High prevalence of asymptomatic malaria in Forest Guinea: Results from a rapid community survey.

Malaria is endemic in Guinea; however, the extent and role in transmission of asymptomatic malaria are not well understood. In May 2023, we conducted a rapid community survey to determine Plasmodium falciparum (P. falciparum) prevalence among asymptomatic individuals in Middle Guinea (Prefecture Dalaba) and Forest Guinea (Prefecture Guéckédou). In Dalaba, 6 of 239 (2.1%, confidence interval (CI) 0.9-4.8%) individuals tested positive for P. falciparum by a rapid diagnostic test (RDT), while in Guéckédou, 147 of 235 (60.9%, CI 54.5-66.9%) participants tested positive. Asymptomatic malaria needs to be considered more strongly as a driver of transmission when designing control strategies, especially in Forest Guinea and potentially other hyper-endemic settings.

Spatial parasitology and the unmapped human helminthiases.

Helminthiases are a class of neglected tropical diseases that affect at least 1 billion people worldwide, with a disproportionate impact on resource-poor areas with limited disease surveillance. Geospatial methods can offer valuable insights into the burden of these infections, particularly given that many are subject to strong ecological influences on the environmental, vector-borne or zoonotic stages of their life cycle. In this study, we screened 6829 abstracts and analysed 485 studies that use maps to document, infer or predict transmission patterns for over 200 species of parasitic worms. We found that quantitative mapping methods are increasingly used in medical parasitology, drawing on One Health surveillance data from the community scale to model geographic distributions and burdens up to the regional or global scale. However, we found that the vast majority of the human helminthiases may be entirely unmapped, with research effort focused disproportionately on a half-dozen infections that are targeted by mass drug administration programmes. Entire regions were also surprisingly under-represented in the literature, particularly southern Asia and the Neotropics. We conclude by proposing a shortlist of possible priorities for future research, including several neglected helminthiases with a burden that may be underestimated.

Evaluation of the first two Frontline cohorts of the field epidemiology training program in Guinea, West Africa.

BACKGROUND: The 2014-2016 Ebola virus disease outbreak in West Africa revealed weaknesses in the health systems of the three most heavily affected countries, including a shortage of public health professionals at the local level trained in surveillance and outbreak investigation. In response, the Frontline Field Epidemiology Training Program (FETP) was created by CDC in 2015 as a 3-month, accelerated training program in field epidemiology that specifically targets the district level. In Guinea, the first two FETP-Frontline cohorts were held from January to May, and from June to September 2017. Here, we report the results of a cross-sectional evaluation of these first two cohorts of FETP-Frontline in Guinea. METHODS: The evaluation was conducted in April 2018 and consisted of interviews with graduates, their supervisors, and directors of nearby health facilities, as well as direct observation of data reports and surveillance tools at health facilities. Interviews and site visits were conducted using standardized questionnaires and checklists. Qualitative data were coded under common themes and analyzed using descriptive statistics. RESULTS: The evaluation revealed a significant perception of improvement in all assessed skills by the graduates, as well as high levels of self-reported involvement in key activities related to data collection, analysis, and reporting. Supervisors highlighted improvements to systematic and quality case and summary reporting as key benefits of the FETP-Frontline program. At the health facility level, staff reported the training had resulted in improvements to information sharing and case notifications. Reported barriers included lack of transportation, available support personnel, and other resources. Graduates and supervisors both emphasized the importance of continued and additional training to solidify and retain skills. CONCLUSIONS: The evaluation demonstrated a strongly positive perceived benefit of the FETP-Frontline training on the professional activities of graduates as well as the overall surveillance system. However, efforts are needed to ensure greater gender equity and to recruit more junior trainee candidates for future cohorts. Moreover, although improvements to the surveillance system were observed concurrent with the completion of the two cohorts, the evaluation was not designed to directly measure impact on surveillance or response functions. Combined with the rapid implementation of FETP-Frontline around the world, this suggests an opportunity to develop standardized evaluation toolkits, which could incorporate metrics that would directly assess the impact of equitable field epidemiology workforce development on countries' abilities to prevent, detect, and respond to public health threats.

