Informing the pandemic response: the role of the WHO's COVID-19 Weekly Epidemiological Update.

On 31 December 2019, the Municipal Health Commission of Wuhan, China, reported a cluster of atypical pneumonia cases. On 5 January 2020, the WHO publicly released a Disease Outbreak News (DON) report, providing information about the pneumonia cases, implemented response interventions, and WHO's risk assessment and advice on public health and social measures. Following 9 additional DON reports and 209 daily situation reports, on 17 August 2020, WHO published the first edition of the COVID-19 Weekly Epidemiological Update (WEU). On 1 September 2023, the 158th edition of the WEU was published on WHO's website, marking its final issue. Since then, the WEU has been replaced by comprehensive global epidemiological updates on COVID-19 released every 4 weeks. During the span of its publication, the webpage that hosts the WEU and the COVID-19 Operational Updates was accessed annually over 1.4 million times on average, with visits originating from more than 100 countries. This article provides an in-depth analysis of the WEU process, from data collection to publication, focusing on the scope, technical details, main features, underlying methods, impact and limitations. We also discuss WHO's experience in disseminating epidemiological information on the COVID-19 pandemic at the global level and provide recommendations for enhancing collaboration and information sharing to support future health emergency responses.

Disseminating information on acute public health events globally: experiences from the WHO's Disease Outbreak News.

WHO works, on a daily basis, with countries globally to detect, prepare for and respond to acute public health events. A vital component of a health response is the dissemination of accurate, reliable and authoritative information. The Disease Outbreak News (DON) reports are a key mechanism through which WHO communicates on acute public health events to the public. The decision to produce a DON report is taken on a case-by-case basis after evaluating key criteria, and the subsequent process of producing a DON report is highly standardised to ensure the robustness of information. DON reports have been published since 1996, and up to 2022 over 3000 reports have been published. Between 2018 and 2022, the most frequently published DON reports relate to Ebola virus disease, Middle East respiratory syndrome, yellow fever, polio and cholera. The DON web page is highly visited with a readership of over 2.6 million visits per year, on average. The DON report structure has evolved over time, from a single paragraph in 1996 to a detailed report with seven sections currently. WHO regularly reviews the DON report process and structure for improvements. In the last 25 years, DON reports have played a unique role in rapidly disseminating information on acute public health events to health actors and the public globally. They have become a key information source for the global public health response to the benefit of individuals and communities.

Global public health intelligence: World Health Organization operational practices.

Early warning and response are key to tackle emerging and acute public health risks globally. Therefore, the World Health Organization (WHO) has implemented a robust approach to public health intelligence (PHI) for the global detection, verification and risk assessment of acute public health threats. WHO's PHI operations are underpinned by the International Health Regulations (2005), which require that countries strengthen surveillance efforts, and assess, notify and verify events that may constitute a public health emergency of international concern (PHEIC). PHI activities at WHO are conducted systematically at WHO's headquarters and all six regional offices continuously, throughout every day of the year. We describe four interlinked steps; detection, verification, risk assessment, and reporting and dissemination. For PHI operations, a diverse and interdisciplinary workforce is needed. Overall, PHI is a key feature of the global health architecture and will only become more prominent as the world faces increasing public health threats.

Mpox in Children and Adolescents during Multicountry Outbreak, 2022-2023.

The 2022-2023 mpox outbreak predominantly affected adult men; 1.3% of reported cases were in children and adolescents <18 years of age. Analysis of global surveillance data showed 1 hospital intensive care unit admission and 0 deaths in that age group. Transmission routes and clinical manifestations varied across age subgroups.

WHO Global Situational Alert System: a mixed methods multistage approach to identify country-level COVID-19 alerts.

