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.

The Effects of Border Shutdowns on the Spread of COVID-19.

OBJECTIVES: At the beginning of the coronavirus disease 2019 (COVID-19) pandemic, some countries imposed entry bans against Chinese visitors. We sought to identify the effects of border shutdowns on the spread of the COVID-19 outbreak. METHODS: We used the synthetic control method to measure the effects of entry bans against Chinese visitors on the cumulative number of confirmed cases using World Health Organization situation reports as the data source. The synthetic control method constructs a synthetic country that did not shut down its borders, but is similar in all other aspects. RESULTS: Six countries that shut down their borders were evaluated. For Australia, the effects of the policy began to appear 4 days after implementation, and the number of COVID-19 cases dropped by 94.4%. The border shutdown policy took around 13.2 days to show positive effects and lowered COVID-19 cases by 91.7% on average by the end of February. CONCLUSIONS: The border shutdowns in early February significantly reduced the spread of the virus. Our findings are informative for future planning of public health policies.

Buying Time with COVID-19 Outbreak Response, Israel.

Israel's response during the containment phase of the COVID-19 outbreak in early 2020 led to a delay in sustained community transmission and effective mitigation. During February-April 2020, a total of 15,981 confirmed cases resulted in 223 deaths. A total of 179,003 persons reported electronically to self-quarantine and were entitled to paid sick leave.

Understanding the impact of state vaccination laws on exemption rates.

PURPOSE OF REVIEW: This review summarizes the current state of school-entry vaccination requirements and related exemption policies in the United States and examines recent changes to these policies. RECENT FINDINGS: With recent infectious disease outbreaks in the United States, there has been heightened awareness on unvaccinated individuals, and the state-level policies that allow individuals to be exempted from school-entry vaccination requirements. Between 2015 and 2017, there have been eleven states that have altered their policies regarding school-entry vaccination requirements and related reporting for which no formal evaluations have been published. One policy change during that period, California SB 277, which became law in 2016, reduced the nonmedical exemption and increased the childhood vaccination coverage rate in that state, though with some evidence of exemption replacement through the use of medical exemptions. Through September 2019, five additional state law changes have been enacted. SUMMARY: The large number of heterogeneous changes to state-level policies for school-entry vaccination requirements in recent years need rigorous evaluation to identify best practices for balancing public health authority and parental autonomy while seeking to achieve the highest level of infectious disease prevention for children.

An Assessment of State Laws Providing Gubernatorial Authority to Remove Legal Barriers to Emergency Response.

Legal Perspectives is aimed at informing healthcare providers, emergency planners, public health practitioners, and other decision makers about important legal issues related to public health and healthcare preparedness and response. The articles describe these potentially challenging topics and conclude with the authors' suggestions for further action. The articles do not provide legal advice. Therefore, those affected by the issues discussed in this column should seek further guidance from legal counsel. Readers may submit topics of interest to the column's editor, Lainie Rutkow, JD, PhD, MPH, at lrutkow@jhu.edu. Governors play a fundamental role in emergency preparedness and can help facilitate rapid responses to emergencies. However, laws that operate successfully under normal circumstances can inadvertently create barriers during emergencies, delaying a timely response. State laws could thus limit, or even prohibit, necessary response efforts. To combat this risk, legislatures have passed emergency powers laws in each state granting governors the authority to declare a state of emergency and to exercise certain emergency powers to meet the needs of the emergency. Researchers conducted a 50-state legal assessment, which identified and examined state laws that give governors the discretion to modify existing laws or create new laws to respond effectively to any type of declared emergency. This article outlines the findings of that assessment, which identified 35 states that explicitly permit governors to suspend or amend both statutes and regulations; 7 states in which governors are permitted to amend regulations during a declared emergency but are not explicitly authorized to modify or remove statutes; and 8 states and the District of Columbia that provide no explicit authority to governors to change statutes or regulations during a declared emergency. The article also provides examples of how this power has been used in the past to demonstrate the utility and scope of this authority in a variety of public health threats.

