Data and cooperation required for Venezuela's refugee crisis during COVID-19.

The deteriorating political and economic situation in Venezuela has ramifications far beyond the Latin American country's borders as almost five million Venezuelans fled and migrated into countries in the region due to the crisis at home. The scarcity of health services, the lack of information sharing, and the absence of reliable data in Venezuela create challenges for confronting developing health emergencies and disease outbreaks. The need for accurate data is especially dire given the current COVID-19 pandemic and evolving movement of refugees. While countries and international organizations came together to form a coordinated response to Venezuela's political and humanitarian crisis, this geopolitical progress is threatened by the rapid spread of COVID-19, and the instinct for countries to focus inwards on domestic response priorities, rather than engage in regional cooperation. It is critical that the international community set aside geopolitical differences and cooperate to seek an accurate picture of the conditions on the ground to improve the welfare of Venezuelan migrants and to provide a more robust response to the current pandemic.

Assessing One Health capacities for transboundary zoonotic diseases at the Libya-Tunisia border.

BACKGROUND: The dynamic nature of zoonotic emergence, spillover and spread necessitates multisectoral coordination beyond national borders to encompass cross-boundary and regional cooperation. Designated points of entry (POEs), specifically ground crossings, serve as critical locales for establishing and maintaining robust prevention, detection, notification, coordination, and response mechanisms to transboundary emerging and re-emerging disease threats. In order to better assess One Health capacities for transboundary zoonotic diseases (TZD) prevention, detection and response we adapted an existing tool, One Health Systems Assessment for Priority Zoonoses (OHSAPZ), for a cross-border, POE setting in North Africa. METHODS: The One Health Transboundary Assessment for Priority Zoonoses (OHTAPZ) tool was used to support prioritization of transboundary zoonoses and analyze operational capacities between national and subnational-level human and animal health stakeholders from Libya and Tunisia. Country partners jointly identified and prioritized five TZDs of concern. Case study scenarios for each priority pathogen were used to elicit current disease operations, as well as multisectoral and bilateral engagement networks. Finally, a gap analysis was performed to determine bilateral strengths and weaknesses to TZDs. RESULTS: The five priority TZDs jointly confirmed to undergo One Health assessment were avian influenza (low and high pathogenic strains); brucellosis; Rift Valley fever; Crimean-Congo hemorrhagic fever; and rabies. Using the qualitative information collected, a transboundary systems map schematic was developed outlining the movement of human patients, animals, diagnostic samples, and routes of communication and coordination both within and between countries for zoonotic diseases. CONCLUSIONS: Analysis of current operations (prevention, detection, surveillance, laboratory capacity, quarantine/isolation, and response) and the resulting transboundary systems map schematic helped identify existing capacity strengths for certain priority pathogens, as well as challenges to timely information-sharing and coordination. We developed targeted recommendations to address these limitations for joint action planning between Libya and Tunisia.

An early analysis of the World Bank's Pandemic Fund: a new fund for pandemic prevention, preparedness and response.

In response to shortcomings in epidemic preparedness and response that were revealed by the COVID-19 pandemic, there have been numerous proposals for ways to improve preparedness and response financing. Included among these is the World Bank's Pandemic Fund, formerly known as the Financial Intermediary Fund for Pandemic Prevention, Preparedness, and Response, which was launched in September 2022. This analysis piece examines the Pandemic Fund, where it fits into ongoing discussions surrounding financing for preparedness and response efforts and discusses emerging apprehensions about the new financing mechanism. Briefly, the Pandemic Fund is not the first time that the World Bank has hosted a financing mechanism to provide support for pandemic response. Notably the Pandemic Emergency Financing Facility (PEF)-which was launched in 2017 and closed in 2021-was criticised for generally failing to realise its potential. However, the Pandemic Fund seems to be addressing several of these critiques by placing a greater emphasis on prevention and preparedness financing, as opposed to response financing. Still, there is an important need for response funding mechanisms, and concerningly, the Pandemic Fund seems to support response efforts in name only. While it is clearly desirable to prepare for and prevent outbreaks for a multitude of reasons, it is also naive to assume that strengthening preparedness capacities will eliminate outbreaks and the need for response financing altogether. Accordingly, there is a need to complement this new financing mechanism with dedicated funding for responding to infectious disease outbreaks and to closely link this response financing with health security frameworks and instruments.

One Health Systems Assessments for Sustainable Capacity Strengthening to Control Priority Zoonotic Diseases Within and Between Countries.

