Understanding the secondary outcomes of international travel measures during the covid-19 pandemic: a scoping review of social impact evidence.

BACKGROUND: Assessment of the effective use of international travel measures during the COVID-19 pandemic has focused on public health goals, namely limiting virus introduction and onward transmission. However, risk-based approaches includes the weighing of public health goals against potential social, economic and other secondary impacts. Advancing risk-based approaches thus requires fuller understanding of available evidence on such impacts. METHODS: We conducted a scoping review of existing studies of the social impacts of international travel measures during the COVID-19 pandemic. Applying a standardized typology of travel measures, and five categories of social impact, we searched 9 databases across multiple disciplines spanning public health and the social sciences. We identified 26 studies for inclusion and reviewed their scope, methods, type of travel measure, and social impacts analysed. RESULTS: The studies cover a diverse range of national settings with a strong focus on high-income countries. A broad range of populations are studied, hindered in their outbound or inbound travel. Most studies focus on 2020 when travel restrictions were widely introduced, but limited attention is given to the broader effects of their prolonged use. Studies primarily used qualitative or mixed methods, with adaptations to comply with public health measures. Most studies focused on travel restrictions, as one type of travel measure, often combined with domestic public health measures, making it difficult to determine their specific social impacts. All five categories of social impacts were observed although there was a strong emphasis on negative social impacts including family separation, decreased work opportunities, reduced quality of life, and inability to meet cultural needs. A small number of countries identified positive social impacts such as restored work-life balance and an increase in perceptions of safety and security. CONCLUSIONS: While international travel measures were among the most controversial interventions applied during the COVID-19 pandemic, given their prolonged use and widespread impacts on individuals and populations, there remains limited study of their secondary impacts. If risk-based approaches are to be advanced, involving informed choices between public health and other policy goals, there is a need to better understand such impacts, including their differential impacts across diverse populations and settings.

A closer look at the international health regulations capacities in Lebanon: a mixed method study.

BACKGROUND: Lebanon ratified the International Health Regulations (IHR) (2005) in 2007, and since then, it has been facing complex political deadlocks, financial deterioration, and infectious disease emergencies. We aimed to understand the IHR capacities' scores of Lebanon in comparison to other countries, the IHR milestones and activities in Lebanon, the challenges of maintaining the IHR capacities, the refugee crisis's impact on the development of these capacities; and the possible recommendations to support the IHR performance in Lebanon. METHODS: We used a mixed-method design. The study combined the use of secondary data analysis of the 2020 State Party Self-Assessment Annual Report (SPAR) submissions and qualitative design using semi-structured interviews with key informants. Semi-structured interviews were conducted with nine key informants. The analysis of the data generated was based on inductive thematic analysis. RESULTS: According to SPAR, Lebanon had levels of 4 out of 5 (≤ 80%) in 2020 in the prevention, detection, response, enabling functions, and operational readiness capacities, pertaining that the country was functionally capable of dealing with various events at the national and subnational levels. Lebanon scored more than its neighboring countries, Syria, and Jordan, which have similar contexts of economic crises, emergencies, and refugee waves. Despite this high level of commitment to meeting IHR capacities, the qualitative findings demonstrated several gaps in IHR performance as resource shortage, governance, and political challenges. The study also showed contradictory results regarding the impact of refugees on IHR capacities. Some key informants agreed that the Syrian crisis had a positive impact, while others suggested the opposite. Whether refugees interfere with IHR development is still an area that needs further investigation. CONCLUSION: The study shows that urgent interventions are needed to strengthen the implementation of the IHR capacities in Lebanon. The study recommends 1) reconsidering the weight given to IHR capacities; 2) promoting governance to strengthen IHR compliance; 3) strengthening the multisectoral coordination mechanisms; 4) reinforcing risk communication strategies constantly; 5) mobilizing and advancing human resources at the central and sub-national levels; 6) ensuring sustainable financing; 7) integrating refugees and displaced persons in IHR framework and its assessment tools; 8) acknowledging risk mapping as a pre-requisite to a successful response; and 9) strengthening research on IHR capacities in Lebanon.

