How prepared is the world? Identifying weaknesses in existing assessment frameworks for global health security through a One Health approach.

The COVID-19 pandemic has exposed faults in the way we assess preparedness and response capacities for public health emergencies. Existing frameworks are limited in scope, and do not sufficiently consider complex social, economic, political, regulatory, and ecological factors. One Health, through its focus on the links among humans, animals, and ecosystems, is a valuable approach through which existing assessment frameworks can be analysed and new ways forward proposed. Although in the past few years advances have been made in assessment tools such as the International Health Regulations Joint External Evaluation, a rapid and radical increase in ambition is required. To sufficiently account for the range of complex systems in which health emergencies occur, assessments should consider how problems are defined across stakeholders and the wider sociopolitical environments in which structures and institutions operate. Current frameworks do little to consider anthropogenic factors in disease emergence or address the full array of health security hazards across the social-ecological system. A complex and interdependent set of challenges threaten human, animal, and ecosystem health, and we cannot afford to overlook important contextual factors, or the determinants of these shared threats. Health security assessment frameworks should therefore ensure that the process undertaken to prioritise and build capacity adheres to core One Health principles and that interventions and outcomes are assessed in terms of added value, trade-offs, and cobenefits across human, animal, and environmental health systems.

Which countries need COVID-19 vaccines the most? Development of a prioritisation tool.

BACKGROUND: The COVID-19 pandemic and associated non-pharmaceutical interventions (NPIs) have affected all countries. With a scarcity of COVID-19 vaccines there has been a need to prioritize populations, but assessing relative needs has been challenging. The COVAX Facility allocates vaccines to cover 20% of each national population, followed by a needs assessment that considers five quantitative metrics alongside a qualitative assessment. The objective of this study was to identify the most important factors for assessing countries' needs for vaccines, and to weight each, generating a scoring tool for prioritising countries. METHODS: The study was conducted between March and November 2021. The first stage involved an online Delphi survey with a purposive and snowball sample of public health experts, to reach consensus on country-level factors for assessing relative needs for COVID-19 vaccines. The second stage involved a discrete choice experiment (DCE) to determine weights for the most important factors. RESULTS: Responses were received from 28 experts working across 13 different countries and globally. The most common job titles reported were director and professor, with most based in national public health institutes (n = 9) and universities (n = 8). The Delphi survey found 37 distinct factors related to needs. Nine of the most important factors were included in the DCE. Among these, the most important factor was the 'proportion of overall population not fully vaccinated' (with a mean weight of 19.5), followed by 'proportion of high-risk population not fully vaccinated' (16.1), 'health system capacity' (14.2), 'capacity to purchase vaccines' (11.9) and the 'proportion of the population clinically vulnerable' (11.3). CONCLUSIONS: Several factors exist, extending beyond those currently used, which may lead to some countries having a greater need for vaccines compared to others. By assessing relative needs, this scoring tool can build on existing methods to further the role of equity in global COVID-19 vaccine allocation.

The impact of pausing the Oxford-AstraZeneca COVID-19 vaccine on uptake in Europe: a difference-in-differences analysis.

BACKGROUND: Several countries paused their rollouts of the Oxford-AstraZeneca coronavirus disease-19 (COVID-19) vaccine in mid-March 2021 due to concerns about vaccine-induced thrombosis and thrombocytopenia. Many warned that this risked damaging public confidence during a critical period of pandemic response. This study investigated whether the pause in the use of the Oxford-AstraZeneca vaccine had an impact on subsequent vaccine uptake in European countries. METHODS: We used a difference-in-differences approach capitalizing on the fact that some countries halted their rollouts whilst others did not. A longitudinal panel was constructed for European Economic Area countries spanning 15 weeks in early 2021. Media reports were used to identify countries that paused the Oxford-AstraZeneca vaccine and the timing of this. Data on vaccine uptake were available through the European Centre for Disease Control and Prevention COVID-19 Vaccine Tracker. Difference-in-differences linear regression models controlled for key confounders that could influence vaccine uptake, and country and week fixed effects. Further models and robustness checks were performed. RESULTS: The panel included 28 countries, with 19 in the intervention group and 9 in the control group. Pausing the Oxford-AstraZeneca vaccine was associated with a 0.52% decrease in uptake for the first dose of a COVID-19 vaccine and a 1.49% decrease in the uptake for both doses, comparing countries that paused to those that did not. These estimates are not statistically significant (P = 0.86 and 0.39, respectively). For the Oxford-AstraZeneca vaccine only, the pause was associated with a 0.56% increase in uptake for the first dose and a 0.07% decrease in uptake for both doses. These estimates are also not statistically significant (P = 0.56 and 0.51, respectively). All our findings are robust to sensitivity analyses. CONCLUSIONS: As new COVID-19 vaccines emerge, regulators should be cautious to deviate from usual protocols if further investigation on clinical or epidemiological grounds is warranted.