BACKGROUND: Globally, since 1 January 2020 and as of 24 January 2023, there have been over 664 million cases of COVID-19 and over 6.7 million deaths reported to WHO. WHO developed an evidence-based alert system, assessing public health risk on a weekly basis in 237 countries, territories and areas from May 2021 to June 2022. This aimed to facilitate the early identification of situations where healthcare capacity may become overstretched. METHODS: The process involved a three-stage mixed methods approach. In the first stage, future deaths were predicted from the time series of reported cases and deaths to produce an initial alert level. In the second stage, this alert level was adjusted by incorporating a range of contextual indicators and accounting for the quality of information available using a Bayes classifier. In the third stage, countries with an alert level of 'High' or above were added to an operational watchlist and assistance was deployed as needed. RESULTS: Since June 2021, the system has supported the release of more than US$27 million from WHO emergency funding, over 450 000 rapid antigen diagnostic testing kits and over 6000 oxygen concentrators. Retrospective evaluation indicated that the first two stages were needed to maximise sensitivity, where 44% (IQR 29%-67%) of weekly watchlist alerts would not have been identified using only reported cases and deaths. The alerts were timely and valid in most cases; however, this could only be assessed on a non-representative sample of countries with hospitalisation data available. CONCLUSIONS: The system provided a standardised approach to monitor the pandemic at the country level by incorporating all available data on epidemiological analytics and contextual assessments. While this system was developed for COVID-19, a similar system could be used for future outbreaks and emergencies, with necessary adjustments to parameters and indicators.

Description of the first global outbreak of mpox: an analysis of global surveillance data.

BACKGROUND: In May 2022, several countries with no history of sustained community transmission of mpox (formerly known as monkeypox) notified WHO of new mpox cases. These cases were soon followed by a large-scale outbreak, which unfolded across the world, driven by local, in-country transmission within previously unaffected countries. On July 23, 2022, WHO declared the outbreak a Public Health Emergency of International Concern. Here, we aim to describe the main epidemiological features of this outbreak, the largest reported to date. METHODS: In this analysis of global surveillance data we analysed data for all confirmed mpox cases reported by WHO Member States through the global surveillance system from Jan 1, 2022, to Jan 29, 2023. Data included daily aggregated numbers of mpox cases by country and a case reporting form (CRF) containing information on demographics, clinical presentation, epidemiological exposure factors, and laboratory testing. We used the data to (1) describe the key epidemiological and clinical features of cases; (2) analyse risk factors for hospitalisation (by multivariable mixed-effects binary logistic regression); and (3) retrospectively analyse transmission trends. Sequencing data from GISAID and GenBank were used to analyse monkeypox virus (MPXV) genetic diversity. FINDINGS: Data from 82 807 cases with submitted CRFs were included in the analysis. Cases were primarily due to clade IIb MPXV (mainly lineage B.1, followed by lineage A.2). The outbreak was driven by transmission among males (73 560 [96·4%] of 76 293 cases) who self-identify as men who have sex with men (25 938 [86·9%] of 29 854 cases). The most common reported route of transmission was sexual contact (14 941 [68·7%] of 21 749). 3927 (7·3%) of 54 117 cases were hospitalised, with increased odds for those aged younger than 5 years (adjusted odds ratio 2·12 [95% CI 1·32-3·40], p=0·0020), aged 65 years and older (1·54 [1·05-2·25], p=0·026), female cases (1·61 [1·35-1·91], p<0·0001), and for cases who are immunosuppressed either due to being HIV positive and immunosuppressed (2·00 [1·68-2·37], p<0·0001), or other immunocompromising conditions (3·47 [1·84-6·54], p=0·0001). INTERPRETATION: Continued global surveillance allowed WHO to monitor the epidemic, identify risk factors, and inform the public health response. The outbreak can be attributed to clade IIb MPXV spread by newly described modes of transmission. FUNDING: WHO Contingency Fund for Emergencies. TRANSLATIONS: For the French and Spanish translations of the abstract see Supplementary Materials section.

Epidemiology of dengue reported in the World Health Organization's Western Pacific Region, 2013-2019.