Asbestos exposure and asbestosis mortality in Italian cement-asbestos cohorts: Dose-response relationship and the role of competing death causes.

OBJECTIVES: In Italy, asbestos was used intensively until its ban in 1992, which was extended for asbestos cement factories until 1994. The aim of this study was to evaluate the dose-response between asbestos exposure and asbestosis mortality across a pool of Italian occupational cohorts, taking into account the presence of competing risks. METHODS: Cohorts were followed for vital status and the cause of death was ascertained by a linkage with mortality registers. Cause-specific (CS) Cox-regression models were used to evaluate the dose-exposure relationship between asbestosis mortality and the time-dependent cumulative exposure index (CEI) to asbestos. Fine and Gray regression models were computed to assess the effect of competing risks of death. RESULTS: The cohort included 12,963 asbestos cement workers. During the follow-up period (1960-2012), of a total of 6961 deaths, we observed 416 deaths attributed to asbestosis, 879 to lung cancer, 400 to primary pleural cancer, 135 to peritoneal cancer, and 1825 to diseases of the circulatory system. The CS model showed a strong association between CEI and asbestosis mortality. Dose-response models estimated an increasing trend in mortality even below a CEI of 25 ff/mL-years. Lung cancer and circulatory diseases were the main competing causes of death. CONCLUSIONS: Asbestos exposure among Italian asbestos-cement workers has led to a very high number of deaths from asbestosis and asbestos-related diseases. The increasing risk trend associated with excess deaths, even at low exposure levels, suggests that the proposed limit values would not have been adequate to prevent disability and mortality from asbestosis.

Improving global health security through implementation of the National Action Plan for Health Security in Sierra Leone, 2018-2021: lessons from the field.

BACKGROUND: All countries are required to implement International Health Regulations (IHR) through development and implementation of multi-year National Action Plans for Health Security (NAPHS). IHR implementation requires annual operational planning which involves several tools such as NAPHS, State Party Annual Report (SPAR), Joint External Evaluation (JEE) and WHO IHR Benchmarks tool. Sierra Leone has successfully improved IHR capacities across the years through successful annual operational planning using the above tools. We conducted a study to document and share the country's unique approach to implementation of NAPHS. METHODS: This was an observational study where the process of implementing and monitoring NAPHS in Sierra Leone was observed at the national level from 2018 to 2021. Data was obtained through review and analysis of NAPHS annual operational plans, quarterly review reports and annual IHR assessment reports. Available data was supplemented by information from key informants. Qualitative data was captured as notes and analysed for various themes while quantitative data was analyzed mainly for means and proportions. RESULTS: The overall national IHR Joint External Evaluation self-assessment score for human health improved from 44% in 2018 to 51% in 2019 and 57% in 2020. The score for the animal sector improved from 32% in 2018 to 43% in 2019 and 52% in 2020. A new JEE tool with new indicators was used in 2021 and the score for both human and animal sectors declined slightly to 51%. Key enablers of success included strong political commitment, whole-of-government approach, annual assessments using JEE tool, annual operational planning using WHO IHR Benchmarks tool and real time online monitoring of progress. Key challenges included disruption created by COVID-19 response, poor health infrastructure, low funding and inadequate health workforce. CONCLUSION: IHR annual operational planning and implementation using evidence-based data and tools can facilitate strengthening of IHR capacity and should be encouraged.

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.

COVID-19 in the Americas: the role of collaborating centers in understanding lessons and best practices in pandemic preparedness and response.