Policy and planning for large epidemics and pandemics - challenges and lessons learned from COVID-19.

PURPOSE OF REVIEW: The COVID-19 pandemic is a global catastrophe that has led to untold suffering and death. Many previously identified policy challenges in planning for large epidemics and pandemics have been brought to the fore, and new ones have emerged. Here, we review key policy challenges and lessons learned from the COVID-19 pandemic in order to be better prepared for the future. RECENT FINDINGS: The most important challenges facing policymakers include financing outbreak preparedness and response in a complex political environment with limited resources, coordinating response efforts among a growing and diverse range of national and international actors, accurately assessing national outbreak preparedness, addressing the shortfall in the global health workforce, building surge capacity of both human and material resources, balancing investments in public health and curative services, building capacity for outbreak-related research and development, and reinforcing measures for infection prevention and control. SUMMARY: In recent years, numerous epidemics and pandemics have caused not only considerable loss of life, but billions of dollars of economic loss. The COVID-19 pandemic served as a wake-up call and led to the implementation of relevant policies and countermeasures. Nevertheless, many questions remain and much work to be done. Wise policies and approaches for outbreak control exist but will require the political will to implement them.

Attendance at London workplaces after symptom onset: a retrospective cohort study of staff members with confirmed COVID-19.

BACKGROUND: Coronavirus disease (COVID)-secure workplace guidance, including the prompt self-isolation of those with COVID-19 symptoms, is fundamental to disease control in workplaces. Despite guidance, a large number of workplace outbreaks have been observed. This study aimed to identify the proportion of symptomatic staff members attending workplaces after symptom onset or testing, and associated factors. METHODS: This study of symptomatic COVID-19 cases associated with London workplaces used London Coronavirus Response Centre (LCRC) records from routine telephone calls with cases and employers, from 17th July to 10th September. For each case, symptoms, date of onset, date of testing and the last attendance at work were extracted. Univariable logistic regression was performed to investigate whether age, gender or occupation was associated with workplace attendance after the onset of symptoms. RESULTS: Out of 130 symptomatic COVID-19 cases, 42 (32.3%) attended the workplace after their reported date of symptom onset, including 16 (12.3%) with recorded COVID-19 symptoms. Five staff members attended after COVID-19 testing. Males were 66% less likely to attend the workplace after the onset of COVID-19 symptoms compared to females (odds ratio 0.34, P = 0.05). Age and occupation were not predictive for workplace attendance after the onset of symptoms. CONCLUSION: A minority of symptomatic cases attended the workplace after the onset of COVID-19 symptoms, with a smaller proportion attending after testing. Males appeared less likely to attend the workplace after the onset of COVID-19 symptoms. This study highlights the need for ongoing COVID-19 secure workplace practices and prompt self-isolation after COVID-19 symptom onset or testing.

Planning for large epidemics and pandemics: challenges from a policy perspective.

PURPOSE OF REVIEW: Less than two decades into the 21st century, the world has already witnessed numerous large epidemics or pandemics. These events have highlighted inadequacies in both national and international capacity for outbreak prevention, detection, and response. Here, we review some of the major challenges from a policy perspective. RECENT FINDINGS: The most important challenges facing policymakers include financing outbreak preparedness and response in a complex political environment with limited resources, coordinating response efforts among a growing and diverse range of national and international actors, accurately assessing national outbreak preparedness, addressing the shortfall in the global biomedical workforce, building surge capacity of both human and material resources, balancing investments in public health and curative services, building capacity for outbreak-related research and development, and reinforcing measures for infection prevention and control. SUMMARY: In recent years, numerous epidemics and pandemics have caused not only considerable loss of life but also billions of dollars of economic loss. Although the events have served as a wake-up call and led to the implementation of relevant policies and counter-measures, such as the Global Health Security Agenda, many questions remain and much work to be done. Wise policies and approaches for outbreak control exist, but will require the political will to implement them.

Prevalence of and risk factors for severe cognitive and sleep symptoms in ME/CFS and MS.