One Health is increasingly recognized as an important approach for health systems, particularly with respect to strengthening prevention, detection and response to zoonotic and other emerging disease threats. While many global health security frameworks reference the importance of One Health, there are fewer existing methodologies, tools, and resources for supporting countries and other regional or sub-national authorities in systematically assessing their One Health capabilities. We describe here two methodologies, One Health Systems Assessment for Priority Zoonoses (OHSAPZ) and One Health Transboundary Assessment for Priority Zoonoses (OHTAPZ), which have been developed to assist with creating consensus lists of priority zoonotic diseases for cross-sectoral consideration; identification of current strengths and gaps in One Health communication and coordination between sectors (and, in the case of OHTAPZ, between countries); and the development and dissemination of prioritized recommendations for future capacity strengthening. Implemented to date in seven diverse countries in Africa and the Eastern Mediterranean regions, these tools provide a modular, flexible and easily adaptable approach to One Health systems assessment that can support national capacity strengthening, regional epidemic preparedness, and compliance with international frameworks.

Using One Health assessments to leverage endemic disease frameworks for emerging zoonotic disease threats in Libya.

Continued emergence, re-emergence and spread of zoonotic diseases demonstrates the imperative need for multisectoral communication and joint coordination of disease detection and response. While there are existing international frameworks underpinning One Health capacity building for pandemic prevention and response, often guidance does not account for challenges faced by countries undergoing long-term conflict and sociopolitical instability. The purpose of this research was to identify Libya's laboratory and surveillance networks and routes of inter- and multisectoral communication and coordination for priority zoonotic diseases. The One Health Systems Assessment for Priority Zoonoses (OH-SAPZ) tool is an established methodology that was adapted and applied to the Libyan context to support prioritization of zoonotic diseases, development of systems map schematics outlining networks of communication and coordination, and analysis of operations for targeted capacity building efforts. Five zoonotic diseases were selected to undergo assessment: highly pathogenic avian influenza, brucellosis, Rift Valley fever, leishmaniasis and rabies. Through decisive acknowledgement of Libya's unique health setting, we mapped how patient and sample information is both communicated within and between the human, animal and environmental health sectors, spanning from local index case identification to international notification. Through our assessment we found strong communication within the public and animal health sectors, as well as existing multisectoral coordination on zoonotic disease response. However, local-level communication between the sectors is currently lacking. Due to the ongoing conflict, resources (financial and human) and access have been severely impacted, resulting in limited laboratory diagnostic capacity and discontinued disease prevention and control measures. We sought to identify opportunities to leverage existing operations for endemic diseases like brucellosis for emerging zoonotic threats, such as Rift Valley fever. Analysis of these operations and capabilities supports the development of targeted recommendations that address gaps and may be used as an implementation guide for future One Health capacity building efforts.

Assessing the impact of regional laboratory networks in East and West Africa on national health security capacities.

National laboratories are a fundamental capacity for public health, contributing to disease surveillance and outbreak response. The establishment of regional laboratory networks has been posited as a means of improving health security across multiple countries. Our study objective was to assess whether membership in regional laboratory networks in Africa has an effect on national health security capacities and outbreak response. We conducted a literature review to select regional laboratory networks in the Eastern and Western African regions. We examined data from the World Health Organization Joint External Evaluation (JEE) mission reports, the 2018 WHO States Parties Annual Report (SPAR), and the 2019 Global Health Security Index (GHS). We compared the average scores of countries that are members of a regional laboratory network to those that are not. We also assessed country-level diagnostic and testing indicators during the COVID-19 pandemic. We found no significant differences in any of the selected health security metrics for member versus non-member countries of the either the East Africa Public Health Laboratory Networking Project (EAPHLNP) in the Eastern Africa region, nor for the West African Network of Clinical Laboratories (RESAOLAB) in the Western Africa region. No statistically significant differences were observed in COVID-19 testing rates in either region. Small sample sizes and the inherent heterogeneities in governance, health, and other factors between countries within and between regions limited all analyses. These results suggest potential benefit in setting baseline capacity for network inclusion and developing regional metrics for measuring network impact, but also beyond national health security capacities, other effects that may be required to justify continued support for regional laboratory networks.

Lost in translation: the importance of addressing language inequities in global health security.