COVID-19 exposed major gaps in global, regional, state, and local responses to public health emergencies. In preparation for the WHA Special Session to consider the benefits of developing an international instrument on pandemic preparedness, the O'Neill Institute in partnership with Foundation for the National Institutes of Health convened 30 of the world's leading authorities on global health law, financing, biomedical science, implementation, and emergency response along with leaders from prominent international organizations. This meeting was followed by regional consultations convened in Latin America-Caribbean, Africa, and Southeast Asia. These high-level expert consultations generated in-depth discussions on weaknesses and persisting gaps in global pandemic preparedness and what a new international agreement might include to address them. Regional intergovernmental organizations like PAHO can work closely with related multilateral development banks to develop financial instruments that can smooth systemic economic disruption; and regional centers of research and manufacturing excellence can offer a strong front line for producing medicines and vaccines rapidly during a pandemic. With our research focused on the regional response to COVID-19 we are able to look at country responses individually and collectively to see how Latin America - Caribbean countries can capitalize and leverage their regional connections to strengthen their pandemic preparedness and response. By identifying existing gaps and examining the responses and approaches taken by PAHO, we can better understand the role of international and regional organizations and their collaborating centers in preparing and responding to pandemics.

La COVID-19 expuso grandes brechas en las respuestas locales, nacionales, regionales y mundiales a las emergencias de salud pública. En preparación para la reunión extraordinaria de la Asamblea Mundial de la Salud para considerar los beneficios de elaborar un instrumento internacional sobre la preparación frente a las pandemias, el Instituto O'Neill, en colaboración con la Fundación para los Institutos Nacionales de Salud, convocó a 30 de las principales autoridades mundiales en materia de derecho, financiamiento, ciencia biomédica, implementación y respuesta a emergencias de salud, así como a líderes de organizaciones internacionales prominentes. A esta reunión le siguieron consultas regionales convocadas en América Latina y el Caribe, África y el sudeste asiático. Estas consultas con expertos de alto nivel generaron debates en profundidad acerca de las debilidades y brechas persistentes en la preparación frente a las pandemias y qué podría incluirse en un nuevo acuerdo internacional sobre cómo abordarlas. Las organizaciones intergubernamentales regionales como la Organización Panamericana de la Salud pueden trabajar en estrecha colaboración con los bancos multilaterales de desarrollo relacionados para elaborar instrumentos financieros que puedan aliviar las perturbaciones económicas sistémicas; y los centros regionales de excelencia en investigación y producción pueden formar una sólida primera línea de acción para producir medicamentos y vacunas rápidamente durante una pandemia. Con esta investigación centrada en la respuesta regional a la COVID-19, podemos analizar las respuestas de los países de forma individual y colectiva para observar la manera en que América Latina y el Caribe pueden capitalizar y aprovechar sus conexiones regionales para fortalecer su preparación y respuesta frente a una pandemia. Al determinar cuáles son las brechas existentes y examinar las respuestas y los enfoques adoptados por la OPS, podemos comprender mejor el papel de las organizaciones regionales e internacionales y sus centros colaboradores en la preparación y respuesta frente a las pandemias.

A COVID-19 expôs grandes lacunas nas respostas globais, regionais, estaduais e locais a emergências de saúde pública. Nos preparativos para a Sessão Especial da Assembleia Mundial da Saúde para avaliar os benefícios de desenvolver um instrumento internacional de preparação para pandemias, o Instituto O'Neill, em parceria com a Fundação para os Institutos Nacionais de Saúde, reuniu 30 das principais autoridades mundiais em direito sanitário global, financiamento, ciências biomédicas, implementação e resposta a emergências, além de líderes de organizações internacionais proeminentes. Essa reunião foi seguida por consultas regionais convocadas na América Latina/Caribe, na África e no sudeste da Ásia. Essas consultas com especialistas de alto nível geraram discussões minuciosas sobre os pontos fracos e as lacunas persistentes na preparação global para pandemias e o que poderia ser incluído em um novo acordo internacional para resolvê-los. Organizações intergovernamentais regionais, como a OPAS, podem trabalhar em estreita colaboração com os bancos multilaterais de desenvolvimento para desenvolver instrumentos financeiros capazes de atenuar a ruptura econômica sistêmica; por outro lado, centros regionais de excelência em pesquisa e fabricação podem oferecer uma linha de frente expressiva para a rápida produção de medicamentos e vacinas durante uma pandemia. Usando os dados da nossa pesquisa sobre a resposta regional à COVID-19, podemos analisar as respostas dos países de forma individual e coletiva para avaliar como os países da América Latina e do Caribe podem capitalizar e alavancar suas conexões regionais para fortalecer sua preparação e resposta à pandemia. Ao identificar lacunas existentes e analisar as respostas e abordagens adotadas pela OPAS, podemos compreender melhor o papel das organizações internacionais e regionais e de seus centros colaboradores na preparação e resposta a pandemias.