Good practices and challenges in addressing poliomyelitis and measles in the European Union.

Background: All European Union (EU) and European Economic Area (EEA) Member States have pledged to ensure political commitment towards sustaining the region's poliomyelitis-free status and eliminating measles. However, there remain significant gaps between policy and practice in many countries. This article reports on an assessment conducted for the European Commission that aimed to support improvements in preparedness and response to poliomyelitis and measles in Europe. Methods: A documentary review was complemented by qualitative interviews with professionals working in International and EU agencies, and in at-risk or recently affected EU/EEA Member States (six each for poliomyelitis and measles). Twenty-six interviews were conducted on poliomyelitis and 24 on measles; the data were subjected to thematic analysis. Preliminary findings were then discussed at a Consensus Workshop with 22 of the interviewees and eight other experts. Results: Generic or disease-specific plans exist in the participating countries and cross-border communications during outbreaks were generally reported as satisfactory. However, surveillance systems are of uneven quality, and clinical expertise for the two diseases is limited by a lack of experience. Serious breaches of protocol have recently been reported from companies producing poliomyelitis vaccines, and vaccine coverage rates for both diseases were also sub-optimal. A set of suggested good practices to address these and other challenges is presented. Conclusions: Poliomyelitis and measles should be brought fully onto the policy agendas of all EU/EEA Member States, and adequate resources provided to address them. Each country must abide by the relevant commitments that they have already made.

Estimated Cost to a Restaurant of a Foodborne Illness Outbreak.

OBJECTIVES: Although outbreaks of restaurant-associated foodborne illness occur periodically and make the news, a restaurant may not be aware of the cost of an outbreak. We estimated this cost under varying circumstances. METHODS: We developed a computational simulation model; scenarios varied outbreak size (5 to 250 people affected), pathogen (n = 15), type of dining establishment (fast food, fast casual, casual dining, and fine dining), lost revenue (ie, meals lost per illness), cost of lawsuits and legal fees, fines, and insurance premium increases. RESULTS: We estimated that the cost of a single foodborne illness outbreak ranged from $3968 to $1.9 million for a fast-food restaurant, $6330 to $2.1 million for a fast-casual restaurant, $8030 to $2.2 million for a casual-dining restaurant, and $8273 to $2.6 million for a fine-dining restaurant, varying from a 5-person outbreak, with no lost revenue, lawsuits, legal fees, or fines, to a 250-person outbreak, with high lost revenue (100 meals lost per illness), and a high amount of lawsuits and legal fees ($1 656 569) and fines ($100 000). This cost amounts to 10% to 5790% of a restaurant's annual marketing costs and 0.3% to 101% of annual profits and revenue. The biggest cost drivers were lawsuits and legal fees, outbreak size, and lost revenue. Pathogen type affected the cost by a maximum of $337 000, the difference between a Bacillus cereus outbreak (least costly) and a listeria outbreak (most costly). CONCLUSIONS: The cost of a single foodborne illness outbreak to a restaurant can be substantial and outweigh the typical costs of prevention and control measures. Our study can help decision makers determine investment and motivate research for infection-control measures in restaurant settings.

Challenges of Designing and Implementing High Consequence Infectious Disease Response.

Ebola is a high consequence infectious disease-a disease with the potential to cause outbreaks, epidemics, or pandemics with deadly possibilities, highly infectious, pathogenic, and virulent. Ebola's first reported cases in the United States in September 2014 led to the development of preparedness capabilities for the mitigation of possible rapid outbreaks, with the Centers for Disease Control and Prevention (CDC) providing guidelines to assist public health officials in infectious disease response planning. These guidelines include broad goals for state and local agencies and detailed information concerning the types of resources needed at health care facilities. However, the spatial configuration of populations and existing health care facilities is neglected. An incomplete understanding of the demand landscape may result in an inefficient and inequitable allocation of resources to populations. Hence, this paper examines challenges in implementing CDC's guidance for Ebola preparedness and mitigation in the context of geospatial allocation of health resources and discusses possible strategies for addressing such challenges. (Disaster Med Public Health Preparedness. 2018;12:563-566).