Language inequities in global health stem from colonial legacies, and global health security is no exception. The International Health Regulations (IHRs), a legally binding framework published by the WHO, lay the foundation for global health security and state the roles and responsibilities States Parties are compelled to follow to improve their capabilities to prevent, detect and respond to potential public health emergencies of international concern. It includes the submission of a mandatory status report that assesses a nation's implementation of IHRs. Known as the States Party Self-Assessment Annual Report (SPAR) tool, WHO has made its guidance document available in all six WHO official languages (Arabic, Chinese, English, French, Russian and Spanish). The Republic of Iraq (Iraq) experienced significant challenges during the completion and submission of the 2022 SPAR. This experience demonstrated that translation of English materials to other languages, such as Arabic, is not prioritised and further underscored how scoring of a country's global health security capacities can be significantly impacted by users' ability to read and comprehend the materials in English. Not only can this lead to inaccurate SPAR scoring, but it can also lead to the improper allocation of resources and prioritisation of policy developments and/or amendments. By drawing attention to this issue, we aim to inform and advocate for global health security decision-makers to consider opportunities for increasing inclusion and accessibility, especially for requirements under legally binding international instruments.

Variations in the hemagglutinin of the 2009 H1N1 pandemic virus: potential for strains with altered virulence phenotype?

A novel, swine-origin influenza H1N1 virus (H1N1pdm) caused the first pandemic of the 21st century. This pandemic, although efficient in transmission, is mild in virulence. This atypical mild pandemic season has raised concerns regarding the potential of this virus to acquire additional virulence markers either through further adaptation or possibly by immune pressure in the human host. Using the mouse model we generated, within a single round of infection with A/California/04/09/H1N1 (Ca/04), a virus lethal in mice--herein referred to as mouse-adapted Ca/04 (ma-Ca/04). Five amino acid substitutions were found in the genome of ma-Ca/04: 3 in HA (D131E, S186P and A198E), 1 in PA (E298K) and 1 in NP (D101G). Reverse genetics analyses of these mutations indicate that all five mutations from ma-Ca/04 contributed to the lethal phenotype; however, the D131E and S186P mutations--which are also found in the 1918 and seasonal H1N1 viruses-in HA alone were sufficient to confer virulence of Ca/04 in mice. HI assays against H1N1pdm demonstrate that the D131E and S186P mutations caused minor antigenic changes and, likely, affected receptor binding. The rapid selection of ma-Ca/04 in mice suggests that a virus containing this constellation of amino acids might have already been present in Ca/04, likely as minor quasispecies.

Minimal molecular constraints for respiratory droplet transmission of an avian-human H9N2 influenza A virus.

Pandemic influenza requires interspecies transmission of an influenza virus with a novel hemagglutinin (HA) subtytpe that can adapt to its new host through either reassortment or point mutations and transmit by aerosolized respiratory droplets. Two previous pandemics of 1957 and 1968 resulted from the reassortment of low pathogenic avian viruses and human subtypes of that period; however, conditions leading to a pandemic virus are still poorly understood. Given the endemic situation of avian H9N2 influenza with human-like receptor specificity in Eurasia and its occasional transmission to humans and pigs, we wanted to determine whether an avian-human H9N2 reassortant could gain respiratory transmission in a mammalian animal model, the ferret. Here we show that following adaptation in the ferret, a reassortant virus carrying the surface proteins of an avian H9N2 in a human H3N2 backbone can transmit efficiently via respiratory droplets, creating a clinical infection similar to human influenza infections. Minimal changes at the protein level were found in this virus capable of respiratory droplet transmission. A reassortant virus expressing only the HA and neuraminidase (NA) of the ferret-adapted virus was able to account for the transmissibility, suggesting that currently circulating avian H9N2 viruses require little adaptation in mammals following acquisition of all human virus internal genes through reassortment. Hemagglutinin inhibition (HI) analysis showed changes in the antigenic profile of the virus, which carries profound implications for vaccine seed stock preparation against avian H9N2 influenza. This report illustrates that aerosolized respiratory transmission is not exclusive to current human H1, H2, and H3 influenza subtypes.

Opportunities and Challenges for Regional Coordination of Infectious Disease Control Comment on "Operationalising Regional Cooperation for Infectious Disease Control: A Scoping Review of Regional Disease Control Bodies and Networks".