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.

Assessment of electronic disease early warning system for improved disease surveillance and outbreak response in Yemen.

BACKGROUND: Diseases Surveillance is a continuous process of data collection, analysis interpretation and dissemination of information for swift public health action. Recent advances in health informatics have led to the implementation of electronic tools to facilitate such critical disease surveillance processes. This study aimed to assess the performance of the national electronic Disease Early Warning System in Yemen (eDEWS) using system attributes: data quality, timeliness, stability, simplicity, predictive value positive, sensitivity, acceptability, flexibility, and representativeness, based on the Centres for Disease Control & Prevention (US CDC) standard indicators. METHODS: We performed a mixed methods study that occurred in two stages: first, the quantitative data was collected from weekly epidemiological bulletins from 2013 to 2017, all alerts of 2016, and annual eDEWS reports, and then the qualitative method using in-depth interviews was carried out in a convergent strategy. The CDC guideline used to describe the following system attributes: data quality (reporting, and completeness), timeliness, stability, simplicity, predictive value positive, sensitivity, acceptability, flexibility and representativeness. RESULTS: The finding of this assessment showed that eDEWS is a resilient and reliable system, and despite the conflict in Yemen, the system is still functioning and expanding. The response timeliness remains a challenge, since only 21% of all eDEWS alerts were verified within the first 24 h of detection in 2016. However, identified gaps did not affect the system's ability to identify outbreaks in the current fragile situation. Findings show that eDEWS data is representative, since it covers the entire country. Although, eDEWS covers only 37% of all health facilities, this represents 83% of all functional health facilities in all 23 governorates and all 333 districts. CONCLUSION: The quality and timeliness of responses are major challenges to eDEWS' functionality, the eDEWS remains the only system that provides regular data on communicable diseases in Yemen. In particular, public health response timeliness needs improvement.

The path of least resistance: aggressive or moderate treatment?

The evolution of resistance to antimicrobial chemotherapy is a major and growing cause of human mortality and morbidity. Comparatively little attention has been paid to how different patient treatment strategies shape the evolution of resistance. In particular, it is not clear whether treating individual patients aggressively with high drug dosages and long treatment durations, or moderately with low dosages and short durations can better prevent the evolution and spread of drug resistance. Here, we summarize the very limited available empirical evidence across different pathogens and provide a conceptual framework describing the information required to effectively manage drug pressure to minimize resistance evolution.

Governance and Public Health Decision-Making During the COVID-19 Pandemic: A Scoping Review.

Objective: We provide an in-depth understanding of how governance and decision-making during the COVID-19 pandemic has been empirically characterized in the literature to identify gaps in research and highlight areas that require further inquiry. Methods: We searched peer-reviewed publications using empirical data published between Jan 1, 2020 and Jan 31, 2022 in three electronic databases to examine the process of governance and decision-making during the COVID-19 pandemic. Two authors independently screened the records and 24 publications were extracted for the review. Results: Governance is analyzed by its level at national, sub-national, community and by its aspects of process, determinants and performance. While different methodological approaches are used, governance is conceptualized in four ways 1) characteristics and elements, 2) leadership, 3) application of power and 4) models or arrangements of governance. Conclusion: For future pandemic preparedness, there is a need for more empirical research using a unified conceptual approach to governance, which integrates decision-making processes and can guide governance structures and mechanisms across different countries and contexts. We call for more inclusivity in who performs the research on governance and where.

Animal health emergencies: a gender-based analysis for planning and policy.