The Joint External Evaluation of Taiwan: The External Evaluators' Perspective.

A team of experts from the Johns Hopkins Center for Health Security conducted an independent external assessment of Taiwan's capabilities under the International Health Regulations 2005 (IHR), using the IHR Joint External Evaluation (JEE) tool adopted by the World Health Organization and the Global Health Security Agenda. In this article we describe the methods and process of the assessment, identify lessons learned, and make recommendations for the government of Taiwan, the JEE process, and the JEE tool.

A Cost-Effectiveness Tool for Informing Policies on Zika Virus Control.

BACKGROUND: As Zika virus continues to spread, decisions regarding resource allocations to control the outbreak underscore the need for a tool to weigh policies according to their cost and the health burden they could avert. For example, to combat the current Zika outbreak the US President requested the allocation of $1.8 billion from Congress in February 2016. METHODOLOGY/PRINCIPAL FINDINGS: Illustrated through an interactive tool, we evaluated how the number of Zika cases averted, the period during pregnancy in which Zika infection poses a risk of microcephaly, and probabilities of microcephaly and Guillain-Barré Syndrome (GBS) impact the cost at which an intervention is cost-effective. From Northeast Brazilian microcephaly incidence data, we estimated the probability of microcephaly in infants born to Zika-infected women (0.49% to 2.10%). We also estimated the probability of GBS arising from Zika infections in Brazil (0.02% to 0.06%) and Colombia (0.08%). We calculated that each microcephaly and GBS case incurs the loss of 29.95 DALYs and 1.25 DALYs per case, as well as direct medical costs for Latin America and the Caribbean of $91,102 and $28,818, respectively. We demonstrated the utility of our cost-effectiveness tool with examples evaluating funding commitments by Costa Rica and Brazil, the US presidential proposal, and the novel approach of genetically modified mosquitoes. Our analyses indicate that the commitments and the proposal are likely to be cost-effective, whereas the cost-effectiveness of genetically modified mosquitoes depends on the country of implementation. CONCLUSIONS/SIGNIFICANCE: Current estimates from our tool suggest that the health burden from microcephaly and GBS warrants substantial expenditures focused on Zika virus control. Our results justify the funding committed in Costa Rica and Brazil and many aspects of the budget outlined in the US president's proposal. As data continue to be collected, new parameter estimates can be customized in real-time within our user-friendly tool to provide updated estimates on cost-effectiveness of interventions and inform policy decisions in country-specific settings.

Funding the Costs of Disease Outbreaks Caused by Non-Vaccination.

While vaccination rates in the United States are high - generally over 90 percent - rates of exemptions have been going up, and preventable diseases coming back. Aside from their human cost and the financial cost of treatment imposed on those who become ill, outbreaks impose financial costs on an already burdened public health system, diverting resources from other areas. This article examines the financial costs of non-vaccination, showing how high they can be and what they include. It makes a case for requiring those who do not vaccinate to cover the costs of outbreak caused by their choice. Such recouping is justified because the choice not to vaccinate can easily be seen as negligent. But even if it is not, that choice involves imposing costs on others, and there are good reasons to require the actors to internalize those costs. The article proposes alternative statutory and regulatory schemes to cover the costs imposed on the public purse, focusing on no-fault mechanisms. We consider both ex ante mechanisms like a tax or a fee that will go into a no-fault fund to cover the costs and ex post mechanisms like a statutory authorization for recoupment of those costs by health officials.

Role of healthcare workers in early epidemic spread of Ebola: policy implications of prophylactic compared to reactive vaccination policy in outbreak prevention and control.