This commentary cites a scoping review by Durrance-Bagale et al (2021) on how regional bodies have approached infectious disease control to determine if those lessons could be applied to assist the Association of Southeast Asian Nations (ASEAN). The author's work is timely and highlights the importance of recognizing and understanding regional context, governance and operational structures to then design effective regional networks. Most factors highlighted as enablers and constraints are quite expected, including stakeholder mapping, a clear mission space with goals and objectives, outreach and advocacy to receive buy-in, political will and sustainable funding. We suggest below that there is an opportunity for further systematic and operational research of enablers and constraints for regional infectious disease control bodies, one that expands on infectious disease control while also continuing to take into account governance, legislative and organizational factors, and strongly emphasizes the development and application of clear metrics to create better measures of impact.

Association of National Football League Fan Attendance With County-Level COVID-19 Incidence in the 2020-2021 Season.

Importance: The 2020-2021 National Football League (NFL) season had some games with fans and others without. Thus, the exposed group (ie, games with fans) and the unexposed group (games without fans) could be examined to better understand the association between fan attendance and local incidence of COVID-19. Objective: To assess whether NFL football games with varying degrees of in-person attendance were associated with increased COVID-19 cases in the counties where the games were held, as well as in contiguous counties, compared with games without in-person attendance for 7-, 14-, and 21-day follow-ups. Design, Setting, and Participants: This cross-sectional study used data for all 32 NFL teams across the entirety of the 2020-2021 season. Separate daily time-series of COVID-19 total cases and case rates were generated using 7-, 14-, and 21-day simple moving averages for every team and were plotted against the actuals to detect potential spikes (outliers) in incidence levels following games for the county in which games took place, contiguous counties, and a combination. Outliers flagged in the period following games were recorded. Poisson exact tests were evaluated for differences in spike incidence as well across games with different rates of attendance. The data were analyzed between February 2021 and March 2021. Exposures: Games with fan attendance vs games with no fan attendance, as well as the number of fans in attendance for games with fans. Main Outcomes and Measures: The main outcome was estimation of COVID-19 cases and rates at the county and contiguous county level at 7-, 14-, and 21-day intervals for in-person attended games and non-fan attended games, which was further investigated by stratifying by the number of persons in fan-attended games. Results: This included a total of 269 NFL game dates. Of these games, 117 were assigned to an exposed group (fans attended), and the remaining 152 games comprised the unexposed group (unattended). Fan attendance ranged from 748 to 31 700 persons. Fan attendance was associated with episodic spikes in COVID-19 cases and rates in the 14-day window for the in-county (cases: rate ratio [RR], 1.36; 95% CI, 1.00-1.87), contiguous counties (cases: RR, 1.31; 95% CI, 1.00-1.72; rates: RR, 1.41; 95% CI, 1.13-1.76), and pooled counties groups (cases: RR, 1.34; 95% CI, 1.01-1.79; rates: RR, 1.72; 95% CI, 1.29-2.28) as well as for the 21-day window in-county (cases: RR, 1.49; 95% CI, 1.21-1.83; rates: RR, 1.50; 95% CI, 1.26-1.78), in contiguous counties(cases: RR, 1.37; 95% CI, 1.14-1.65; rates: RR, 1.45; 95% CI, 1.24-1.71), and pooled counties groups (cases: RR, 1.41; 95% CI, 1.11-1.79; rates: RR, 1.70; 95% CI, 1.35-2.15). Games with fewer than 5000 fans were not associated with any spikes, but in counties where teams had 20 000 fans in attendance, there were 2.23 times the rate of spikes in COVID-19 (95% CI, 1.53 to ∞). Conclusions and Relevance: In this cross-sectional study of the presence of fans at NFL home games during the 2020-2021 season, results indicated that fan attendance was associated with increased levels of COVID-19 in the counties in which the venues are nested within, as well as in surrounding counties. The spikes in COVID-19 for crowds of over 20 000 people suggest that large events should be handled with extreme caution during public health event(s) where vaccines, on-site testing, and various countermeasures are not readily available to the public.

Assessing barriers, opportunities and future directions in health information sharing in humanitarian contexts: a mixed-method study.

