health—are
aligned to support
comprehensive and
universal health services
and can demonstrate that
they are doing this
(R) Implement domestic
and international reforms
to curb illicit financial
flows and tax avoidance
(R) Strengthen and
respect the IHR (2005)
and support globally
coordinated support for
health emergencies
Protecting Humanity
from Future Health
Crises: UNSG’s
High Level Panel on
Global Response to
Health Crises
Ebola 2014 UNGA
Publication
(R) IHR Review
Committee to develop
mechanisms to rapidly
address violations of
PHEIC temporary
recommendations
(R) All countries to fulfill
full IHR (2005)
compliance by 2020
(R) WHO to perform
periodic compliance
review through an
“independent field-based
assessment”
(R) WHO to work with existing
regional and sub-regional
networks to strengthen linkages
and coordination, and thus to
enhance mutual support and
trust, sharing of information and
laboratory resources, and joint
outbreak investigations among
neighboring countries
(R) WHO regional directors to
answer to WHO Emergency
Centre ED in emergencies
(R) WHO to lead efforts to
mobilize international financial
(R) World Bank should
convene funders to
support lower-middle and
low-income countries to
achieve IHR (2005) core
capacities; these countries
should develop plans for
eventual financial self-
sufficiency
(R) Regional and sub-
regional organizations to
develop or strengthen
standing capacities to
monitor, prevent, and
respond to health crises
(R) IHR Review Committee to
develop mechanism to address
undue adoption of trade and
travel bans
(R) WTO and WHO to establish
a commission of experts to
increase coherence between the
IHR (2005) and the WTO legal
regime regarding trade
restrictions imposed for public
health reasons
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
Copyright National Academy of Sciences. All rights reserved.
173
NOTES: DON = disease outbreak new
s; ED = executive director; EIS = epidemic intelligence service; EOC = emergency operations centers; ERF = emergency
response framework; GHSA = Globa
l Health Security Agenda; HSS = health systems strengthening; IHR = International Health Regulations; IMF = International
Monetary Fund; MOH = Ministry o
f Health; PHEIC = public health emergency of international concern; SARS = severe acute respiratory syndrome;
SDG = Sustainable Development Go
al; UHC = universal health coverage; UNGA = United Nations General Assembly; UNSG = United Nations Secretary-General;
WHA = World Health Assembly; WHO
= World Health Organization; WTO = World Trade Organization.
10 of 16 publications had relevant findings for this category a
nd were included.
(R) Recommendations for implementation moving forward.
(R) Global community to
perform country reviews
on rotating basis
(R) Mobilize domestic
and international funding
to support IHR (2005)
core capacity compliance
support for building IHR (2005)
core capacities
Key:
(B) Barriers to pandemic pr
eparedness and response.
(F) Facilitators to pandemic preparedness and response.
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
Copyright National Academy of Sciences. All rights reserved.
174
TABLE A-3 Category 2: Research and Development
Publication Disease
Year of
Outbreak Outlet
Vaccine, Diagnostic, and Therapeutic
Readiness
Delivery Capacity for
Pharmaceutical and Medical
Goods
Sample Sharing
and Knowledge
Sharing
Synergies with One
Health
Twentieth Century
Influenza Pandemics
in Singapore
H1N1 1957–
1968
Annals Academy
of Medicine
Singapore
(R) Use the increased knowledge of
influenza, and the availability of
antivirals (and possibly prepandemic
vaccines), to further reduce the impact
of a future pandemic by combining
pharmaceutical and non-
pharmaceutical interventions based on
available evidence
(R) Perform public health measures,
such as antivirals, vaccination, and
non-pharmaceutical interventions, to
reduce the impact of a future
pandemic
(R) Develop vaccines that can
improve heterotypic immunity, better
techniques for vaccine production,
and more effective antiviral therapies
which may reduce the pandemic’s
spread
The SARS Epidemic
in Hong Kong: What
Lessons Have We
Learned?
SARS 2003 Journal of the
Royal Society of
Medicine
(R) Strengthen the exchange
of epidemiological
information on infectious
diseases, especially the
emergence of new infections,
between the health
authorities in Mainland
China and Hong Kong
SARS in Singapore—
Key Lessons from an
Epidemic
SARS 2003 Annals Academy
of Medicine
Singapore
(R) Develop very rapid and highly
sensitive tests for SARS infection,
which would substantially reduce the
numbers of individuals that need to be
quarantined without decreasing the
effectiveness of the measure
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
Copyright National Academy of Sciences. All rights reserved.