The global burden of dengue, an emerging and re-emerging mosquito-borne disease, increased during the 20-year period ending in 2019, with approximately 70% of cases estimated to have been in Asia. This report describes the epidemiology of dengue in the World Health Organization's Western Pacific Region during 2013-2019 using regional surveillance data reported from indicator-based surveillance systems from countries and areas in the Region, supplemented by publicly available dengue outbreak situation reports. The total reported annual number of dengue cases in the Region increased from 430 023 in 2013 to 1 050 285 in 2019, surpassing 1 million cases for the first time in 2019. The reported case-fatality ratio ranged from 0.19% (724/376 972 in 2014 and 2030/1 050 285 in 2019) to 0.30% (1380/458 843 in 2016). The introduction or reintroduction of serotypes to specific areas caused several outbreaks and rare occurrences of local transmission in places where dengue was not previously reported. This report reinforces the increased importance of dengue surveillance systems in monitoring dengue across the Region.

Tool for tracking all-cause mortality and estimating excess mortality to support the COVID-19 pandemic response.

Problem: Quantifying mortality from coronavirus disease (COVID-19) is difficult, especially in countries with limited resources. Comparing mortality data between countries is also challenging, owing to differences in methods for reporting mortality. Context: Tracking all-cause mortality (ACM) and comparing it with expected ACM from pre-pandemic data can provide an estimate of the overall burden of mortality related to the COVID-19 pandemic and support public health decision-making. This study validated an ACM calculator to estimate excess mortality during the COVID-19 pandemic. Action: The ACM calculator was developed as a tool for computing expected ACM and excess mortality at national and subnational levels. It was developed using R statistical software, was based on a previously described model that used non-parametric negative binomial regression and was piloted in several countries. Goodness-of-fit was validated by forecasting 2019 mortality from 2015-2018 data. Outcome: Three key lessons were identified from piloting the tool: using the calculator to compare reported provisional ACM with expected ACM can avoid potential false conclusions from comparing with historical averages alone; using disaggregated data at the subnational level can detect excess mortality by avoiding dilution of total numbers at the national level; and interpretation of results should consider system-related performance indicators. Discussion: Timely tracking of ACM to estimate excess mortality is important for the response to COVID-19. The calculator can provide countries with a way to analyse and visualize ACM and excess mortality at national and subnational levels.

Epidemiology of Congenital Rubella Syndrome Related to the 2012-2013 Rubella Epidemic in Japan.

This study assessed the epidemiological characteristics of 45 congenital rubella syndrome cases in Japan following the 2012-2013 rubella epidemic. Rubella still poses significant health burdens and the uptake of rubella-containing vaccines among women of childbearing age should be improved.

Nosocomial outbreak of coronavirus disease in two general wards during the initial wave of the pandemic in 2020, Tokyo, Japan.

Objective: Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first reported in China and subsequently spread worldwide. In Japan, many clusters occurred during the first wave in 2020. We describe the investigation of an early outbreak in a Tokyo hospital. Methods: A COVID-19 outbreak occurred in two wards of the hospital from April to early May 2020. Confirmed cases were individuals with laboratory-confirmed SARS-CoV-2 infection linked to Wards A and B, and contacts were patients or workers in Wards A or B 2 weeks before the index cases developed symptoms. All contacts were tested, and cases were interviewed to determine the likely route of infection and inform the development of countermeasures to curb transmission. Results: There were 518 contacts, comprising 472 health-care workers (HCWs) and 46 patients, of whom 517 were tested. SARS-CoV-2 infection was confirmed in 42 individuals (30 HCWs and 12 patients). The proportions of SARS-CoV-2 infections in HCWs were highest among surgeons, nurses, nursing assistants and medical assistants. Several HCWs in these groups reported being in close proximity to one another while not wearing medical masks. Among HCWs, infection was thought to be associated with the use of a small break room and conference room. Discussion: Nosocomial SARS-CoV-2 infections occurred in two wards of a Tokyo hospital, affecting HCWs and patients. Not wearing masks was considered a key risk factor for infection during this outbreak; masks are now a mandated countermeasure to prevent the spread of SARS-CoV-2 infection in hospital settings.