Ebola causes severe illness in humans and has epidemic potential. How to deploy vaccines most effectively is a central policy question since different strategies have implications for ideal vaccine profile. More than one vaccine may be needed. A vaccine optimised for prophylactic vaccination in high-risk areas but when the virus is not actively circulating should be safe, well tolerated, and provide long-lasting protection; a two- or three-dose strategy would be realistic. Conversely, a reactive vaccine deployed in an outbreak context for ring-vaccination strategies should have rapid onset of protection with one dose, but longevity of protection is less important. In initial cases, before an outbreak is recognised, healthcare workers (HCWs) are at particular risk of acquiring and transmitting infection, thus potentially augmenting early epidemics. We hypothesise that many early outbreak cases could be averted, or epidemics aborted, by prophylactic vaccination of HCWs. This paper explores the potential impact of prophylactic versus reactive vaccination strategies of HCWs in preventing early epidemic transmissions. To do this, we use the limited data available from Ebola epidemics (current and historic) to reconstruct transmission trees and illustrate the theoretical impact of these vaccination strategies. Our data suggest a substantial potential benefit of prophylactic versus reactive vaccination of HCWs in preventing early transmissions. We estimate that prophylactic vaccination with a coverage >99% and theoretical 100% efficacy could avert nearly two-thirds of cases studied; 75% coverage would still confer clear benefit (40% cases averted), but reactive vaccination would be of less value in the early epidemic. A prophylactic vaccination campaign for front-line HCWs is not a trivial undertaking; whether to prioritise long-lasting vaccines and provide prophylaxis to HCWs is a live policy question. Prophylactic vaccination is likely to have a greater impact on the mitigation of future epidemics than reactive strategies and, in some cases, might prevent them. However, in a confirmed outbreak, reactive vaccination would be an essential humanitarian priority. The value of HCW Ebola vaccination is often only seen in terms of personal protection of the HCW workforce. A prophylactic vaccination strategy is likely to bring substantial additional benefit by preventing early transmission and might abort some epidemics. This has implications both for policy and for the optimum product profile for vaccines currently in development.

Global Health Security Demands a Strong International Health Regulations Treaty and Leadership From a Highly Resourced World Health Organization.

If the Ebola tragedy of West Africa has taught us anything, it should be that the 2005 International Health Regulations (IHR) Treaty, which gave unprecedented authority to the World Health Organization (WHO) to provide global public health security during public health emergencies of international concern, has fallen severely short of its original goal. After encouraging successes with the 2003 severe acute respiratory syndrome (SARS) pandemic, the intent of the legally binding Treaty to improve the capacity of all countries to detect, assess, notify, and respond to public health threats has shamefully lapsed. Despite the granting of 2-year extensions in 2012 to countries to meet core surveillance and response requirements, less than 20% of countries have complied. Today it is not realistic to expect that these gaps will be solved or narrowed in the foreseeable future by the IHR or the WHO alone under current provisions. The unfortunate failures that culminated in an inadequate response to the Ebola epidemic in West Africa are multifactorial, including funding, staffing, and poor leadership decisions, but all are reversible. A rush by the Global Health Security Agenda partners to fill critical gaps in administrative and operational areas has been crucial in the short term, but questions remain as to the real priorities of the G20 as time elapses and critical gaps in public health protections and infrastructure take precedence over the economic and security needs of the developed world. The response from the Global Outbreak Alert and Response Network and foreign medical teams to Ebola proved indispensable to global health security, but both deserve stronger strategic capacity support and institutional status under the WHO leadership granted by the IHR Treaty. Treaties are the most successful means the world has in preventing, preparing for, and controlling epidemics in an increasingly globalized world. Other options are not sustainable. Given the gravity of ongoing failed treaty management, the slow and incomplete process of reform, the magnitude and complexity of infectious disease outbreaks, and the rising severity of public health emergencies, a recommitment must be made to complete and restore the original mandates as a collaborative and coordinated global network responsibility, not one left to the actions of individual countries. The bottom line is that the global community can no longer tolerate an ineffectual and passive international response system. As such, this Treaty has the potential to become one of the most effective treaties for crisis response and risk reduction worldwide. Practitioners and health decision-makers worldwide must break their silence and advocate for a stronger Treaty and a return of WHO authority.

