Accelerating Diagnostics for Pandemic Preparedness.

Transforming or tinkering: the world remains unprepared for the next pandemic threat

The Global Fund: replenishment and future-proofing

The COVID-19 pandemic highlighted gaps in health surveillance systems, disease prevention, and treatment globally. Among the many factors that might have led to these gaps is the issue of the financing of national health systems, especially in low-income and middle-income countries (LMICs), as well as a robust global system for pandemic preparedness. We aimed to provide a comparative assessment of global health spending at the onset of the pandemic; characterise the amount of development assistance for pandemic preparedness and response disbursed in the first 2 years of the COVID-19 pandemic; and examine expectations for future health spending and put into context the expected need for investment in pandemic preparedness. In this analysis of global health spending between 1990 and 2021, and prediction from 2021 to 2026, we estimated four sources of health spending: development assistance for health (DAH), government spending, out-of-pocket spending, and prepaid private spending across 204 countries and territories. We used the Organisation for Economic Co-operation and Development (OECD)'s Creditor Reporting System (CRS) and the WHO Global Health Expenditure Database (GHED) to estimate spending. We estimated development assistance for general health, COVID-19 response, and pandemic preparedness and response using a keyword search. Health spending estimates were combined with estimates of resources needed for pandemic prevention and preparedness to analyse future health spending patterns, relative to need. In 2019, at the onset of the COVID-19 pandemic, US$9·2 trillion (95% uncertainty interval [UI] 9·1-9·3) was spent on health worldwide. We found great disparities in the amount of resources devoted to health, with high-income countries spending $7·3 trillion (95% UI 7·2-7·4) in 2019; 293·7 times the $24·8 billion (95% UI 24·3-25·3) spent by low-income countries in 2019. That same year, $43·1 billion in development assistance was provided to maintain or improve health. The pandemic led to an unprecedented increase in development assistance targeted towards health; in 2020 and 2021, $1·8 billion in DAH contributions was provided towards pandemic preparedness in LMICs, and $37·8 billion was provided for the health-related COVID-19 response. Although the support for pandemic preparedness is 12·2% of the recommended target by the High-Level Independent Panel (HLIP), the support provided for the health-related COVID-19 response is 252·2% of the recommended target. Additionally, projected spending estimates suggest that between 2022 and 2026, governments in 17 (95% UI 11-21) of the 137 LMICs will observe an increase in national government health spending equivalent to an addition of 1% of GDP, as recommended by the HLIP. There was an unprecedented scale-up in DAH in 2020 and 2021. We have a unique opportunity at this time to sustain funding for crucial global health functions, including pandemic preparedness. However, historical patterns of underfunding of pandemic preparedness suggest that deliberate effort must be made to ensure funding is maintained. Bill & Melinda Gates Foundation.

Pandemic Preparedness and Responses to the 2009 H1N1 Influenza: Crisis Management and Public Policy Insights

We aimed to compare COVID-19 control measures, epidemiological characteristics and economic performance measures in two high-income island nations with small populations, favorable border control options, and relatively good outcomes: Iceland and New Zealand (NZ). We examined peer-reviewed journal articles, official websites, reports, media releases and press articles for data on pandemic preparedness and COVID-19 public health responses from 1 January 2020 to 1 June 2022 in Iceland and NZ. We calculated epidemiological characteristics of the COVID-19 pandemic, as well as measures of economic performance. Both nations had the lowest excess mortality in the OECD from the start of the pandemic up to June 2022. Iceland pursued a mitigation strategy, never used lockdowns or officially closed its border to foreign nationals, and instead relied on extensive testing and contact tracing early in the pandemic. Meanwhile, NZ pursued an elimination strategy, used a strict national lockdown to stop transmission, and closed its international border to everyone except citizens and permanent residents going through quarantine and testing. Iceland experienced a larger decrease in gross domestic product in 2020 (relative to 2019) than NZ (-8·27% vs. -1·22%, respectively). In late 2021, NZ announced a shift to a suppression strategy and in 2022 began to reopen its border in stages, while Iceland ended all public restrictions on 25 February 2022. Many of Iceland's and NZ's pandemic control measures appeared successful and features of the responses in both countries could potentially be adopted by other jurisdictions to address future disease outbreaks and pandemic threats.

