Integrating multi-wet laboratory diagnostics to study staphylococci in animals in Uganda.

BACKGROUND: Several diagnostic environments in Uganda lack real-time, robust and high-throughput technologies for comprehensive typing of microbes, which is a setback to infectious disease surveillance. This study combined various wet laboratory diagnostics to understand the epidemiology of pathogenic staphylococci isolated from animals in Uganda and the implications for global health security priorities. METHODS: A retrospective study was conducted employing records and pathogenic staphylococci (from animals) archived at the Central Diagnostic Laboratory (CDL), Makerere University, Uganda, between January 2012 and December 2019. The bacteria were speciated by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) and tested for virulence factors [beta lactamases, lecithinase, deoxyribonuclease (DNase), haemolysins] and resistance to ten antimicrobials of clinical and veterinary relevance. Tetracycline and methicillin resistance genes were also tested. RESULTS: The prevalent diseases were mastitis in cattle and skin infections in dogs. Of the 111 staphylococci tested by MALDI-TOF MS, 79 (71.2%) were Staphylococcus aureus, 27 (24.3%) were Staphylococcus pseudintermedius and 5 (4.5%) were Staphylococcus schleiferi. All these strains expressed haemolysins. The prevalence of strains with lecithinase, penicillinase, cephalosporinase and DNase was 35.9% (14/39), 89.7% (35/39), 0.0% (0/39) and 87.2% (34/39), respectively. Staphylococci were primarily resistant to early penicillins (over 80%), tetracycline (57.7%), and chloramphenicol (46.2%). Minimal resistance was noted with cloxacillin (0.0%), ciprofloxacin (9.6%), and cefoxitin (3.8%). The prevalence of multidrug resistance (MDR) was 78.8% for general staphylococci, 82.2% for S. aureus, 73.1% for S. pseudintermedius, and 60.0% for S. schleiferi. Multidrug resistant staphylococci were significantly more prevalent in the cattle isolates than in the dog isolates (P < 0.05). The prevalence of methicillin-resistant staphylococci (MRS) tested by resistance to cefoxitin and mecA carriage was 3.8%. These four strains were all isolated from dog skin infections. The tetK gene was the most predominant (35.4%), followed by tetM (25.0%). CONCLUSION: In resource-constrained settings, the approach of integrated diagnostics promises sustainable disease surveillance and the addressing of current capacity gaps. The emergence of MRS (zoonotic bacteria) in companion animals creates a likelihood of reduced treatment options for related human infections, a threat to global health.

Pandemic preparedness improves national-level SARS-CoV-2 infection and mortality data completeness: a cross-country ecologic analysis.

BACKGROUND: Heterogeneity in national SARS-CoV-2 infection surveillance capabilities may compromise global enumeration and tracking of COVID-19 cases and deaths and bias analyses of the pandemic's tolls. Taking account of heterogeneity in data completeness may thus help clarify analyses of the relationship between COVID-19 outcomes and standard preparedness measures. METHODS: We examined country-level associations of pandemic preparedness capacities inventories, from the Global Health Security (GHS) Index and Joint External Evaluation (JEE), on SARS-CoV-2 infection and COVID-19 death data completion rates adjusted for income. Analyses were stratified by 100, 100-300, 300-500, and 500-700 days after the first reported case in each country. We subsequently reevaluated the relationship of pandemic preparedness on SARS-CoV-2 infection and age-standardized COVID-19 death rates adjusted for cross-country differentials in data completeness during the pre-vaccine era. RESULTS: Every 10% increase in the GHS Index was associated with a 14.9% (95% confidence interval 8.34-21.8%) increase in SARS-CoV-2 infection completion rate and a 10.6% (5.91-15.4%) increase in the death completion rate during the entire observation period. Disease prevention (infections: ß = 1.08 [1.05-1.10], deaths: ß = 1.05 [1.04-1.07]), detection (infections: ß = 1.04 [1.01-1.06], deaths: ß = 1.03 [1.01-1.05]), response (infections: ß = 1.06 [1.00-1.13], deaths: ß = 1.05 [1.00-1.10]), health system (infections: ß = 1.06 [1.03-1.10], deaths: ß = 1.05 [1.03-1.07]), and risk environment (infections: ß = 1.27 [1.15-1.41], deaths: ß = 1.15 [1.08-1.23]) were associated with both data completeness outcomes. Effect sizes of GHS Index on infection completion (Low income: ß = 1.18 [1.04-1.34], Lower Middle income: ß = 1.41 [1.16-1.71]) and death completion rates (Low income: ß = 1.19 [1.09-1.31], Lower Middle income: ß = 1.25 [1.10-1.43]) were largest in LMICs. After adjustment for cross-country differences in data completeness, each 10% increase in the GHS Index was associated with a 13.5% (4.80-21.4%) decrease in SARS-CoV-2 infection rate at 100 days and a 9.10 (1.07-16.5%) decrease at 300 days. For age-standardized COVID-19 death rates, each 10% increase in the GHS Index was with a 15.7% (5.19-25.0%) decrease at 100 days and a 10.3% (- 0.00-19.5%) decrease at 300 days. CONCLUSIONS: Results support the pre-pandemic hypothesis that countries with greater pandemic preparedness capacities have larger SARS-CoV-2 infection and mortality data completeness rates and lower COVID-19 disease burdens. More high-quality data of COVID-19 impact based on direct measurement are needed.