An epidemiological overview of human infections with HxNy avian influenza in the Western Pacific Region, 2003-2022.

Avian influenza subtype A(HxNy) viruses are zoonotic and may occasionally infect humans through direct or indirect contact, resulting in mild to severe illness and death. Member States in the Western Pacific Region (WPR) communicate and notify the World Health Organization of any human cases of A(HxNy) through the International Health Regulations (IHR 2005) mechanism. This report includes all notifications in the WPR with illness onset dates from 1 November 2003 to 31 July 2022. During this period, there were 1972 human infections with nine different A(HxNy) subtypes notified in the WPR. Since the last report, an additional 134 human avian influenza infections were notified from 1 October 2017 to 31 July 2022. In recent years there has been a change in the primary subtypes and frequency of reports of human A(HxNy) in the region, with a reduction of A(H7N9) and A(H5N1), and conversely an increase of A(H5N6) and A(H9N2). Furthermore, three new subtypes A(H7N4), A(H10N3) and A(H3N8) notified from the People's Republic of China were the first ever recorded globally. The public health risk from known A(HxNy) viruses remains low as there is no evidence of person-to-person transmission. However, the observed changes in A(HxNy) trends reinforce the need for effective and rapid identification to mitigate the threat of a pandemic from avian influenza if person-to-person transmission were to occur.

The World Health Organization's public health intelligence activities during the COVID-19 pandemic response, December 2019 to December 2021.

The coronavirus disease (COVID-19) presented a unique opportunity for the World Health Organization (WHO) to utilise public health intelligence (PHI) for pandemic response. WHO systematically captured mainly unstructured information (e.g. media articles, listservs, community-based reporting) for public health intelligence purposes. WHO used the Epidemic Intelligence from Open Sources (EIOS) system as one of the information sources for PHI. The processes and scope for PHI were adapted as the pandemic evolved and tailored to regional response needs. During the early months of the pandemic, media monitoring complemented official case and death reporting through the International Health Regulations mechanism and triggered alerts. As the pandemic evolved, PHI activities prioritised identifying epidemiological trends to supplement the information available through indicator-based surveillance reported to WHO. The PHI scope evolved over time to include vaccine introduction, emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants, unusual clinical manifestations and upsurges in cases, hospitalisation and death incidences at subnational levels. Triaging the unprecedented high volume of information challenged surveillance activities but was managed by collaborative information sharing. The evolution of PHI activities using multiple sources in WHO's response to the COVID-19 pandemic illustrates the future directions in which PHI methodologies could be developed and used.

Facilitating the deployment of Japanese human resources for responding global outbreaks of emerging and Re-emerging infectious diseases: A cross-sectional study.

INTRODUCTION: In response to global outbreaks of infectious diseases, the need for support from organizations such as the World Health Organization Global Outbreak Alert and Response Network (GOARN) is increasing. Identifying the obstacles and support needs for applicants could increase GOARN deployments from Japan. METHODS: This cross-sectional study involved a web-based, self-administered questionnaire survey targeting Japanese participants in the GOARN Tier 1.5 training workshop, held in Tokyo in December 2019. RESULTS: All 47 Japanese participants in the workshop responded to the survey. Most responders were male and in their 30s and 40s. Participants specialized in case management (42.6%), infection prevention and control (25.6%), epidemiology and surveillance (19.1%). Only two participants (4.6%) had experienced a GOARN deployment. Their motivations for joining the GOARN training workshop were "Desire to be part of an international emerging infectious disease response team" (44.6%), "Interest in making an international contribution" (19.1%), and "Interest in working for the Japanese government in the field of international infectious diseases" (14.9%). Obstacles to GOARN deployments were "Making time for deployments" (45.7%) and "Lack of required professional skills and knowledge" (40.4%). The support needs for GOARN deployments constituted "Periodic simulation training" (51.1%), "Financial support during deployments" (44.7%), and "Technical support for deployments" (40.4%). CONCLUSIONS: Our study revealed the obstacles and support needs of Japanese candidates for GOARN deployment. Making time and upskilling for GOARN deployment were the main obstacles. More practical training (like GOARN Tier 2.0) with other supports are needed. The national framework is desirable to realize these supports.