[COVID-19 in Latin America: inequalities and response capacity of health systems to health emergenciesCOVID-19 en América Latina: desigualdades y capacidad de respuesta de los sistemas de salud ante emergencias de salud]. / Covid-19 na América Latina: desigualdades e capacidades de resposta dos sistemas de saúde a emergências sanitárias.

Objective: To identify correlations between COVID-19, demographic and socioeconomic characteristics, and the capacity of Latin American health systems to respond to health emergencies. Method: An ecological study was performed using secondary data from 20 Latin American countries regarding incidence, mortality, testing and vaccination coverage for covid-19 from 2020 to 2021 as well as demographic and socioeconomic indicators. The preparedness of countries to respond to health emergencies was explored based on the 2019 State Party Self-Assessment Annual Report on the implementation of the International Health Regulations (IHR). Statistical analyses were performed using the Spearman correlation test (rho). Results: A high positive correlation was noted between gross domestic product per capita and the human development index with the incidence of COVID-19, testing, and vaccination coverage; and between the proportion of elderly population and vaccination coverage. No correlations were identified between the covid-19 indicators and previous IHR implementation capacities. Conclusions: The lack of correlation between indicators related to COVID-19 and the ability to implement the IHR may reflect limitations of the indicators used or of the IHR monitoring tool as an instrument that induces the preparedness of countries to face health emergencies. The results suggest the importance of structural conditioning factors and the need for longitudinal, comparative, and qualitative studies to understand the factors that influenced the response of countries to COVID-19.

Objetivo: Determinar las posibles correlaciones entre la COVID-19, las características demográficas y socioeconómicas, y la capacidad de los sistemas de salud latinoamericanos para responder a emergencias de salud. Método: Se realizó un estudio ecológico con datos secundarios de 20 países latinoamericanos sobre la incidencia, la mortalidad, las pruebas y la cobertura de vacunación relativas a la COVID-19 en el período 2020-2021, y con información demográfica y socioeconómica. Se exploró la preparación de los países para responder a emergencias de salud a partir del Informe Anual de Autoevaluación de los Estados Miembros de la Organización Mundial de la Salud del 2019 sobre la implementación del Reglamento Sanitario Internacional (RSI). Los análisis estadísticos se realizaron con la prueba de correlación (ro) de Spearman. Resultados: Se observó una alta correlación positiva del producto interno bruto per cápita y del índice de desarrollo humano con la incidencia, las pruebas y la cobertura de vacunación respecto a la COVID-19, así como de la proporción de personas mayores en la población con la cobertura de vacunación. No se observó ninguna correlación entre los indicadores de COVID-19 y la capacidad previa de implementación del RSI. Conclusiones: La falta de correlación entre los indicadores relativos a la COVID-19 y la capacidad de implementación del RSI puede deberse a limitaciones de los indicadores utilizados o del mecanismo de seguimiento del RSI como instrumento inductor de la preparación de los países para enfrentar emergencias de salud. Los resultados sugieren la importancia de los factores condicionantes estructurales y la necesidad de realizar estudios longitudinales, comparativos y cualitativos para determinar los factores que influyeron en la respuesta de los países a la COVID-19.

[The World Health Organization: Project of novels in the field of controlling international medical sanitary regulations].

The article considers draft of new edition of the International Health Regulations. The possible risks associated with changing of the document are evaluated from perspective of member countries, in whose territories occur or supposedly occur emergency situations in field of public health having international importance.

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.