Financing pandemic prevention, preparedness and response: lessons learned and perspectives for future.

BACKGROUND: The attainment of global health security goals and universal health coverage will remain a mirage unless African health systems are adequately funded to improve resilience to public health emergencies. The COVID-19 pandemic exposed the global inequity in accessing medical countermeasures, leaving African countries far behind. As we anticipate the next pandemic, improving investments in health systems to adequately finance pandemic prevention, preparedness, and response (PPPR) promptly, ensuring equity and access to medical countermeasures, is crucial. In this article, we analyze the African and global pandemic financing initiatives and put ways forward for policymakers and the global health community to consider. METHODS: This article is based on a rapid literature review and desk review of various PPPR financing mechanisms in Africa and globally. Consultation of leaders and experts in the area and scrutinization of various related meeting reports and decisions have been carried out. MAIN TEXT: The African Union (AU) has demonstrated various innovative financing mechanisms to mitigate the impacts of public health emergencies in the continent. To improve equal access to the COVID-19 medical countermeasures, the AU launched Africa Medical Supplies Platform (AMSP) and Africa Vaccine Acquisition Trust (AVAT). These financing initiatives were instrumental in mitigating the impacts of COVID-19 and their lessons can be capitalized as we make efforts for PPPR. The COVID-19 Response Fund, subsequently converted into the African Epidemics Fund (AEF), is another innovative financing mechanism to ensure sustainable and self-reliant PPPR efforts. The global initiatives for financing PPPR include the Pandemic Emergency Financing Facility (PEF) and the Pandemic Fund. The PEF was criticized for its inadequacy in building resilient health systems, primarily because the fund ignored the prevention and preparedness items. The Pandemic Fund is also being criticized for its suboptimal emphasis on the response aspect of the pandemic and non-inclusive governance structure. CONCLUSIONS: To ensure optimal financing for PPPR, we call upon the global health community and decision-makers to focus on the harmonization of financing efforts for PPPR, make regional financing mechanisms central to global PPPR financing efforts, and ensure the inclusivity of international finance governance systems.

Can global health security frameworks measure One Health implementation in West Africa?A mixed-methods study.