BACKGROUND: There are considerable phenotypic and neuroimmune overlaps between myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and multiple sclerosis (MS). While the precise aetiologies of both MS and ME/CFS are unclear, evidence suggests that deterioration in cognitive function is widely prevalent in patients with either condition. Little is known about differing risk factors or exposures, which may lead to severe cognitive or sleep symptoms. This study aims to gauge the extent of cognitive and sleep symptoms in ME/CFS and MS patients participating in the UK ME/CFS Biobank and identify the characteristics of those experiencing severe symptoms. METHODS: This was a cross-sectional study of 395 UK ME/CFS Biobank participants, recruited from primary care and the community, using similar standardised protocols, and matched by age, sex and geographical area. Data were collected from participants using a standardized written questionnaire at clinical visits. Cognitive symptoms included problems with short-term memory, attention, and executive function. Sleep symptoms included unrefreshing sleep and poor quality or inadequate duration of sleep. All participants reported symptoms based on an ordinal severity scale. Multivariable logistic regression was carried out in the ME/CFS group to investigate socio-demographic factors associated with severe symptoms. RESULTS: All cognitive and sleep symptoms were more prevalent in the ME/CFS group, with 'trouble concentrating' (98.3%) the most commonly reported symptom. Severe symptoms were also more commonly reported in the ME/CFS group, with 55% reporting 'severe, unrefreshing sleep'. Similarly, in the MS group, the most commonly reported severe symptoms were sleep-related. Logistic regression analysis revealed that ME/CFS patients aged over 50 years were more than three times as likely to experience severe symptoms than those younger than 30 (OR 3.23, p = 0.031). Current smoking was associated with severe symptoms, increasing the risk by approximately three times (OR 2.93, p = 0.003) and those with household incomes of more than £15,000 per year were less likely to experience severe symptoms compared to those earning less than this (OR 0.31, p = 0.017). CONCLUSIONS: Cognitive and sleep symptoms are more common in ME/CFS patients than in MS patients and healthy controls, providing further support for existing evidence of central nervous system abnormalities in ME/CFS. Our findings suggest that people with ME/CFS who are smokers, or have a low income, are more likely to report severe cognitive and sleep symptoms. Future research should aim to develop strategies to prevent the progression of severe cognitive and sleep symptoms through early interventions that prioritise patients identified as being at highest risk.

The association between cigarette smoking and primary open-angle glaucoma: a systematic review.

Glaucoma is one of the most common causes of irreversible blindness, globally. Findings from the Blue Mountain Eye Study suggest a moderate positive association between smoking and increased IOP (a significant risk factor for glaucoma). The previous two reviews investigating the association between smoking and primary open-angle glaucoma (POAG) show inconsistent findings and do not include recent studies investigating the dose-response effect of smoking. The current study aims to conduct an up-to-date, comprehensive evaluation of the existing literature. Identification of relevant existing literature was performed by an online search in MEDLINE for studies published from 1st January 1946 to 5th February 2015. The MESH headings (keywords) included "open-angle glaucoma" and "cigarette" or "smoking" or "tobacco". Two independent reviewers assessed the eligibility of each report based on predefined inclusion criteria. Odds ratios and 95 % confidence intervals (95 % CIs) were obtained from studies, for the change in risk of glaucoma due to both past and current smoking. Of the 26 abstracts reviewed, 17 papers were included in the final analysis. Nine of these were case-control studies, five cohort studies and three cross-sectional in design. Six of the case-control studies found a positive association between smoking and POAG, unlike the remaining studies. However, two relatively recent, large studies (including one prospective cohort study) investigating the effect of smoking dose have found a significant increase in risk of POAG in very heavy smokers. There is limited evidence for a causal association between tobacco smoking and POAG. The evidence for a link between current smoking and POAG appears stronger than that of past smoking, but recent studies suggest that heavy smoking may increase the risk of POAG. Future studies must further investigate the possible positive association between heavy smoking and POAG by stratifying participants by pack years and age.

What are the best and worst things about having a father in UK Armed Forces? Analysis of free text responses.

OBJECTIVE: This study aims to explore what adolescents report as the best and worst aspects of having a father in the UK military. METHODS: Qualitative data were collected from 171 adolescents aged 11-16 years, via an online questionnaire exploring the impact of paternal military service on childhood well-being (response rate=70%). Questions about the best and worst aspects of their father's military role were examined. Content analysis has been used to code the qualitative data into themes. RESULTS: 85 girls and 86 boys were included with a mean age of 13 years (SD 1.92). The results showed lack of contact as the single most commonly reported negative factor of having a father in the military (61%). Positive aspects of their fathers' job most frequently reported included a sense of pride (25%) and financial benefits (25%). CONCLUSIONS: Adolescents take a great deal of pride in their father's jobs in the military, and they enjoy the financial benefits. A majority, however, feel a lack of contact with their father is the most negative factor.