Compulsory Licensing of Pharmaceuticals in High-Income Countries: A Comparative Analysis.

Policy Points Pharmaceutical trade organizations and media outlets in the United States regularly point to compulsory licensing-or even its threat-as the mechanism that peer countries use to control the price of prescription drugs. Our comparative analysis shows that compulsory licensing is not frequently employed in high-income countries outside the United States as a direct response to drug prices. When its use is threatened, a license is rarely issued and even less often does it lead to a price discount. Accordingly, compulsory licensing is unlikely to contribute to price discrepancies between the United States and other developed nations. In fact, of the 21 compulsory licensing petitions we identified outside the United States, over one-third were made by pharmaceutical companies themselves and only three were threatened by a government authority. CONTEXT: Compulsory licensing is a practice whereby national authorities can license a third party to produce a patented product, such as a pharmaceutical drug, effectively enabling the production of a generic before the original patent expires. The policy was designed-and has historically been used-to improve access to essential medicines in low-income countries and during public health crises. Although it was not intended to impact drug prices directly, the threat of compulsory licensing may indeed contribute to lower drug prices in high-income countries outside the United States. Our study sought to determine the plausibility of this claim. METHODS: We compiled a comprehensive database of compulsory licensing episodes in the United States and 17 comparator nations over the 20 years following the 2001 Doha Declaration, and we recorded the motivation and outcome of each instance. Our search began with publicly available reports compiled by organizations specializing in pharmaceutical intellectual property, expanded to a query of legal proceedings in Westlaw, and concluded with a comprehensive literature review on PubMed. FINDINGS: This strategy yielded 45 unique episodes of compulsory licensing, 24 in the United States and 21 outside. A minority (24%) of petitions outside the United States were motivated by high prices, and in all countries, only three cases were clearly associated with a price discount. CONCLUSIONS: We found no evidence to suggest that compulsory licensing is either frequently threatened or successfully implemented by countries outside the United States to secure price discounts for the most expensive pharmaceuticals, those that are newly patented and just entering the market.

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.

An ecological study on the association between International Health Regulations (IHR) core capacity scores and the Universal Health Coverage (UHC) service coverage index.

BACKGROUND: The pandemic situation due to COVID-19 highlighted the importance of global health security preparedness and response. Since the revision of the International Health Regulations (IHR) in 2005, Joint External Evaluation (JEE) and States Parties Self-Assessment Annual Reporting (SPAR) have been adopted to track the IHR implementation stage in each country. While national IHR core capacities support the concept of Universal Health Coverage (UHC), there have been limited studies verifying the relationship between the two concepts. This study aimed to investigate empirically the association between IHR core capacity scores and the UHC service coverage index. METHOD: JEE score, SPAR score and UHC service coverage index data from 96 countries were collected and analyzed using an ecological study design. The independent variable was IHR core capacity scores, measured by JEE 2016-2019 and SPAR 2019 from the World Health Organization (WHO) and the dependent variable, UHC service coverage index, was extracted from the 2019 UHC monitoring report. For examining the association between IHR core capacities and the UHC service coverage index, Spearman's correlation analysis was used. The correlation between IHR core capacities and UHC index was demonstrated using a scatter plot between JEE score and UHC service coverage index, and the SPAR score and UHC service coverage index were also presented. RESULT: While the correlation value between JEE and SPAR was 0.92 (p < 0.001), the countries' external evaluation scores were lower than their self-evaluation scores. Some areas such as available human resources and points of entry were mismatched between JEE and SPAR. JEE was associated with the UHC score (r = 0.85, p < 0.001) and SPAR was also associated with the UHC service coverage index (r = 0.81, p < 0.001). The JEE and SPAR scores showed a significant positive correlation with the UHC service coverage index after adjusting for several confounding variables. CONCLUSION: The study result supports the premise that strengthening national health security capacities would in turn contribute to the achievement of UHC. With the help of the empirical result, it would further guide each country for better implementation of IHR.

Legal issues and challenges in addressing the coronavirus outbreak on large cruise ships: A critical examination of port state measures.