BACKGROUND: The 2014 outbreak of the Ebola virus disease highlighted the importance of overhauling and transforming healthcare systems in West Africa to improve the ability of individual countries to deal with infectious diseases. As part of this effort, in November 2016 the West African Health Organization (WAHO) began the process of institutionalizing the One Health (OH) approach to health security across the Economic Community of West African States (ECOWAS). The lack of clear metrics and evaluation frameworks to measure the progress of OH implementation in West Africa has been reported as a challenge. Therefore, this study sought to assess and explore whether the existing metrics of global health security frameworks can measure the successful implementation of OH activities, evaluate the progress made since 2016, and identify key areas for improvement in the region. METHOD: The study employed predetermined keywords to select indicators from the International Health Regulations (IHR) Monitoring Frameworks, specifically the State Party Self-Assessment Annual Report (SPAR) and Joint External Evaluation (JEE), deemed relevant to the OH approach. In addition, the COVID-19 performance index scores (severity and recovery) for June 2022 were extracted from the Global COVID-19 Index (GCI). The GCI Recovery Index evaluated the major recovery parameters reported daily to indicate how a country performed on the path to recovery from the COVID-19 pandemic compared to other countries. National documents were also analyzed using categorical variables to assess the performance status of OH platforms across implementing countries. A quantitative analysis of these indicators was conducted and supplemented with qualitative data gathered through interviews with key stakeholders. Between March and April 2022, we conducted 18 key informant interviews with purposively selected representatives from regional governmental agencies and international multilateral agencies, including ECOWAS member states. Interviews were conducted online, transcribed, and analysed following the tenets of thematic analysis. RESULTS: Our quantitative analysis revealed no significant association between the implementation status of OH activities and any of the selected indicators from SPAR and JEE. The descriptive analysis of the JEE scores at the country level revealed that countries with existing OH platforms scored relatively higher on the selected JEE indicators than other countries in the pre-implementation stage. OH implementation status did not significantly affect COVID-19 recovery and severity indices. The qualitative findings with relevant stakeholders revealed noteworthy challenges related to insufficient human capacity, inadequate coordination, and a lack of government funding for the sustainability of OH initiatives. Nonetheless, countries in the ECOWAS region are making progress toward the integration of OH into their health security systems. CONCLUSION: Standardized metrics were used to assess the implementation and efficacy of OH systems in the ECOWAS region. Current indicators for monitoring global health security frameworks lack specificity and fail to comprehensively capture essential OH components, particularly at the sub-national level. To ensure consistency and effectiveness across countries, OH implementation metrics that align with global frameworks such as IHR should be developed.

Piecing together Pakistan's health system and global health security.

Pakistan's health system has a critical role to play in global health security, however, it faces numerous structural and systemic challenges while contributing to international health efforts. Understanding the dynamics of health system is essential for developing effective strategies to prevent, detect, and respond to health emergencies, ensuring regional stability, and the overall global health security This paper documents the strengths and weaknesses of Pakistan's health systems, the impact of the COVID-19 pandemic, challenges such as funding constraints and fragmented healthcare delivery, threats including antimicrobial resistance, and the importance of international collaboration. Anti-microbial particularly multi-drug resistance, food safety in emergencies, surge capacity of the frontline workforce, patient safety at the health care facilities to curtail healthcare associated infections, and strengthening the points of entry are still the areas that need special attention. To optimise the system's performance, governance and accountability mechanisms are necessary to be put in place under the auspices of national public health agency. Pakistan has the potential to transform its health system by addressing these critical areas and improve its preparedness and readiness for any future health emergency of this scale.

Does it matter that standard preparedness indices did not predict COVID-19 outcomes?

A number of scientific publications and commentaries have suggested that standard preparedness indices such as the Global Health Security Index (GHSI) and Joint External Evaluation (JEE) scores did not predict COVID-19 outcomes. To some, the failure of these metrics to be predictive demonstrates the need for a fundamental reassessment which better aligns preparedness measurement with operational capacities in real-world stress situations, including the points at which coordination structures and decision-making may fail. There are, however, several reasons why these instruments should not be so easily rejected as preparedness measures.From a methodological point of view, these studies use relatively simple outcome measures, mostly based on cumulative numbers of cases and deaths at a fixed point of time. A country's "success" in dealing with the pandemic is highly multidimensional - both in the health outcomes and type and timing of interventions and policies - is too complex to represent with a single number. In addition, the comparability of mortality data over time and among jurisdictions is questionable due to highly variable completeness and representativeness. Furthermore, the analyses use a cross-sectional design, which is poorly suited for evaluating the impact of interventions, especially for COVID-19.Conceptually, a major reason that current preparedness measures fail to predict pandemic outcomes is that they do not adequately capture variations in the presence of effective political leadership needed to activate and implement existing system, instill confidence in the government's response; or background levels of interpersonal trust and trust in government institutions and country ability needed to mount fast and adaptable responses. These factors are crucial; capacity alone is insufficient if that capacity is not effectively leveraged. However, preparedness metrics are intended to identify gaps that countries must fill. As important as effective political leadership and trust in institutions, countries cannot be held accountable to one another for having good political leadership or trust in institutions. Therefore, JEE scores, the GHSI, and similar metrics can be useful tools for identifying critical gaps in capacities and capabilities that are necessary but not sufficient for an effective pandemic response.