OBJECTIVES: Health information sharing continues to play a crucial yet underappreciated role in humanitarian settings, to guide evidence-based disease prevention, detection and response. We conducted a mixed-methods study to investigate and analyse existing approaches and practices to health information sharing across humanitarian settings over the past 20 years. SETTING: We sought to identify studies from any self-described humanitarian setting worldwide, and also targeted experts familiar with refugee settings, specifically long-term camps in Kenya, Jordan and Bangladesh, for key informant interviews. PARTICIPANTS: The systematic review did not directly involve participants. The identified reports were largely retrospective and observational, and focused on populations affected by humanitarian crises worldwide. Participants in the key informant interviews were experts with either broad geographical expertise or direct experience in refugee camp settings. PRIMARY AND SECONDARY OUTCOME MEASURES: Our study was qualitative, and both the systematic review and analysis of key informant interview responses focused on identifying themes related to barriers, tools and recommendations used between stakeholders to share health information, with a particular emphasis on infectious disease and surveillance data. RESULTS: We identified logistical challenges, difficulties with data collection and a lack of health information sharing frameworks as the most significant barriers to health information sharing. The most important tools to health information sharing included the use of third-party technologies for data collection and standardisation, formalised health information sharing frameworks, establishment of multilevel coordination mechanisms and leadership initiatives which prioritised the sharing of health information. CONCLUSIONS: We conclude that health information sharing can be strengthened in humanitarian settings with improvements to existing frameworks, coordination and leadership tools, in addition to promotion of health information communication. Furthermore, specific recommendations for improving health information sharing should be pursued according to the nature of the humanitarian setting and the efficacy of the health system present.

A 27-amino-acid deletion in the neuraminidase stalk supports replication of an avian H2N2 influenza A virus in the respiratory tract of chickens.

The events and mechanisms that lead to interspecies transmission of, and host adaptation to, influenza A virus are unknown; however, both surface and internal proteins have been implicated. Our previous report highlighted the role that Japanese quail play as an intermediate host, expanding the host range of a mallard H2N2 virus, A/mallard/Potsdam/178-4/83 (H2N2), through viral adaptation. This quail-adapted virus supported transmission in quail and increased its host range to replicate and be transmitted efficiently in chickens. Here we report that of the six amino acid changes in the quail-adapted virus, a single change in the hemagglutinin (HA) was crucial for transmission in quail, while the changes in the polymerase genes favored replication at lower temperatures than those for the wild-type mallard virus. Reverse genetic analysis indicated that all adaptive mutations were necessary for transmission in chickens, further implicating quail in extending this virus to terrestrial poultry. Adaptation of the quail-adapted virus in chickens resulted in the alteration of viral tropism from intestinal shedding to shedding and transmission via the respiratory tract. Sequence analysis indicated that this chicken-adapted virus maintained all quail-adaptive mutations, as well as an additional change in the HA and, most notably, a 27-amino-acid deletion in the stalk region of neuraminidase (NA), a genotypic marker of influenza virus adaptation to chickens. This stalk deletion was shown to be responsible for the change in virus tropism from the intestine to the respiratory tract.

Assessment of West Nile Virus Lineage 2 Dynamics in Greece and Future Implications.

The emergence of West Nile Virus lineage 2 (WNV-2) has contributed to multiple major human outbreaks in Greece since 2010. Studies to date investigating biological and environmental factors that contribute to West Nile Virus (WNV) transmission have resulted in complex statistical models. We sought to examine open publicly available data to ascertain if a predictive risk assessment could be employed for WNV-2 in Greece. Based on accessible data, factors such as precipitation, temperature, and range of avian host species did not yield conclusive outcomes. However, by measuring the average rate of temperature change leading up to peak caseloads, we found a predictive characteristic to the timing of outbreaks. Detailed evolutionary studies revealed possible multiple introductions of WNV-2 in Europe, and that Greece acts through a source-sink inversion model, thereby allowing continued reseeding of WNV transmission each year by overwintering the Culex pipiens mosquito vector. Greece has proven an excellent model in WNV surveillance and has demonstrated the importance of rapid reporting for proper preparedness and response to vector-borne diseases.

Public health emergency management capacity building in Guinea: 2014-2019.

Before the Ebola virus disease (EVD) outbreak of 2014-2016, Guinea did not have an emergency management system in place. During the outbreak, Global Health Security Agenda (GHSA) 2014-2019 funds made it possible to rapidly improve the country's capacity to manage epidemics through the development of public health emergency operation centres (PHEOCs) at the national and district levels. Since the end of the response, the infrastructure, staff, and systems of these PHEOCs have been further reinforced and well-integrated in the daily activities of Guinea's National Agency for Health Security, the entity responsible for the management of epidemics. The development of PHEOCs as emergency management tools for epidemics in Guinea would not have been possible without a strong endorsement within the Ministry of Health. Guinea's PHEOC network is well-positioned to serve as a model of excellence for other Ministries in Guinea and Ministries of Health of other countries of West Africa.