The impact of the 2022 spring COVID-19 booster vaccination programme on hospital occupancy in England: An interrupted time series analysis.

Regular booster vaccination programmes help protect the most vulnerable from COVID-19 and limit pressure on health systems. Existing studies find booster doses to be effective in preventing hospital admissions and deaths but focus on individual effects, failing to consider the population impact of incomplete vaccination coverage and seasonal patterns in disease transmission. We estimated the effectiveness of the 2022 spring booster vaccination programme, available for those aged 75 years and older, residents in care homes, and adults with weakened immune systems, on COVID-19 hospital bed occupancy in England. Booster vaccine coverage in the eligible population increased rapidly in the months after rollout (from 21st March 2022), flattening out just below 80% by July 2022. We used interrupted time series analysis to estimate a 23.7% overall reduction in the rate of hospital occupancy for COVID-19 following the programme, with a statistically significant benefit in the 6-12 weeks following rollout. In the absence of the programme, we calculate that a total of 380,104 additional hospital bed-days would have been occupied by patients with COVID-19 from 4th April to 31st August 2022 (95% CI: -122,842 to 1,034,590). The programme delayed and shortened the duration of the peak while not reducing its magnitude. In sensitivity analyses adjusting the start of the post-intervention period or removing the rate of COVID-19 infection in the over 60s from the model, the effect of the spring booster programme on hospital bed occupancy remained similar. Our findings suggest that timing is a critical consideration in the implementation of COVID-19 booster programmes and that policymakers cannot rely on intermittent booster vaccination of high-risk groups alone to mitigate anticipated peaks in hospital pressure due to COVID-19 epidemics.

A public health framework for the equitable global allocation of vaccines: COVID-NEEDS.

The equitable global allocation of COVID-19 vaccines has received much attention yet been poorly defined. Understanding equity requires assessing needs for vaccines across countries. Making distinctions is especially challenging when countries perform similarly on traditional epidemiological metrics. This Viewpoint offers a novel conceptual framework (COVID-NEEDS) based on empirical evidence and public health guidance. It encompasses health, social, and economic impacts of COVID-19 and associated non-pharmaceutical interventions. We intend this framework to complement existing needs assessment methods to help identify countries most in need of vaccines. We present factors to consider, but future work will be required to understand how to weight the factors and to determine the practical utility of the framework for supplementing existing COVID-19 vaccine allocation mechanisms.

The Real-World Impact of Vaccination on COVID-19 Cases During Europe's Fourth Wave.

Objectives: Disease control is important to limit the social, economic and health effects of COVID-19 and reduce the risk of novel variants emerging. Evidence suggests vaccines are less effective against the Omicron variant, but their impact on disease control is unclear. Methods: We used a longitudinal fixed effects Poisson regression model to assess the impact of vaccination on COVID-19 case rates across 32 countries in Europe from 13th October to 01st January 2022. We controlled for country and time fixed effects and the severity of public health restrictions. Results: Full vaccination coverage increased by 4.2%, leading to a 54% reduction in case rates across Europe (p < 0.001). This protection decreased over time but remained significant at 5 weeks after the detection of Omicron. Mean booster vaccination rates increased from 2.71% to 24.5% but provided no significant additional benefit. For every one-unit increase in the severity of public health restrictions, case rates fell by a further 2% (p = 0.019). Conclusion: Full vaccination significantly limited the spread of COVID-19 and blunted the impact of the Omicron variant, despite becoming less useful over time.

Association between democratic governance and excess mortality during the COVID-19 pandemic: an observational study.