Increase in congenital syphilis cases and challenges in prevention in Japan, 2016-2017.

In Japan, the increase in congenital syphilis (CS) notifications has become a public health concern. We conducted a case series study to describe the characteristics of CS patients and their mothers. Of the 13 mothers who consented to participate, seven had regular prenatal care visits, including four who had tested negative at their first trimester syphilis screening. Only three mothers noted that their partners were tested, with all three partners being diagnosed with syphilis. Raising awareness for syphilis prevention during pregnancy, partner testing, and considering additional syphilis testing at the third trimester of pregnancy during times of increased syphilis prevalence is imperative.

Strengthening national, regional and global health capacity through the WHO Western Pacific Region's Field Epidemiology Fellowship Programme.

OBJECTIVE: The World Health Organization's (WHO's) Field Epidemiology Fellowship Programme in the Western Pacific Region aims to strengthen countries' capacities for surveillance and risk assessment and build a workforce to tackle public health emergencies. A survey was conducted to assess the on-the-job training experience of the Regional Fellows, evaluate the strengths of the Programme and gain feedback on areas for improvement. METHODS: Between 25 September and 25 October 2018, an online survey was sent to Regional Fellows who had participated in the Programme between July 2006 and September 2018. The survey was shared with WHO country offices in the Western Pacific Region and directly with graduates of the Programme. Responses were recorded electronically and analysed. RESULTS: A total of 53 former Regional Fellows responded (54% response rate; 53/98). At the time of Programme participation, the Fellows' median age was 35, 62% (33/53) were female and 72% (38/53) were affiliated with a national or subnational health department. Fellows gained experience in event-based surveillance and risk assessment and worked among a diverse group of professionals in various Member States. Altogether, 77% (41/53) of respondents believed that the Programme had helped them move into a better career position with greater responsibility. Ninety-four percent (50/53) would recommend the Programme to their colleagues. DISCUSSION: Alumni from the Western Pacific Region's Field Epidemiology Fellowship Programme perform key health security roles, particularly within governmental systems, and directly contribute to managing health emergencies in their countries, in the Region and globally. The Programme is building a workforce with surge capacity to ensure that public health events in the Region can be addressed. Furthermore, connections developed through the Programme are helping to develop an alumni network, and enhance communications among Member States and between Member States and WHO.

A Genome Epidemiological Study of SARS-CoV-2 Introduction into Japan.

After the first case of coronavirus disease 2019 (COVID-19) in Japan on 15 January 2020, multiple nationwide COVID-19 clusters were identified by the end of February. The Japanese government focused on mitigating the emerging COVID-19 clusters by conducting active nationwide epidemiological surveillance. However, an increasing number of cases continued to appear until early April 2020, many with unclear infection routes and no recent history of travel outside Japan. We aimed to evaluate the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) genome sequences from the COVID-19 cases that appeared until early April 2020 and to characterize their genealogical networks in order to demonstrate possible routes of spread in Japan. Nasopharyngeal specimens were collected from patients, and reverse transcription-quantitative PCR tests for SARS-CoV-2 were performed. Positive RNA samples were subjected to whole-genome sequencing, and a haplotype network analysis was performed. Some of the primary clusters identified during January and February 2020 in Japan descended directly from the Wuhan-Hu-1-related isolates from China and other distinct clusters. Clusters were almost contained until mid-March; the haplotype network analysis demonstrated that the COVID-19 cases from late March through early April may have created an additional large cluster related to the outbreak in Europe, leading to additional spread within Japan. In conclusion, genome surveillance has suggested that there were at least two distinct SARS-CoV-2 introductions into Japan from China and other countries.IMPORTANCE This study aimed to evaluate the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) genome sequences from COVID-19 cases and to characterize their genealogical networks to demonstrate possible routes of spread in Japan. We found that there were at least two distinct SARS-CoV-2 introductions into Japan, initially from China and subsequently from other countries, including Europe. Our findings can help understand how SARS-CoV-2 entered Japan and contribute to increased knowledge of SARS-CoV-2 in Asia and its association with implemented stay-at-home/shelter-in-place/self-restraint/lockdown measures. This study suggested that it is necessary to formulate a more efficient containment strategy using real-time genome surveillance to support epidemiological field investigations in order to highlight potential infection linkages and mitigate the next wave of COVID-19 in Japan.