There has been increasing recognition of gender-based inequity as a barrier to successful policy implementation. This consensus, coupled with an increasing frequency of emergencies in human and animal populations, including infectious disease events, has prompted policy makers to re-evaluate gender-sensitivity in emergency management planning. Seeking to identify key publications relating to gendered impacts and considerations across diverse stakeholders in different types of animal health emergencies, we conducted a non-exhaustive, targeted scoping review. We developed a matrix for both academic and policy literature that separated animal health emergencies into two major categories: humanitarian crises and infectious disease events. We then conducted semi-structured interviews with key animal health experts. We found minimal evidence of explicit gender responsive planning in animal health emergencies, whether humanitarian or infectious disease events. This was particularly salient in Global North literature and policy planning documents. Although there are some references to gender in policy documents pertaining to endemic outbreaks of African swine fever (ASF) in Uganda, most research remains gender blind. Despite this, implicit gendered themes emerged from the literature review and interviews as being direct or indirect considerations of some research, policy, and implementation efforts: representation; gendered exposure risks; economic impact; and unpaid care. Absent from both the literature and our conversations with experts were considerations of mental health, gender-based violence, and intersectional impacts. To remedy the gaps in gender-based considerations, we argue that the intentional inclusion of a gender transformative lens in animal health emergency planning is essential. This can be done in the following ways: (1) collection of disaggregated data (race, gender, sexual orientation, etc.); (2) inclusion of gender experts; and (3) inclusion of primary gendered impacts (minimal representation of women in policy positions, gender roles, economic and nutrition impacts) and secondary gendered impacts (gender-based violence, mental health, additional unpaid care responsibilities) in future planning.

Introducing www.epidemic-em.org: A Collection of Online Resources and Training Materials for Strengthening use of Emergency Operations Centers for Epidemic Response.

OBJECTIVE: This work aimed to demonstrate that a website, www.epidemic-em.org, encompassing "static" resources, and videos, as well as other tools, can be used to strengthen public health emergency management capacity during epidemic response. METHODS: Existing resources were updated and developed for self-directed Emergency Operations Centers' capacity strengthening, in order to encompass current best practices, and to emphasize how public health emergency management concepts can support epidemic response activities. These materials formed the core of the website, launched in June 2020, to which country case studies were added. In 2021, a pilot virtual training program was designed using recorded video lectures and interviews with global experts in addition to the website material, which was delivered to South African responders. RESULTS: The website has been accessed in more than 135 countries, demonstrating widespread reach and interest in online and freely accessible materials to support public health emergency operations. Over 30 people participated in the pilot virtual training, and the evaluation showed improvement in knowledge, confidence in using emergency management concepts for epidemic response, and positive feedback on the virtual modality. CONCLUSIONS: Online tools can expand access to materials and resources for public health emergency management capacity strengthening. Virtual modalities can further serve as a powerful complement, and perhaps replacement, for traditional in-person technical assistance, despite some limitations.

How can gender considerations be better integrated into animal health emergency preparedness and response?

Global and national authorities have not historically approached animal health emergencies through a gendered lens. Yet these events almost certainly have gendered dimensions, such as differential engagement of women or men depending on their culturally accepted or assigned roles for animal care; risk of exposure to zoonoses; and access to emergency resources during response and recovery. Despite the role that gender seems to play with respect to animal health emergencies, little research has been conducted to better understand such dynamics, and little policy has been promulgated to address it in a way that optimizes response while ensuring equitable outcomes. This piece summarizes 3 key themes that emerged from a panel discussion on gender and animal health emergencies at the World Organisation for Animal Health Global Conference on Emergency Management in April 2023. These themes were differential gendered exposure to pathogens; a lack of equitable gender representation in animal health decision-making; and enhancement of pathways for recognizing gender in national and international actions in preparing for, detecting, and responding to animal health emergencies. Beyond increasing opportunities for women to engage in leadership, the animal health and veterinary communities will benefit from connecting practitioners with gender experts to develop more integrative approaches to emergency preparedness and management. Animal health professionals should also advocate for further research to elucidate gender-specific dynamics in human populations in the context of animal emergencies and the promulgation of evidence-based policies. Such transformative efforts will lead to better outcomes for all people who depend on and provide care for animals.