BACKGROUND: Excess mortality has been used to assess the overall health impact of COVID-19 across countries. Democracies aim to build trust in government and enable checks and balances on decision making, which may be useful in a pandemic. But during the pandemic, they have been criticised as being hesitant to enforce restrictive public health measures. METHODS: Through linking open-access datasets we constructed univariable and multivariable linear regression models investigating the association between country V-Dem Liberal Democracy Indices (LDI), representing strength of democratic governance and excess mortality rates, from January 2020 to September 2021. We adjusted for several important confounders and conducted a range of sensitivity analyses to assess the robustness of our findings. RESULTS: Across 78 countries, 4.19 million deaths million excess deaths were recorded. On multivariable regression, a one-point increase in V-Dem LDI was associated with a decrease in excess mortality of 2.18 per 100 000 (p=0.004), after accounting for age, gender, wealth and universal health coverage. This association was only partially attenuated by COVID-19 vaccination rates and remained robust in all sensitivity analyses. CONCLUSIONS: Democratic governance may have played an important role in mitigating the overall health impact of COVID-19 across countries. This study strengthens the case to broaden the scope of traditional pandemic risk assessment and discussions on preparedness.

Joint External Evaluation scores and communicable disease deaths: An ecological study on the difference between epidemics and pandemics.

The Joint External Evaluation (JEE) assesses national capacities to implement the International Health Regulations (IHR). Previous studies have found that higher JEE scores are associated with fewer communicable disease deaths. But given the impact of COVID-19 in many countries, including those believed to have developed IHR capacities, the validity of the JEE for pandemic preparedness has been questioned. We constructed univariable and multivariable linear regression models to investigate the relationship between JEE scores and i) deaths from communicable diseases before the pandemic and ii) deaths from COVID-19. We adjusted for country differences in age, health system access, national wealth, health expenditure, democratic governance, government restrictions, pre-pandemic tourist arrivals and testing capacity (estimated by test positivity rates). For COVID-19 deaths, we calculated cumulative deaths per 100,000 at 3, 6 and 12 months into the pandemic. A total of 91 countries were included, with a median JEE score of 50%. On multivariable linear regression the association between JEE scores and log COVID-19 deaths was significant and positive at 3 months (ß 0.05, p = 0.02), becoming statistically non-significant, at 6 (ß 0.02, p = 0.27) and 12 months (ß -0.03, p = 0.19), while the association with log communicable disease deaths was significant and negative (ß -0.03, p = 0.003). A higher Stringency Index was significantly associated with higher log COVID-19 deaths at 3 (ß 0.04, p = 0.003) and 6 (ß 0.04, p = 0.001) months, but not at 12 months (ß 0.02, p = 0.08). Higher test positivity rates were associated with higher log COVID-19 deaths at all time points, at least partially attenuating the positive association between Stringency Index and log COVID-19 deaths. While universal health coverage indices (ß -0.04 p<0.001) and international tourist arrivals were associated with log communicable disease deaths (ß 0.02, p = 0.002), they were not associated with log COVID-19 deaths. Although the same tool is used to assess capacities for both epidemics and pandemics, the JEE may be better suited to small outbreaks of known diseases, compared to pandemics of unknown pathogens.

Assessment of the non-communicable diseases kit for humanitarian emergencies in Yemen and Libya.

Emergency health kits are a vital way of providing essential medicines and supplies to health clinics during humanitarian crises. The WHO non-communicable diseases (NDCs) kit was developed 5 years ago, recognising the increasing challenge of providing continuity of care and secondary prevention of NCDs and exacerbations, in such settings. Monitoring and evaluation of emergency health kits is an important process to ensure the contents are fit for purpose and to assess usability and utility. However, there are also challenges and limitations in collecting the relevant data to do so.This Practice paper provides a summary of the key methodologies, findings and limitations of NCD kit assessments conducted in Libya and Yemen. Methodologies included a combination of semistructured interviews, surveys with healthcare workers, NCD knowledge tests and quantifying the remaining contents.The kit was able to support the vital delivery of NCD patient care in some complex humanitarian settings and was appreciated by health facilities. However, there were also some challenges affecting kit use. Some kit contents were found to be in greater or lesser quantities than required, and medicine brands and country of origin affected acceptability. Supply chains were affected by the humanitarian situations, with some kits being held up for months prior to arrival. Furthermore, healthcare staff had received limited NCD training and were unable to dispense certain medicines, such as psychotropics, at the primary care level. Further granularity of kit modules, predeployment facility assessments, increased NCD training opportunities and a monitoring system could improve the utility of the kits.

A Rapid Review of COVID-19 Vaccine Prioritization in the U.S.: Alignment between Federal Guidance and State Practice.