Contribution of the one health approach to strengthening health security in Uganda: a case study.

BACKGROUND: The One Health approach is key in implementing International Health Regulations (IHR, 2005) and the Global Health Security Agenda (GHSA). Uganda is signatory to the IHR 2005 and in 2017, the country conducted a Joint External Evaluation (JEE) that guided development of the National Action Plan for Health Security (NAPHS) 2019-2023. AIM: This study assessed the contribution of the One Health approach to strengthening health security in Uganda. METHODS: A process evaluation between 25th September and 5th October 2020, using a mixed-methods case study. Participants were Subject Matter Experts (SMEs) from government ministries, departments, agencies and implementing partners. Focus group discussions were conducted for five technical areas (workforce development, real-time surveillance, zoonotic diseases, national laboratory systems and emergency response operations), spanning 18 indicators and 96 activities. Funding and implementation status from the NAPHS launch in August 2019 to October 2020 was assessed with a One Health lens. RESULTS: Full funding was available for 36.5% of activities while 40.6% were partially funded and 22.9% were not funded at all. Majority (65%) of the activities were still in progress, whereas 8.6% were fully implemented and14.2% were not yet done. In workforce development, several multisectoral trainings were conducted including the frontline public health fellowship program, the One Health fellowship and residency program, advanced field epidemiology training program, in-service veterinary trainings and 21 district One Health teams' trainings. Real Time Surveillance was achieved through incorporating animal health events reporting in the electronic integrated disease surveillance and response platform. The national and ten regional veterinary laboratories were assessed for capacity to conduct zoonotic disease diagnostics, two of which were integrated into the national specimen referral and transportation network. Multisectoral planning for emergency response and the actual response to prioritized zoonotic disease outbreaks was done jointly. CONCLUSIONS: This study demonstrates the contribution of 'One Health' implementation in strengthening Uganda's health security. Investment in the funding gaps will reinforce Uganda's health security to achieve the IHR 2005. Future studies could examine the impacts and cost-effectiveness of One Health in curbing prioritized zoonotic disease outbreaks.

Global Health Security amid COVID-19: Tanzanian government's response to the COVID-19 Pandemic.

Several stakeholders assumed different responsibilities for global health security and safety during the COVID-19 pandemic. This study aims to highlight how the Tanzanian government, in collaboration with the international government, non-governmental organizations (NGOs), donor agencies, and stakeholders responded to the pandemic to improve health security and community well-being. This article analyzed secondary data sources from the World Health Organization's (WHO) country report and published reports from Tanzania's government to evaluate vaccine availability and health security. Findings from the data gathered indicate that the initial response from the Tanzanian government concerning the fight against the COVID-19 pandemic was rather abysmal due to the posture of the late President John Pombe Magufuli who at first downplayed the severity and seriousness of the COVID-19 pandemic. However, with the swearing-in of the new President, Samia Suluhu, there was a new approach and strategy instituted to deal with the pandemic which has resulted in the country making headway in containing the pandemic. Data gathered thus, indicate that, as of 11th February 2022, the total number of fully vaccinated individuals in the country as of 12th April 2022 stood at 3,435,513 from the total number of 2,205,815 reported on 11th February 2022. This study thus, concludes that there is a need for a strong stakeholder engagement with high-level political, community, and religious leaders and increased access to COVID-19 vaccination as well as a mass campaign to scale up vaccination activities with adequate resource mobilization and plan.