International cruises have drawn worldwide attention since the outbreak of coronavirus (COVID-19). This article first examines the legal issues, challenges and impact of the pandemic on large cruise ships, like the Diamond Princess, and then probes into corresponding pandemic preventive measures which port states employ. A State is obliged under the International Health Regulations 2005 (IHR) to grant foreign cruise ships free pratique, but there is an exception when public health emergencies of international concern occur. Therefore, this article argues that a port state is not obliged to allow foreign cruise ships to dock at its port at the cost of its domestic public health safety. Regarding the Diamond Princess, the Japanese government has undertaken pandemic preventive measures upon passengers on board the ship and complied with its domestic laws, including the Japanese Quarantine Act. This article further evaluates whether a port state's pandemic preventive measures concerning cruise ships are appropriate from the perspective of law. More importantly, it is necessary to consider the characteristics and specialities of international cruise ships to improve future pandemic preventive measures against large passenger ships and cruise passengers.

A virus unites the world while national border closures divide it: Epidemiologic, legal, and political analysis on border closures during COVID-19.

This article critically examines the use of national border closures at the outset of the COVID-19 pandemic. After explaining why targeted border closures generally do not work and how they violated international law at the time, we examine the unprecedented case of total border closures. Positing that since the current instruments and institutions of global health governance did not anticipate this phenomenon, the legality of total border closures rests on less certain grounds. Then, after asking why nearly every government implemented some form of border closure in March 2020 if neither science nor law provided adequate motivation for their use, we conclude that in the face of a global health emergency, border closures represent an opportunity for political leaders to show determined action, redirect blame to other jurisdictions, and reinforce nationalism. We proceed to argue that both targeted and total border closures have profound legal, epidemiological, and political significance as performances that contradict global realities while undermining notions of global solidarity. Such political theatre means that citizens must weigh these consequences against any perceived benefits of border closures as they would any other politically driven government action, and contest and challenge them appropriately. Citizens must not unduly defer to scientists or lawyers on early COVID-19 border closures because these were primarily political-not scientific or legal-decisions. In this vein, we conclude with some guiding political considerations for scrutinizing government decisions to close borders and observations for the future of global health cooperation during infectious disease outbreaks.

Performance and impact of disposable and reusable respirators for healthcare workers during pandemic respiratory disease: a rapid evidence review.

OBJECTIVES: To synthesise evidence concerning the range of filtering respirators suitable for patient care and guide the selection and use of different respirator types. DESIGN: Comparative analysis of international standards for respirators and rapid review of their performance and impact in healthcare. DATA SOURCES: Websites of international standards organisations, Medline and Embase, hand-searching of references and citations. STUDY SELECTION: Studies of healthcare workers (including students) using disposable or reusable respirators with a range of designs. We examined respirator performance, clinician adherence and performance, comfort and impact, and perceptions of use. RESULTS: We included standards from eight authorities across Europe, North and South America, Asia and Australasia and 39 research studies. There were four main findings. First, international standards for respirators apply across workplace settings and are broadly comparable across jurisdictions. Second, effective and safe respirator use depends on proper fitting and fit testing. Third, all respirator types carry a burden to the user of discomfort and interference with communication which may limit their safe use over long periods; studies suggest that they have little impact on specific clinical skills in the short term but there is limited evidence on the impact of prolonged wearing. Finally, some clinical activities, particularly chest compressions, reduce the performance of filtering facepiece respirators. CONCLUSION: A wide range of respirator types and models is available for use in patient care during respiratory pandemics. Careful consideration of performance and impact of respirators is needed to maximise protection of healthcare workers and minimise disruption to care.

A pandemic treaty, revised international health regulations, or both?