Compensating the victims of failure to vaccinate: what are the options?

This Article asks whether parents who choose not to vaccinate their child should be liable if that child, at higher risk of infectious disease than vaccinated children, transmits a vaccine-preventable disease to another. The Article argues that a tort remedy in this situation is both desirable and appropriate. It is desirable to assure compensation to the injured child and the family, who should not have to face the insult of financial ruin on top of the injury from the disease. It is appropriate to require that a family that chooses not to vaccinate a child fully internalizes the costs of that decision, and does not pass it on to others. This Article argues there should be a duty to act in the aforementioned situation, since the non-vaccinating parents create a risk. Even if not vaccinating is seen as nonfeasance, there are policy reasons to create an exception to the default rule that there is no duty to act. As an alternative, the Article suggests creating a statutory duty to act. This Article suggests that legal exemptions from school immunization requirements are not a barrier to liability, since the considerations behind those exemptions are separate from tort liability. It addresses the problem of demonstrating causation, and suggests in which types of cases showing causation would be possible, and when proximate cause is capable of extending from an index case to subsequent cases. The Article concludes by addressing potential counter arguments.

Strengthening global health security by developing capacities to deploy medical countermeasures internationally.

In 2014, the United States in partnership with international organizations and nearly 30 partner countries launched the Global Health Security Agenda (GHSA) to accelerate progress to improve prevention, detection, and response capabilities for infectious disease outbreaks that can cause public health emergencies. Objective 9 of the GHSA calls for improved global access to medical countermeasures and establishes as a target the development of national policy frameworks for sending and receiving medical countermeasures from and to international partners during public health emergencies. The term medical countermeasures refers to vaccines, antimicrobials, therapeutics, and diagnostics that address the public health and medical consequences of chemical, biological, radiological, and nuclear events; pandemic influenza; and emerging infectious diseases. They are stockpiled by a few countries to protect their own populations and by international organizations, such as the World Health Organization (WHO), for the international community, typically for recipients with limited resources. However, as observed during the 2009 H1N1 influenza pandemic, legal, regulatory, logistical, and funding barriers slowed the ability of WHO and countries to quickly deploy or receive vaccine. Had the 2009 H1N1 influenza pandemic been more severe, the world would have been ill prepared to cope with the global demand for rapid access to medical countermeasures. This article summarizes the US government efforts to develop a national framework to deploy medical countermeasures internationally and a number of engagements to develop regional and international mechanisms, thus increasing global capacity to respond to public health emergencies.

[Estimation of the financial reserves required by livestock disease compensation funds for rebates in the course of disease outbreaks using the example of Saxony-Anhalt (Germany)]. / Abschätzung der für Kompensationen im Zusammenhang mit Tierseuchenausbrüchen erforderlichen finanziellen Rücklagen einer Tierseuchenkasse am Beispiel Sachsen-Anhalts.

With certain restrictions, the federal states of Germany are obligated to financially compensate livestock owners for animal losses due to livestock diseases. If livestock disease compensation funds demand contributions from livestock owners for certain species in order to pay compensations, the federal states have to pay only one half of the rebate. The remaining 50% has to be financed through reserves of the respective compensation fund built up with the contributions. But there is no reference on how to calculate such financial reserves. Therefore, for the livestock disease compensation fund of Saxony-Anhalt (Germany), an attempt was made to estimate the required reserves.To this end, expert opinions concerning the expected number of affected holdings in potential outbreaks of different diseases were collected. In a conservative approach, assuming these diseases occur in parallel within a single year, overall costs as well as individual costs for altogether 25 categories and subcategories of livestock species were stochastically modeled.The 99.9th percentile of the resulting frequency distribution of the overall costs referred to a financial volume of about 23 million euro. Thus, financial reserves of 11,5 million euro were recommended to the livestock disease compensation fund.