COVID-19 Response Roles among CDC International Public Health Emergency Management Fellowship Graduates.

Since 2013, the US Centers for Disease Control and Prevention has offered the Public Health Emergency Management Fellowship to health professionals from around the world. The goal of this program is to build an international workforce to establish public health emergency management programs and operations centers in participating countries. In March 2021, all 141 graduates of the fellowship program were invited to complete a web survey designed to examine their job roles and functions, assess their contributions to their country's COVID-19 response, and identify needs for technical assistance to strengthen national preparedness and response systems. Of 141 fellows, 89 successfully completed the survey. Findings showed that fellowship graduates served key roles in COVID-19 response in many countries, used skills they gained from the fellowship, and desired continuing engagement between the Centers for Disease Control and Prevention and fellowship alumni to strengthen the community of practice for international public health emergency management.

Adapting Longstanding Public Health Collaborations between Government of Kenya and CDC Kenya in Response to the COVID-19 Pandemic, 2020-2021.

Kenya's Ministry of Health (MOH) and the US Centers for Disease Control and Prevention in Kenya (CDC Kenya) have maintained a 40-year partnership during which measures were implemented to prevent, detect, and respond to disease threats. During the COVID-19 pandemic, the MOH and CDC Kenya rapidly responded to mitigate disease impact on Kenya's 52 million residents. We describe activities undertaken jointly by the MOH and CDC Kenya that lessened the effects of COVID-19 during 5 epidemic waves from March through December 2021. Activities included establishing national and county-level emergency operations centers and implementing workforce development and deployment, infection prevention and control training, laboratory diagnostic advancement, enhanced surveillance, and information management. The COVID-19 pandemic provided fresh impetus for the government of Kenya to establish a national public health institute, launched in January 2022, to consolidate its public health activities and counter COVID-19 and future infectious, vaccine-preventable, and emerging zoonotic diseases.

Leveraging Lessons Learned from Yellow Fever and Polio Immunization Campaigns during COVID-19 Pandemic, Ghana, 2021.

Ghana is a yellow fever-endemic country and experienced a vaccine-derived polio outbreak in July 2019. A reactive polio vaccination campaign was conducted in September 2019 and preventive yellow fever campaign in November 2020. On March 12, 2020, Ghana confirmed its first COVID-19 cases. During February-August 2021, Ghana received 1,515,450 COVID-19 vaccines through the COVID-19 Vaccines Global Access initiative and other donor agencies. We describe how systems and infrastructure used for polio and yellow fever vaccine deployment and the lessons learned in those campaigns were used to deploy COVID-19 vaccines. During March-August 2021, a total of 1,424,008 vaccine doses were administered in Ghana. By using existing vaccination and health systems, officials in Ghana were able to deploy COVID-19 vaccines within a few months with <5% vaccine wastage and minimal additional resources despite the short shelf-life of vaccines received. These strategies were essential in saving lives in a resource-limited country.

Continuing Contributions of Field Epidemiology Training Programs to Global COVID-19 Response.

We documented the contributions of Field Epidemiology Training Program (FETP) trainees and graduates to global COVID-19 preparedness and response efforts. During February-July 2021, we conducted surveys designed in accordance with the World Health Organization's COVID-19 Strategic Preparedness and Response Plan. We quantified trainee and graduate engagement in responses and identified themes through qualitative analysis of activity descriptions. Thirty-two programs with 2,300 trainees and 7,372 graduates reported near-universal engagement across response activities, particularly those aligned with the FETP curriculum. Graduates were more frequently engaged than were trainees in pandemic response activities. Common themes in the activity descriptions were epidemiology and surveillance, leading risk communication, monitoring and assessment, managing logistics and operations, training and capacity building, and developing guidelines and protocols. We describe continued FETP contributions to the response. Findings indicate the wide-ranging utility of FETPs to strengthen countries' emergency response capacity, furthering global health security.