BACKGROUND: A special session of the World Health Assembly (WHA) will be convened in late 2021 to consider developing a WHO convention, agreement or other international instrument on pandemic preparedness and response - a so-called 'Pandemic Treaty'. Consideration is given to this treaty as well as to reform of the International Health Regulations (IHR) as our principal governing instrument to prevent and mitigate future pandemics. MAIN BODY: Reasons exist to continue to work with the IHR as our principal governing instrument to prevent and mitigate future pandemics. All WHO member states are party to it. It gives the WHO the authority to oversee the collection of surveillance data and to issue recommendations on trade and travel advisories to control the spread of infectious diseases, among other things. However, the limitations of the IHR in addressing the deep prevention of future pandemics also must be recognized. These include a lack of a regulatory framework to prevent zoonotic spillovers. More advanced multi-sectoral measures are also needed. At the same time, a pandemic treaty would have potential benefits and drawbacks as well. It would be a means of addressing the gross inequity in global vaccine distribution and other gaps in the IHR, but it would also need more involvement at the negotiation table of countries in the Global South, significant funding, and likely many years to adopt. CONCLUSIONS: Reform of the IHR should be undertaken while engaging with WHO member states (and notably those from the Global South) in discussions on the possible benefits, drawbacks and scope of a new pandemic treaty. Both options are not mutually exclusive.

Managing borders during public health emergencies of international concern: a proposed typology of cross-border health measures.

BACKGROUND: The near universal adoption of cross-border health measures during the COVID-19 pandemic worldwide has prompted significant debate about their effectiveness and compliance with international law. The number of measures used, and the range of measures applied, have far exceeded previous public health emergencies of international concern. However, efforts to advance research, policy and practice to support their effective use has been hindered by a lack of clear and consistent definition. RESULTS: Based on a review of existing datasets for cross-border health measures, such as the Oxford Coronavirus Government Response Tracker and World Health Organization Public Health and Social Measures, along with analysis of secondary and grey literature, we propose six categories to define measures more clearly and consistently - policy goal, type of movement (travel and trade), adopted by public or private sector, level of jurisdiction applied, stage of journey, and degree of restrictiveness. These categories are then brought together into a proposed typology that can support research with generalizable findings and comparative analyses across jurisdictions. Addressing the current gaps in evidence about travel measures, including how different jurisdictions apply such measures with varying effects, in turn, enhances the potential for evidence-informed decision-making based on fuller understanding of policy trade-offs and externalities. Finally, through the adoption of standardized terminology and creation of an agreed evidentiary base recognized across jurisdictions, the typology can support efforts to strengthen coordinated global responses to outbreaks and inform future efforts to revise the WHO International Health Regulations (2005). CONCLUSIONS: The widespread use of cross-border health measures during the COVID-19 pandemic has prompted significant reflection on available evidence, previous practice and existing legal frameworks. The typology put forth in this paper aims to provide a starting point for strengthening research, policy and practice.

Strengthening the WHO in the pandemic era by removing a persistent structural defect in financing.

BACKGROUND: The WHO's success in its vital role is constrained by inadequate financial support from member states and overreliance on earmarked voluntary contributions, which erodes autonomy. The agency's broad functions, including coordination among 194 members, cannot be performed by any other entity. However, despite experts' well-articulated concerns that the agency's legitimacy and authority in global health matters have been undermined, a decades-long freeze on member assessments means that WHO priorities are disproportionately influenced by a few powerful donors. A STRUCTURAL DEFECT: To overcome inertia in addressing well-known limitations, it may be helpful to consider the weaknesses in WHO's financing mechanism as a persistent structural defect. This perspective strengthens the focus on corrections needed to remove the defect. In our view, the main features of the structural defect are the self-imposed constraints that foster the perception-if not the reality-that the agency's legitimacy is compromised. These constraints include WHO's inadequate level of financing; lack of direct control over 80% of its funds; and unbalanced participation, such that over 60% of financing originates from only 9 donors. With renewed commitment, however, member countries can remove these constraints. REMOVING THE STRUCTURAL DEFECT: To meaningfully strengthen structural integrity of the financing mechanism, restore WHO's autonomy, and minimize concerns about wealthy-donor supremacy, it will be necessary to define specific requirements and implement restrictions on financial contributions. We make five recommendations, including tripling total financing; ensuring that 70% or more of financial support derives from member assessments; limiting contributions from individual members to a maximum of 4% of total WHO financing; and limiting donations from individual partners to a maximum of 3% of total WHO financing (1% for earmarked donations). Although some might consider these measures impractical, they are justified by the magnitude of the crises the world faces, by member states' increased economic strength in recent decades, and by the importance of shielding the WHO's financing structure from perceived neocolonialism. This necessary step calls for an adjustment of priorities: the higher level of assessed contribution-from nearly all members regardless of wealth-required to reach the proposed targets would still represent only a small fraction of most members' annual military expenditures. CONCLUSION: The COVID-19 pandemic, with its devastating toll on human life and global economic stability, presents an opportunity for reflection and refocusing. Realigning WHO's financial structure to its founders' vision, as proposed here, would likely safeguard both the agency's autonomy and member states' trust, while alleviating concerns about undue influence from powerful donors. Removing the persistent structural defect in financing would empower WHO to lead and coordinate global response to meet the inevitable challenges of the coming decades.