Factors associated with COVID-19 vaccine uptake and hesitancy among healthcare workers in the Democratic Republic of the Congo.

Vaccination is a critical intervention to reduce morbidity and mortality and limit strain on health systems caused by COVID-19. The slow pace of COVID-19 vaccination uptake observed in some settings raises concerns about COVID-19 vaccine hesitancy. The Democratic Republic of the Congo experienced logistical challenges and low uptake at the start of vaccine distribution, leading to one of the lowest overall COVID-19 vaccine coverage rates in the world in 2021. This study assessed the magnitude and associated factors of COVID-19 vaccine uptake among healthcare workers (HCWs) in seven provinces in DRC. We implemented a cross-sectional Knowledge, Attitudes, and Practices (KAP) questionnaire targeting HCWs, administered by trained data collectors in Haut-Katanga, Kasaï Orientale, Kinshasa, Kongo Centrale, Lualaba, North Kivu, and South Kivu provinces. Data were summarized and statistical tests were performed to assess factors associated with vaccine uptake. HCWs across the seven provinces completed the questionnaire (N = 5,102), of whom 46.3% had received at least one dose of COVID-19 vaccine. Older age, being married, being a medical doctor, being a rural resident, and having access to or having previously worked in a COVID-19 vaccination site were all strongly associated with vaccination uptake. Vaccinated individuals most frequently cited protection of themselves, their families, and their communities as motivations for being vaccinated, whereas unvaccinated individuals were most concerned about safety, effectiveness, and risk of severe side effects. The findings suggest an opinion divide between vaccine-willing and vaccine-hesitant HCWs. A multidimensional approach may be needed to increase the acceptability of the COVID-19 vaccine for HCWs. Future vaccine campaign messaging could center around the positive impact of vaccination on protecting friends, family, and the community, and also emphasize the safety and very low risk of adverse effects. These types of messages may further be useful when planning future immunization campaigns with new vaccines.

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.

Provincial Intra-Action Review of the COVID-19 Vaccination Programme: Opportunities to Improve Vaccine Response in North Kivu, Democratic Republic of Congo.

Background: Low levels of COVID-19 vaccination coverage in many countries prompted the use of rapid assessments to characterize barriers to vaccination and identify corrective measures. The World Health Organization recommended the use of intra-action reviews (IARs) to identify best practices, gaps, and lessons learned to make real-time improvements to the COVID-19 vaccination response. Objective: The Democratic Republic of the Congo (DRC) implemented a national IAR in July 2021 that was poorly attended by the provincial health level, where vaccination activities are planned and implemented. To bridge this gap, we proposed sub-national IARs focused on COVID-19 vaccine program implementation at the provincial level. Methods: Using the WHO methodology, we organized a four-day provincial IAR workshop and invited national, provincial and health zone Ministry of Health (MoH) representatives and private and non-governmental organizations involved in the provincial COVID-19 vaccination response. Participants were divided into six groups based on their expertise, affiliation, and role within the health system to assess and identify lessons learned, challenges and the solutions within each of the six technical areas: (1) coordination, planning and monitoring; (2) service delivery; (3) risk communication and community engagement; (4) adverse effects following immunization (AEFI); (5) logistics; (6) and data management, monitoring and evaluation. Results: The first provincial COVID-19 IAR was conducted in Goma, North Kivu, from January 19-22, 2022. A total of 56 participants came from provincial and health zone offices, and non-governmental organizations. Through work group discussions, they identified best practices, challenges, and lessons learned, and made recommendations to improve implementation of vaccination activities and reach coverage targets. Activities were proposed to operationalize recommendations and address challenges to improve the provincial response. Conclusion: This provincial IAR was a useful tool for reviewing progress and areas of improvement, while evaluating aspects of the COVID-19 vaccine rollout. It provided a means to share information with vaccination partners on areas of intervention, tailored to the local context.