175
continued
Responding to the
Avian Influenza
Pandemic Threat
H5N1 2003 WHO
Communicable
Disease
Surveillance and
Response Global
Influenza
Programme
(R) Expedite the development of a
pandemic vaccine (shorten the time
between emergence of a pandemic
virus and the start of commercial
production, and increase the supply of
influenza vaccines)
(R) Improve approaches to
environmental detection of the virus
(R) Assist developing countries that
plan to manufacture their own
vaccines
(R) Contain or delay spread
at the source by establishing
an international stockpile of
antiviral drugs, developing
mass delivery mechanisms
for antiviral drugs, and
conducting surveillance of
antiviral susceptibility
(R) Compile and
compare clinical
data on human
cases in order to
elucidate modes of
transmission,
identify groups at
risk, and find better
treatments
(B) Most affected
countries were not
able to adequately
compensate farmers
for culled poultry.
This discouraged
reporting of
outbreaks in rural
areas where the
majority of human
cases occurred
(B) Domestic ducks
were able to excrete
large quantities of
pathogenic virus
without showing
signs of illness.
Their silent role
maintained
transmission and
further complicated
control in humans
and poultry
Pandemic
Preparedness and
Response—Lessons
from the H1N1
Influenza of 2009
H1N1 2009 New England
Journal of
Medicine
(R) Ensure better antiviral agents and
more effective influenza vaccines,
greater production capacity, and faster
throughput
(R) Pursue a comprehensive influenza
research and evaluation program
(R) Improve scientific understanding
and technical capacity (beyond
institutional, political, and managerial
difficulties)
(R) Develop better antiviral
agents and more effective
influenza vaccines, greater
production capacity, and
faster throughput
(R) Recommend encouraging
advance agreements for
vaccine distribution and
delivery
(R) Reach an
agreement on the
sharing of viruses,
access to vaccines,
and other benefits
Influenza A (H1N1-
2009) Pandemic in
Singapore—Public
Health Control
Measures
H1N1 2009 Annals Academy
of Medicine
Singapore
(F) Frequent
information
reviews guided
local decisions on
the implementation
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
Copyright National Academy of Sciences. All rights reserved.
176
Implemented and
Lessons Learnt
of public health
control measures
Lessons from
Pandemic H1N1 2009
to Improve
Prevention, Detection,
and Response to
Influenza Pandemics
from a One Health
Perspective
H1N1 2009 ILAR Journal (R) Invest in One
Health research to
enhance
understanding of the
emergence,
prevention,
detection, and
control of pandemic
influenza viruses
Avian Influenza A
(H7N9) Response: An
Investment in Public
Health Preparedness
H7N9 2013 WHO
Publication
(R) Ensure that the
timely release of
data does not
jeopardize future
publication of the
data in scientific
journals
Global Health
Security: The Wider
Lessons from the
West African Ebola
Virus Disease
Epidemic
Ebola 2014 The Lancet (R) Address issues of drug quality,
which pose social, economic, and
political challenges to health security
by undermining ability to address
diseases while eroding public
confidence in governments and
international institutions
(R) Prevent market forces from being
the only driver of medical research
The Neglected
Dimension of Global
Security: A
Framework for
Countering Infectious
Disease Crises
Ebola 2014 New England
Journal of
Medicine
(R) Need to address the many gaps in
our R&D armory, as Ebola and other
outbreaks have shown, which range
from vaccine development and
capacity, diagnostic tools,
therapeutics, and protective equipment
to anthropological research. Relying
on the disparate efforts of the R&D
community—academia, government,
industry, and civil society—has not
worked
(R) Enhance our scientific
armory against infectious
disease, including
prioritization, mobilization,
and deployment of
significantly greater
resources and harmonization
of development and
regulatory approval
processes
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
Copyright National Academy of Sciences. All rights reserved.
177
NOTES: ILAR = Institute for Labor
atory Animal Research; R&D = research and development; SARS = severe acute respiratory syndrome; UNGA = United
Nations General Assembly; UNSG =
United Nations Secretary-General; WHO = World Health Organization.
11 of 16 publications had relevant findings for this category a
nd were included.
(R) Recommendations for implementation moving forward.
Protecting Humanity
from Future Health
Crises: UNSG’s High
Level Panel on Global
Response to Health
Crises
Ebola 2014 UNGA
Publication
(B) Investment in medical R&D for
diseases that largely affect the poor is
deeply inadequate. Of the $214 billion
invested in health R&D globally in
2010, less than 2 percent was
allocated to neglected diseases
(R) Dedicating resources to R&D on
prioritized pathogens will ensure the
greater availability of critical vaccines
and treatments when they are most
needed
Key:
(B) Barriers to pandemic pr
eparedness and response.