BACKGROUND: Population groups to be prioritized for COVID-19 vaccinations in the U.S. have been determined at the Federal level, but there is variation in how States have implemented guidance. This review examines how the position of population groups in vaccine priority lists varies between Federal guidance and State practice. METHODS: An online search of State vaccination prioritization plans was conducted. Data were extracted on each population group included and their relative position. A standardized ranking method was applied to provide a directional measure of variability in prioritization between State and Federal guidance, for each population group. RESULTS: Healthcare workers and those in long-term care facilities were largely prioritized in line with Federal guidance. Aside from early education staff, essential workers were often excluded at State level. Almost all States included the 65-74 year age group and most assigned them to a higher position than recommended in Federal guidance. Those with underlying medical conditions were similarly highly prioritized, although there was more variability across States. Some socially vulnerable groups (not included in Federal guidance) were highly prioritized by many States. CONCLUSIONS: The prioritization of groups for COVID-19 vaccination has been highly variable despite clear Federal guidance. Future guidance must be relevant to local needs, values, and constraints, to minimize any unwarranted heterogeneity in vaccine access across populations.

Evaluations of public health interventions produced by health technology assessment agencies: A mapping review and analysis by type and evidence content.

OBJECTIVES: Health technology assessments (HTAs) have been suggested as a strategy to bridge the evidence-to-policy gap in public health. It is unclear to what extent HTAs have been prepared to assist decisions to implement public health interventions (PHIs). We aimed to describe the experience of HTA agencies by mapping, classifying, and analyzing the evidence content of HTAs of PHIs. METHODS: We systematically searched databases of 35 HTA agencies from 18 countries for evaluations of PHIs between 2008-2018. Interventions were classified using the International Classification of Health Interventions and the evidence content analysed with the INAHTA Product-Type-mark checklist. RESULTS: Only 1010 (9%) of HTAs were on PHIs. 500 (50%) publications targeted Body Systems and Functions, 302 (30%) Health-related Behaviours, 137 (14%) the Environment and 44 (4%) Activities and Participation Domains. Out of 734 publications perused, few met the criteria of full-HTAs (71;10%) or mini-HTAs (110;15%). Most were rapid reviews (420;57%). 72% of all reports came from only 6 countries. CONCLUSION: HTAs on PHIs were uncommon relative to clinical interventions. HTAs on population-based PHIs were less comprehensive in quality and rigor of the evidence. Countries with more resources and mature HTA-systems had done the most evaluations. Exploring the experiences of forerunners could help overcome barriers to evaluations of PHIs and exploit the full potential of HTAs to promote evidence-based public health.

The Underrepresentation of Females in Studies Assessing the Impact of High-Dose Exercise on Cardiovascular Outcomes: a Scoping Review.

High-dose exercise-induced cardiac outcomes may vary between sexes. However, many studies investigating the cardiovascular effects of high-dose exercise have excluded or under-recruited females. This scoping review aimed to describe the recruitment of females in studies assessing the impact of high-dose exercise on cardiovascular outcomes and describe how this has changed over time. This scoping review followed the protocol outlined by Arksey and O'Malley and is reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guidelines. The OVID and EMBASE databases were searched for studies that assessed the effects of high-dose exercise on cardiovascular outcomes. Both professional and nonprofessional groups were included. The review found 2973 studies, and 250 met the inclusion criteria including cumulatively 17,548,843 subjects. Over half the studies (n = 127) excluded females entirely, and only 8 (3.2%) studies recruited all-female participants. The overall mean percentage of females recruited was 18.2%. The mean percentage was 14.5% in studies conducted before 2011 and 21.8% in studies conducted after 2011. Females are an underrepresented group in studies assessing the cardiovascular outcomes related to high-dose exercise. As cardiovascular outcomes vary between sexes, translating findings from a largely male-based evidence may not be appropriate. Future investigators should aim to establish and overcome barriers to female recruitment.

Financing global health emergency response: outbreaks, not agencies.

Effectively responding to global health emergencies requires substantial financial commitment from many stakeholders, including governments, multilateral agencies, and nongovernmental organizations. A major current policy challenge needs attention: how to better coordinate investment among actors aiming to address a common problem, disease outbreaks. For donors who commit colossal sums of money to outbreak response, the current model is neither efficient nor transparent. Innovative approaches to coordinate financing have recently been tested as part of a broader development agenda for humanitarian response. Adopting a system that enables donors to invest in disease outbreaks rather than actors represents an opportunity to deliver a more cost-effective, transparent, and unified global response to infectious disease outbreaks. Achieving this will be challenging, but the World Health Organization (WHO) must play a vital role. New thinking is required to improve emergency response in an increasingly crowded and financially convoluted global health arena.