A case-based approach to teaching epidemic and pandemic-related global health diplomacy and security in African countries.

A challenging concept to teach, few combined courses on epidemic-related global health diplomacy and security exist, and no known courses are currently available that have been exclusively designed for African nationals. In response, the University of California, San Francisco's Center for Global Health Delivery, Diplomacy and Economics (CGHDDE) developed and delivered a workshop for LMIC learners to better understand how politics, policy, finance, governance and security coalesce to influence global health goals and outcomes.

Strengthening global health security - lessons learned from public health England's international health regulations strengthening project.

BACKGROUND: Country experiences of responding to the challenges of COVID-19 in 2020 highlighted how critical it is to have strong, in-country health security capacity. The UK government has invested in health security capacity development through various projects and agencies, including the UK Department of Health and Social Care, whose Global Health Security Programme provides funding to Public Health England (PHE) to implement health security support. This article describes the results and conclusions of the midterm evaluation, undertaken by Itad, of one of Public Health England's global health projects: International Health Regulations Strengthening, which operates across six countries and works with the Africa Centres for Disease Control. It also highlights some of the key lessons learned for the benefit of other agencies moving into supporting national health security efforts. RESULTS: The Itad team found strong evidence that the IHR Project is well aligned with, and responding to, partners' capability strengthening needs and that the three workstreams - systems coordination, workforce development and technical systems strengthening are implementing relevant and appropriate action to support national priorities. The IHR Project is also aligned with and complementary to other relevant UK development assistance although the Project could strengthen the strategic collaboration with WHO, US CDC and other UK government projects in countries. The Itad team also found that the IHR Project could be more effective if the technical assistance activities were accompanied by relevant materials and equipment while maintaining its supportive role. There was evidence of where technical assistance in the form of training and follow-up mentoring had led to improvements in practice and in IHR compliance, but these were not being systematically captured by the Project's routine reporting. CONCLUSIONS: There was good evidence that the project was doing the right things and aligning its work in the right way, with more limited evidence at the time of the midterm evaluation that it was making progress towards achieving the right results.

Successes and challenges of health systems governance towards universal health coverage and global health security: a narrative review and synthesis of the literature.

BACKGROUND: The shift in the global burden of disease from communicable to noncommunicable was a factor in mobilizing support for a broader post-Millennium Development Goals (MDGs) health agenda. To curb these and other global health problems, 193 Member States of the United Nations (UN) became signatories of the Sustainable Development Goals (SDGs) and committed to achieving universal health coverage (UHC) by 2030. In the context of the coronavirus disease 2019 (COVID-19) pandemic, the importance of health systems governance (HSG) is felt now more than ever for addressing the pandemic and continuing to provide essential health services. However, little is known about the successes and challenges of HSG with respect to UHC and health security. This study, therefore, aims to synthesize the evidence and identify successes and challenges of HSG towards UHC and health security. METHODS: We conducted a structured narrative review of studies published through 28 July 2021. We searched the existing literature using three databases: PubMed, Scopus and Web of Science. Search terms included three themes: HSG, UHC and health security. We synthesized the findings using the five core functions of HSG: policy formulation and strategic plans; intelligence; regulation; collaboration and coalition; and accountability. RESULTS: A total of 58 articles were included in the final review. We identified that context-specific health policy and health financing modalities helped to speed up the progress towards UHC and health security. Robust health intelligence, intersectoral collaboration and coalition were also essential to combat the pandemic and ensure the delivery of essential health services. On the contrary, execution of a one-size-fits-all HSG approach, lack of healthcare funding, corruption, inadequate health workforce, and weak regulatory and health government policies were major challenges to achieving UHC and health security. CONCLUSIONS: Countries, individually and collectively, need strong HSG to speed up the progress towards UHC and health security. Decentralization of health services to grass root levels, support of stakeholders, fair contribution and distribution of resources are essential to support the implementation of programmes towards UHC and health security. It is also vital to ensure independent regulatory accreditation of organizations in the health system and to integrate quality- and equity-related health service indicators into the national social protection monitoring and evaluation system; these will speed up the progress towards UHC and health security.