(F) Facilitators to pandemic preparedness and response.
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
Copyright National Academy of Sciences. All rights reserved.
178
TABLE A-4 Category 3—Global Governance
System Wide WHO
Publication Disease
Year of
Outbreak Outlet
Cooperation and
Operational
Response Accountability Financing/Aid
New Bodies and Actions
for Future Outbreaks Function and Role
Leadership/Human
Resources
Avian
Influenza A
(H7N9)
Response: An
Investment in
Public Health
Preparedness
H7N9 2013 WHO
Publication
(F) The WHO Western
Pacific regional office
developed a framework for
national health authorities
to highlight areas of public
health emergency response
that may need specific
action for avian influenza
(the framework was based
on the Asia Pacific
Strategy for Emerging
Diseases [2010], which
covered the key technical
areas [e.g., command and
control, surveillance, risk
assessment, etc.])
The Neglected
Dimension of
Global
Security: A
Framework for
Countering
Infectious
Disease Crises
Ebola 2014 New
England
Journal of
Medicine
(R) WHO and
UN to establish
clear
mechanisms for
coordination
and escalation in
health crises
(R) Use existing
institutions
rather than
creating new
bodies (e.g.,
United Nations
Mission for
Ebola
Emergency
Response)
(R)
Commission
an
independent
assessment in
2017 and then
every 3 years
following
2017
(R) IMF to develop
capacity to provide
budgetary support to
governments that raise
outbreak alerts
through the existing
Rapid Credit Facility
(R) Develop a World
Bank Pandemic
Emergency Facility
(R) WHO to establish a
WHO Centre for Health
Emergency Preparedness
and Response governed by
independent technical
governing board
(R) WHO Emergency
Centre to coordinate global
health emergency
workforce by
strengthening and
expanding GOARN
(R) WHO to take
the lead in the
global system to
identify, prevent,
and respond to
potential pandemics
(R) WHO to
increase its
capability and
resources while
demonstrating
better leadership
across actors
(R) WHO to
enhance means of
cooperation with
non-state actors,
including local and
(R) Next DG should
reenergize and refocus
WHO on core
priorities and on
relationship building
with other actors, such
as other multilateral
agencies and non-state
actors;
(R) Next DG needs
stature and courage to
engage with other
global leaders, accept
accountability, and
hold countries
accountable
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
Copyright National Academy of Sciences. All rights reserved.
179
continued
international civil
society
organizations, the
private sector, and
the media
A Wake Up
Call: Lessons
from Ebola for
the World’s
Health Systems
Ebola 2014 Save the
Children
Publication
(R) Develop
disease
surveillance
systems with
strong regional
networks for
better
forecasting and
control
(R) Use SDG
target
indicators to
hold globe
accountable to
UHC (key
health
services) and
for financial
risk protection
(R) Ensure
that SDG
targets apply
to all social
groups in a
country and
are not just
reported as
national
averages (e.g.,
“no target met
unless met for
all”)
(R) Civil
society to
monitor
domestic
budgets to
track resource
flows and to
advocate for
increased and
more equitable
revenue in
(R) Ensure that aid
and global support is
increased and better
aligned to help build
suitable and
comprehensive health
services, and increase
public financing for
health
(R) Ensure that
multilateral initiatives
are aligned to support
comprehensive and
universal health
services and can
demonstrate that they
are doing this
(R) Implement
domestic and
international reforms
to curb illicit financial
flows and tax
avoidance
(R) WHO to revise
how elections are
conducted for WHO
officials, specifically:
improve transparency
and democratic nature
of elections
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
Copyright National Academy of Sciences. All rights reserved.