Over-diagnosis of malaria by microscopy in the Kilombero Valley, Southern Tanzania: an evaluation of the utility and cost-effectiveness of rapid diagnostic tests.

BACKGROUND: Early and accurate diagnosis of febrile patients is essential to treat uncomplicated malaria cases properly, prevent severe malaria, and avert unnecessary anti-malarial treatments. Improper use of anti-malarials increases the risk of adverse drug reaction and the evolution of drug/parasite resistance. While microscopy is the most common form of malaria diagnosis, concerns over its accuracy have prompted the incorporation of malaria rapid diagnostic tests (RDTs) into many national malaria control programmes. METHODS: Over a three-month period, a direct comparison between microscopy and RDTs was made in a rural, private dispensary in the Kilombero Valley, Morogoro District, southern Tanzania, with the aim of estimating the extent of malaria over-diagnosis and over-treatment with anti-malarials. The study cohort was made up of patients referred by the dispensary's clinician for malaria testing. One hundred percent of patients approached agreed to participate in this study and were then tested using both microscopy and RDTs. Using the results from the comparison of the two tests at this dispensary, the potential cost effectiveness of introducing RDTs to a neighbouring public health centre was estimated on the basis of this centre's past malaria records spanning December 2007 to August 2011. RESULTS: At the private dispensary, the apparent prevalence of malaria was 78% based on microscopy whereas the true prevalence, calculated using RDTs as the gold standard, was estimated at 14%. This discrepancy indicates that when using microscopy as the sole diagnostic test, malaria is being over-diagnosed by approximately a factor of five in this setting. At the public clinic, apparent malaria prevalence based on microscopy was 74%. If similar rates of over-diagnosis are assumed, 5,285 patients of the 6,769 patients positively diagnosed with malaria using microscopy were likely given unnecessary anti-malarials, and their true cause of illness was not addressed. The introduction of RDTs to the public clinic would be highly cost-efficient, with an estimated net saving of over 96 USD/month. CONCLUSIONS: Compared with RDTs, microscopy led to almost four out of five patients being over-diagnosed with malaria in this rural part of Tanzania. A policy that encompasses both the private and public sectors of health care is needed to ensure quality diagnostic testing for febrile patients. With estimated prevalence at 14%, RDT introduction is recommended given WHO findings that RDTs are predicted to be cost-effective in prevalence areas of less than 20%. The use of RDTs in malaria diagnosis would not only reduce government spending but would prove beneficial to ensuring appropriate care and treatment of febrile illness.

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.

National and subnational governance and decision-making processes during the COVID-19 pandemic in Nigeria: an empirical analysis.

Governance of the COVID-19 pandemic required decision-makers to make and implement decisions amidst uncertainty, public pressure and time constraints. However, few studies have attempted to assess these decision-making processes empirically during health emergencies. Thus, we aimed to understand governance, defined as the process of decision-making and implementation of decisions, during the COVID-19 pandemic in Nigeria. We conducted key informant interviews and focus group discussions with national and subnational government officials, civil society organisation (CSO) members, development partners and academic experts. Our study identified several themes on governance and decision-making processes. First, Nigeria established high-level decision-making structures at the federal and state levels, providing clear and integrated multisectoral decision-making mechanism. However, due to the emergence of conflicts between government levels, there is a need to strengthen intergovernmental arrangements. Second, while decision-makers relied on input from academic experts and CSOs, additional efforts are required to engage such stakeholders in decision-making processes, especially during the early stages of health emergencies. Third, Nigeria's previous experiences responding to disease outbreaks aided the overall response, as many capacities and coordination mechanisms for cohesive action were present. Fourth, while decision-makers took a holistic view of scientific, social and economic factors for decision-making, this process was also adaptive to account for rapidly evolving information. Lastly, more efforts are needed to ensure decisions are inclusive, equitable and transparent, and improve overall public trust in governance processes. This study provides insights and identifies opportunities to enhance governance and decision-making processes in health emergency responses, aiding future pandemic preparedness 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.