The science of the host-virus network.

Better methods to predict and prevent the emergence of zoonotic viruses could support future efforts to reduce the risk of epidemics. We propose a network science framework for understanding and predicting human and animal susceptibility to viral infections. Related approaches have so far helped to identify basic biological rules that govern cross-species transmission and structure the global virome. We highlight ways to make modelling both accurate and actionable, and discuss the barriers that prevent researchers from translating viral ecology into public health policies that could prevent future pandemics.

Leveraging Partnerships to Maximize Global Health Security Improvements in Guinea, 2015-2019.

In response to the 2014-2016 West Africa Ebola virus disease (EVD) outbreak, a US congressional appropriation provided funds to the US Centers for Disease Control and Prevention (CDC) to support global health security capacity building in 17 partner countries, including Guinea. The 2014 funding enabled CDC to provide more than 300 deployments of personnel to Guinea during the Ebola response, establish a country office, and fund 11 implementing partners through cooperative agreements to support global health security engagement efforts in 4 core technical areas: workforce development, surveillance systems, laboratory systems, and emergency management. This article reflects on almost 4 years of collaboration between CDC and its implementing partners in Guinea during the Ebola outbreak response and the recovery period. We highlight examples of collaborative synergies between cooperative agreement partners and local Guinean partners and discuss the impact of these collaborations in strengthening the above 4 core capacities. Finally, we identify the key elements of the successful collaborations, including communication and information sharing as a core cooperative agreement activity, a flexible funding mechanism, and willingness to adapt to local needs. We hope these observations can serve as guidance for future endeavors seeking to establish strong and effective partnerships between government and nongovernment organizations providing technical and operational assistance.

Assessing health systems in Guinea for prevention and control of priority zoonotic diseases: A One Health approach.

To guide One Health capacity building efforts in the Republic of Guinea in the wake of the 2014-2016 Ebola virus disease (EVD) outbreak, we sought to identify and assess the existing systems and structures for zoonotic disease detection and control. We partnered with the government ministries responsible for human, animal, and environmental health to identify a list of zoonotic diseases - rabies, anthrax, brucellosis, viral hemorrhagic fevers, trypanosomiasis and highly pathogenic avian influenza - as the country's top priorities. We used each priority disease as a case study to identify existing processes for prevention, surveillance, diagnosis, laboratory confirmation, reporting and response across the three ministries. Results were used to produce disease-specific systems "maps" emphasizing linkages across the systems, as well as opportunities for improvement. We identified brucellosis as a particularly neglected condition. Past efforts to build avian influenza capabilities, which had degraded substantially in less than a decade, highlighted the challenge of sustainability. We observed a keen interest across sectors to reinvigorate national rabies control, and given the regional and global support for One Health approaches to rabies elimination, rabies could serve as an ideal disease to test incipient One Health coordination mechanisms and procedures. Overall, we identified five major categories of gaps and challenges: (1) Coordination; (2) Training; (3) Infrastructure; (4) Public Awareness; and (5) Research. We developed and prioritized recommendations to address the gaps, estimated the level of resource investment needed, and estimated a timeline for implementation. These prioritized recommendations can be used by the Government of Guinea to plan strategically for future One Health efforts, ideally under the auspices of the national One Health Platform. This work demonstrates an effective methodology for mapping systems and structures for zoonotic diseases, and the benefit of conducting a baseline review of systemic capabilities prior to embarking on capacity building efforts.

Creating a National Specimen Referral System in Guinea: Lessons From Initial Development and Implementation.

In the wake of the 2014-2016, West Africa Ebola virus disease (EVD) outbreak, the Government of Guinea recognized an opportunity to strengthen its national laboratory system, incorporating capacity and investments developed during the response. The Ministry of Health (MOH) identified creation of a holistic, safe, secure, and timely national specimen referral system as a priority for improved detection and confirmation of priority diseases, in line with national Integrated Disease Surveillance and Response guidelines. The project consisted of two parts, each led by different implementing partners working collaboratively together and with the Ministry of Health: the development and approval of a national specimen referral policy, and pilot implementation of a specimen referral system, modeled on the policy, in three prefectures. This paper describes the successful execution of the project, highlighting the opportunities and challenges of building sustainable health systems capacity during and after public health emergencies, and provides lessons learned for strengthening national capabilities for surveillance and disease diagnosis.