180
global health
expenditure
Protecting
Humanity from
Future Health
Crises:
UNSG’s High
Level Panel on
Global
Response to
Health Crises
Ebola 2014 UNGA
Publication
(R) Reinforce a
clear line of
command
throughout the
UN system
(e.g., WHO DG
reports to
UNSG, WHO
regional
directors report
to WHO
Emergency
Centre ED, ED
to become
UNSG’s
Emergency
Coordinator)
(R) Integrate
UN health and
humanitarian
crisis trigger
systems e.g.,
ERF Grade 2 or
3 heath crisis
automatically
triggers an
interagency
multisectoral
assessment
(R) Increase assessed
contributions to WHO
by at least 10 percent
with a share
mandatorily directed
to support the
proposed Emergency
Centre
(R) Build a
“Contingency Fund”
of at least $300
million by 2016 that is
financed according to
assessment scale and
managed by the
proposed Emergency
Centre (to be
immediately
replenished when
depleted)
(R) Guarantee that aid
is disbursed according
to Paris Declaration
principles, especially
alignment of support,
harmonization, and
mutual accountability
(R) Support the
creation of a World
Bank Pandemic
Emergency Financing
Facility (national
governments should
decide how funds are
spent in-country)
(R) WHO to establish a
WHO Centre for
Emergency Response with
a multisectoral advisory
board
(R) WHO Emergency
Centre and Inter-Agency
Standing Committee to
establish Standard
Operating Procedures for
humanitarian actors in
health crises
(R) WHO Emergency
Centre to incorporate
GOARN and foreign
medical team programs in
coordinating the global
health emergency
workforce
(R) WHO to serve
as the single global
health leader,
determining and
executing global
health priorities
(R) WHO to build
unified and
effective
operational capacity
(R) WHO to work
closely with
development actors
to ensure
complementarity
between
development
programs and
efforts to build
health care systems
and public health
(R) WHO to
establish a culture
of emergency
response and to
develop the
capacity and
instinct to lead
major operations
(R) WHO to increase
investment in training
health professionals at
national level
(especially community
health workers)
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
Copyright National Academy of Sciences. All rights reserved.
181
continued
Report 2:
Advisory
Group on
Reform of
WHO’s Work
in Outbreaks
and
Emergencies
Ebola 2014 WHO (R) WHO to
work with
health cluster
partners to build
dedicated
capacity for
coordination,
planning,
information
management,
and
communications
(R) Integrate
cluster partners’
capacities in
emergency
operations
(R) Articulate
linkages
between the
Emergency
Program, the
Health Clusters,
and overall
humanitarian
system
(R) Fund Emergency
Program baseline
capacity through
predictable and
reliable financing
streams, including
assessed contributions
(this money should be
different from
emergency funds
deployed in specific
responses)
(R) Maximize the use
of existing funding
mechanisms, such as
the Central
Emergency Response
Fund, to support
emergency operations
(R) Seek full
capitalization of the
Contingency Fund
(R) WHO to develop the
internal capacity to
function as an operational
organization
(R) WHO to define and
promote acceptance of
common professional
standards on health
interventions, on sharing
information and handling
personal health data, and
on building robust capacity
for systematized
information management
and protocols for
information sharing
(R) WHO to
develop the
capacity to function
as and position
itself as an
operational
organization since
working in
outbreaks and
emergencies is part
of WHO's core
mandate
(R) Reflect WHO’s
mandate (working
in outbreaks and
emergencies) in the
focus of its
governing bodies
(R) Demonstrate
that WHO is
independent and
impartial while
reviving and
improving
relationships with
member states and
partners
(R) Engage in a
profound
organizational
transformation
rather than
piecemeal reform
(i.e., a single
merger of
organizational units
within WHO will
not suffice; it will
need new
organizational
(R) Next DG should
remain accountable for
incident management
within WHO
(R) Ensure that
WHO’s mandate to
work in outbreaks and
emergencies is
reflected in the
capabilities of its staff
(R) WHO to facilitate
the diversification of
the health workforce:
engaging multiple
actors from multiple
sectors and at multiple
levels, rather than a
single global
workforce of “white
helmets”
(R) WHO to increase
its staff
Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop
Copyright National Academy of Sciences. All rights reserved.
182
NOTES: DG = director-general; ED
= executive director; ERF = emergency response framework; GOARN = Global Outbreak Alert and Response Network;
IMF = International Monetary Fund; MERs-CoV = Middle East respi
ratory syndrome coronavirus; SDG = Sustainable Development Goal; UHC = universal health
coverage; UN = United Nations;
UNGA = United Nations General Assembly; UNSG = United Nations Secretary-General; WHO = World Health Organization.
6 of 16 publications had relevant findings for this category an
d were included.
(R) Recommendations for implementation moving forward.
structures and
procedures)
Middle East
Respiratory
Syndrome
Coronavirus
(MERS-CoV):
What Lessons
Can We Learn?
MERS-
CoV
2013 Journal of
Hospital
Infection
(R) Global
system to
ensure
adequate
assessment of
patients
presenting
with febrile
illness prior to
international
air travel
(R) WHO to act as a
knowledge broker: WHO
guidelines should not
prevail over clinical
judgment during a
pandemic because such
guidelines are inevitably
based on incomplete
evidence
Key:
(B) Barriers to pandemic pr
eparedness and response.
(F) Facilitators to pandemic preparedness and response.
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