Syphilis in heterosexual women: case characteristics and risk factors for recent syphilis infection in Tokyo, Japan, 2017-2018.

In response to an increase in heterosexual syphilis notifications in Tokyo, we conducted a questionnaire-based case-control study among women aged ≥20 years and sexually active in the past six months who sought a syphilis test in Tokyo during 2017-2018. Cases were women diagnosed as recent syphilis infection based on serological tests. Controls were serologically non-reactive or those with only a past syphilis infection. We described cases and assessed for risk factors of recent syphilis using logistic regression. A total of 524 women (60 cases, 464 controls) were enrolled. Notably, among cases, 10 (16.7%) were students, 3 (5.0%) had a history of syphilis, and 14 (23.3%) had a single sex partner in the past six months. Female sex worker (FSW) status was strongly associated with syphilis (odds ratio [OR] = 3.40; 95% confidence interval [CI] = 1.96-5.90). In multivariable analysis, recent syphilis was associated with inconsistent condom use for vaginal/anal sex among FSWs (adjusted OR [aOR] = 3.42; 95%CI = 0.92-12.70) and among non-FSWs, with younger age (aOR = 0.36; 95%CI = 0.19-0.70; increase per category from 20-24, 25-29 to ≥30 years) and ≤high school education (aOR = 5.24; 95%CI = 1.95-14.10). A notable proportion of cases were those with first time infection and those with only a single partner. Moreover, risk factors differed between FSWs and non-FSWs, and a multi-pronged approach to prevent syphilis is required.

Rubella outbreak among workers in three small- and medium-size business establishments associated with imported genotype 1E rubella virus-Shizuoka, Japan, 2015.

On 12 February 2015, a local health department (LHD) in Shizuoka prefecture identified two reported rubella cases in its jurisdiction as employees of the same company. As other employees at the company resided both inside and outside of the health department's jurisdiction, it began collaborating with two additional LHDs and the National Institute of Infectious Diseases to investigate and respond to the outbreak, which subsequently identified cases in two additional companies. We obtained epidemiological, clinical, and outbreak response information from the national epidemiological surveillance of infectious disease system's database, the local health departments, and the associated companies. One specimen for genetic sequencing was collected from each of the three companies. The outbreak included a total of twenty-five cases, with seventeen confirmed and eight probable cases from three companies. Among them, 24 (96%) were male, 22 (88%) were employees of one company (Company X), and none had rubella vaccination history. The median age was 45 years (interquartile range: 40-51). Epidemiological information did not reveal the source of infection nor transmission route. All rubella viruses sequenced from the three specimens were classified into genotype 1E. The nucleotide sequences in the 739 bp-window region were completely identical in two specimens, with only one nucleotide difference in the third specimen. According to phylogenetic analysis, these strains were closely related to the Southeast and East Asian lineage. This rubella outbreak at three companies, ranging in size from small- to medium-size, in Japan occurred among unvaccinated employees aged at least 30 years, most of whom were male. Virologic analyses suggest all cases were infected with the same viral strain imported from Southeast Asia. Similar to these companies, most employees at small- and medium-size businesses in Japan are males with no vaccination history for rubella, which poses a serious risk for associated cases of congenital rubella syndrome (CRS).