The predictors of COVID-19 mortality among health systems parameters: an ecological study across 203 countries.

BACKGROUND: Health systems responsiveness is the key to addressing infectious disease threats such as pandemics. The paper outlines an assessment of health systems resilience by exploring the association of health systems and Global Health Security (GHS) parameters with case load and mortality resulting from COVID-19 across 203 countries using an ecological design. METHODOLOGY: Correlation analysis was performed to assess the relationship of each of the indicators with COVID 19 cases and deaths per million population. Stepwise multiple regression models were developed to determine the predictors of COVID-19 cumulative cases and deaths per million population separately. RESULTS: Global health security indicators seemed to have a strong association when analyzed individually but those did not necessarily translate into less burden of cases or deaths in the multivariable analysis. The predictors of cumulative deaths per million population included general government expenditure on health as a proportion of general government expenditure, responsiveness of the system to prevent the emergence and release of pathogens and governance related voice and accountability. CONCLUSION: To conclude, health financing parameters and preventive activities with regard to emergence of pathogens were better predictors of cumulative COVID-19 cases and deaths per million population compared to other health systems and global health security indicators.

Evaluating implementation of International Health Regulations core capacities: using the Electronic States Parties Self-Assessment Annual Reporting Tool (e-SPAR) to monitor progress with Joint External Evaluation indicators.

BACKGROUND: The International Health Regulations (IHR) are a legally binding instrument designed to improve Global Health Security by limiting the cross boarder spread of health risks. All 196 signatories to the IHR (2005) are required to report progress towards IHR core capacity implementation through an annual multi-sectoral self-assessment process known as the State Parties Self-Assessment Annual Reporting (SPAR). This mandatory process sits alongside the voluntary, external, peer-reviewed Joint External Evaluations (JEE) as two core components of the IHR monitoring and evaluation framework. JEEs are intended to occur once every 4-5 years following a voluntary request from the member state. This means that interim monitoring of IHR core capacity compliance, can be challenging and additional data sources are required. The outputs of the SPAR process represent one such source. Although the JEE and SPAR tools are intended to be complimentary, there has been no publicly available mapping of JEE indicators to SPAR indicators in order to inform progress on IHR compliance. RESULTS: This paper mapped JEE indicators to SPAR indicators and found a high level of correlation suggesting the SPAR process offers a method for countries and technical assistance programmes to monitor progress on IHR compliance and identify gaps in between JEE visits. However, coverage was not complete, and several gaps were identified most notably in antimicrobial resistance (AMR) and vaccinations. CONCLUSION: Enhancing alignment between JEE and SPAR could offer a more consistent and complete way of assessing compliance with IHR.

Multi-country cross-sectional study of colonization with multidrug-resistant organisms: protocol and methods for the Antibiotic Resistance in Communities and Hospitals (ARCH) studies.