Trust, risk, and the challenge of information sharing during a health emergency.

Information sharing is a critical element of an effective response to infectious disease outbreaks. The international system of coordination established through the World Health Organization via the International Health Regulations largely relies on governments to communicate timely and accurate information about health risk during an outbreak. This information supports WHO's decision making process for declaring a public health emergency of international concern. It also aides the WHO to work with governments to coordinate efforts to contain cross-border outbreaks.Given the importance of information sharing by governments, it is not surprising that governments that withhold or delay sharing information about outbreaks within their borders are often condemned by the international community for non-compliance with the International Health Regulations. The barriers to rapid and transparent information sharing are numerous. While governments must be held accountable for delaying or withholding information, in many cases non-compliance may be a rational response to real and perceived risks rather than a problem of technical incapacity or a lack of political commitment. Improving adherence to the International Health Regulations will require a long-term process to build trust that incorporates recognizing and mitigating the potential and perceived risks of information sharing.

A survey of International Health Regulations National Focal Points experiences in carrying out their functions.

BACKGROUND: The 2005 International Health Regulations (IHR (2005)) require States Parties to establish National Focal Points (NFPs) responsible for notifying the World Health Organization (WHO) of potential events that might constitute public health emergencies of international concern (PHEICs), such as outbreaks of novel infectious diseases. Given the critical role of NFPs in the global surveillance and response system supported by the IHR, we sought to assess their experiences in carrying out their functions. METHODS: In collaboration with WHO officials, we administered a voluntary online survey to all 196 States Parties to the IHR (2005) in Africa, Asia, Europe, and South and North America, from October to November 2019. The survey was available in six languages via a secure internet-based system. RESULTS: In total, 121 NFP representatives answered the 56-question survey; 105 in full, and an additional 16 in part, resulting in a response rate of 62% (121 responses to 196 invitations to participate). The majority of NFPs knew how to notify the WHO of a potential PHEIC, and believed they have the content expertise to carry out their functions. Respondents found training workshops organized by WHO Regional Offices helpful on how to report PHEICs. NFPs experienced challenges in four critical areas: 1) insufficient intersectoral collaboration within their countries, including limited access to, or a lack of cooperation from, key relevant ministries; 2) inadequate communications, such as deficient information technology systems in place to carry out their functions in a timely fashion; 3) lack of authority to report potential PHEICs; and 4) inadequacies in some resources made available by the WHO, including a key tool - the NFP Guide. Finally, many NFP representatives expressed concern about how WHO uses the information they receive from NFPs. CONCLUSION: Our study, conducted just prior to the COVID-19 pandemic, illustrates key challenges experienced by NFPs that can affect States Parties and WHO performance when outbreaks occur. In order for NFPs to be able to rapidly and successfully communicate potential PHEICs such as COVID-19 in the future, continued measures need to be taken by both WHO and States Parties to ensure NFPs have the necessary authority, capacity, training, and resources to effectively carry out their functions as described in the IHR.