BACKGROUND: Antimicrobial resistance is a global health emergency. Persons colonized with multidrug-resistant organisms (MDROs) are at risk for developing subsequent multidrug-resistant infections, as colonization represents an important precursor to invasive infection. Despite reports documenting the worldwide dissemination of MDROs, fundamental questions remain regarding the burden of resistance, metrics to measure prevalence, and determinants of spread. We describe a multi-site colonization survey protocol that aims to quantify the population-based prevalence and associated risk factors for colonization with high-threat MDROs among community dwelling participants and patients admitted to hospitals within a defined population-catchment area. METHODS: Researchers in five countries (Bangladesh, Chile, Guatemala, Kenya, and India) will conduct a cross-sectional, population-based prevalence survey consisting of a risk factor questionnaire and collection of specimens to evaluate colonization with three high-threat MDROs: extended-spectrum cephalosporin-resistant Enterobacteriaceae (ESCrE), carbapenem-resistant Enterobacteriaceae (CRE), and methicillin-resistant Staphylococcus aureus (MRSA). Healthy adults residing in a household within the sampling area will be enrolled in addition to eligible hospitalized adults. Colonizing isolates of these MDROs will be compared by multilocus sequence typing (MLST) to routinely collected invasive clinical isolates, where available, to determine potential pathogenicity. A colonizing MDRO isolate will be categorized as potentially pathogenic if the MLST pattern of the colonizing isolate matches the MLST pattern of an invasive clinical isolate. The outcomes of this study will be estimates of the population-based prevalence of colonization with ESCrE, CRE, and MRSA; determination of the proportion of colonizing ESCrE, CRE, and MRSA with pathogenic characteristics based on MLST; identification of factors independently associated with ESCrE, CRE, and MRSA colonization; and creation an archive of ESCrE, CRE, and MRSA isolates for future study. DISCUSSION: This is the first study to use a common protocol to evaluate population-based prevalence and risk factors associated with MDRO colonization among community-dwelling and hospitalized adults in multiple countries with diverse epidemiological conditions, including low- and middle-income settings. The results will be used to better describe the global epidemiology of MDROs and guide the development of mitigation strategies in both community and healthcare settings. These standardized baseline surveys can also inform future studies seeking to further characterize MDRO epidemiology globally.

An innovative and integrated model for global outbreak response and research - a case study of the UK Public Health Rapid Support Team (UK-PHRST).

BACKGROUND: Despite considerable institutional experimentation at national and international levels in response to calls for global health security reform, there is little research on organisational models that address outbreak preparedness and response. Created in the aftermath of the 2013-16 West African Ebola epidemic, the United Kingdom's Public Health Rapid Support Team (UK-PHRST) was designed to address critical gaps in outbreak response illuminated during the epidemic, while leveraging existing UK institutional strengths. The partnership between the government agency, Public Health England, and an academic consortium, led by the London School of Hygiene and Tropical Medicine, seeks to integrate outbreak response, operational research and capacity building. We explored the design, establishment and early experiences of the UK-PHRST as one of the first bodies of its kind globally, paying particular attention to governance decisions which enabled them to address their complex mission. METHODS: We conducted a qualitative case study using 19 in-depth interviews with individuals knowledgeable about the team's design and implementation, review of organisational documents, and observations of meetings to analyse the UK-PHRST's creation, establishment and initial 2 years of operations. RESULTS: According to key informants, adopting a triple mandate (response, research and capacity building) established the team as novel in the global epidemic response architecture. Key governance decisions recognised as vital to the model included: structuring the team as a government-academic collaboration which leveraged long-term and complementary UK investments in public health and the higher education sector; adopting a more complex, dual reporting and funding structure to maintain an ethos of institutional balance between lead organisations; supporting a multidisciplinary team of experts to respond early in outbreaks for optimal impact; prioritising and funding epidemic research to influence response policy and practice; and ensuring the team's activities reinforced the existing global health architecture. CONCLUSION: The UK-PHRST aims to enhance global outbreak response using an innovative and integrated model that capitalises on institutional strengths of the partnership. Insights suggest that despite adding complexity, integrating operational research through the government-academic collaboration contributed significant advantages. This promising model could be adopted and adapted by countries seeking to build similar outbreak response and research capacities.

The density paradox: Are densely-populated regions more vulnerable to Covid-19?

The "density paradox" refers to the observation that some highly populated cities and countries have recorded a smaller number of Covid-19 cases than regions that are sparsely populated. We present empirical evidence on the role played by population density in spreading the coronavirus, based on cross-sectional data covering 172 countries (obtained from several sources, including the European Centre for Disease Prevention and Control, the World Bank and the Center for Health Security). The results, obtained by using the techniques of extreme bounds analysis (EBA) and variable addition tests, show that population density has a significantly positive effect on the number of cases but not the number of deaths, as the latter is better explained by measures of preparedness. Plausible explanations are presented for the results to conclude that the "density paradox" is not really a paradox. This paper makes a contribution by shedding more light on a frequently debated issue by using a completely different, and more robust, statistical techniques and by providing results that may be helpful for health and urban planners.