Reconceptualizing successful pandemic preparedness and response: A feminist perspective

Effective post-pandemic governance must focus on shared challenges

Eloise Todd: mobilising civil society for pandemic prevention

Despite the devastating impact of COVID-19 and repeated calls for political commitment to health security, our analysis of 43 manifestos from 16 countries and the European Parliamentary elections revealed that only four parties made specific policy pledges on pandemic prevention, preparedness and response, with six providing brief mentions. The vast majority (33 parties) did not mention pandemic prevention, preparedness and response. When referenced, the pandemic was often framed as a rare, one-off crisis or an economic shock rather than a catalyst for systemic health reform. Some parties used it for political critique or validation of past performance, while others framed preparedness in terms of national security or economic resilience rather than public health. In contrast, manifestos overwhelmingly prioritized healthcare system expansion, equity, and access, with a significant emphasis on universal health coverage, mental health, and workforce development. The findings underscore a stark misalignment between global health priorities and domestic political agenda. Political reluctance to emphasize pandemic prevention, preparedness and response appears to be influenced by pandemic fatigue, voter preferences for forward-looking narratives, and institutional incentives favouring short-term tangible outcomes. This persistent neglect of the pandemic in electoral discourse raises concerns about the global community’s ability to sustain momentum for pandemic resilience. We call for stronger engagement between the global health community and political actors to elevate pandemic prevention, preparedness and response as a strategic, cross-cutting priority for future policymaking.

Background: Prior experience and the persisting threat of influenza pandemic indicate the need for global and local preparedness and public health response capacity. The pandemic of 2009 highlighted the importance of such planning and the value of prior efforts at all levels. Our review of the public health response to this pandemic in Pune, India, considers the challenges of integrating global and national strategies in local programmes and lessons learned for influenza pandemic preparedness. Methods: Global, national and local pandemic preparedness and response plans have been reviewed. In-depth interviews were undertaken with district health policy-makers and administrators who coordinated the pandemic response in Pune. Results: In the absence of a comprehensive district-level pandemic preparedness plan, the response had to be improvised. Media reporting of the influenza pandemic and inaccurate information that was reported at times contributed to anxiety in the general public and to widespread fear and panic. Additional challenges included inadequate public health services and reluctance of private healthcare providers to treat people with flu-like symptoms. Policy-makers developed a response strategy that they referred to as the Pune plan, which relied on powers sanctioned by the Epidemic Act of 1897 and resources made available by the union health ministry, state health department and a government diagnostic laboratory in Pune. Conclusion: The World Health Organization’s (WHO’s) global strategy for pandemic control focuses on national planning, but state-level and local experience in a large nation like India shows how national planning may be adapted and implemented. The priority of local experience and requirements does not negate the need for higher level planning. It does, however, indicate the importance of local adaptability as an essential feature of the planning process. Experience and the implicit Pune plan that emerged are relevant for pandemic preparedness and other public health emergencies.

The COVID-19 pandemic highlighted the critical role of human behaviour in times of crisis. However, it also revealed that the behavioural sciences were not optimally prepared to provide actionable insights to policy makers to support preventive and coping behaviours in a crisis context. To ensure that the behavioural sciences can provide timely and effective advice to policy makers during future emergencies, it is key to act before a crisis occurs. The current workshop chaired by the Behavioural and Cultural Insights Unit of the WHO, will offer five perspectives to explore how behavioural science as a discipline is being applied to our understanding of pandemic and emergency preparedness and what concrete actions can and are already being taken now. Following five short presentations, a discussion with the panel and the audience will take place. The Dutch National Institute of Public Health and the Environment (RIVM) will start by presenting their approach toward embedding behavioural science of pandemic preparedness: the organisation of a national stakeholder network, the development of a conceptual framework, and3) development of a quantitative survey monitor for individual level behaviour. monitoring pandemic preparedness. f The Spanish Carlos III Health Institute and Slovenian Public Health institute will present insights about operationalising this monitor in their given context. They will present results of the first two rounds of this monitor on behalf of the four European member states, focusing on comparative insights on perceptions and states of preparedness, vaccination, citizen wellbeing and resilience with respect to their context. Next, the Competence Centre on Behavioural Insights of the European Commission will present an experimental approach toward preparedness. They will present results based on a scenario study, focused on understanding behaviours in the broader context of pandemic and disaster preparedness. The last two presentations will reflect on qualitative approaches. The Behavioural and Cultural Insights Unit of the WHO will present their qualitative study on health-service access, needs and behaviours of Ukrainian refugees in neighbouring countries, and reflect on operating under emergency constraints. In the final presentation the RIVM will present their findings of qualitative methods to study perceived emergency readiness. In particular, their study focuses on what citizens understand by pandemic preparedness, and to what extent they perceive their government as prepared for a future pandemic. Overall, the workshop aims to equip participants with a comprehensive understanding of the importance of behavioural science in pandemic and disaster preparedness and inspire collaborative action towards building resilient and effective strategies for future crises. Key messages • The workshop underlines the importance of behavioural science in preventing and responding to infectious disease outbreaks. • Participants learn how behavioural sciences can already be applied now to prepare citizens and organisations for future pandemics and crises.

On 24 April 2009 the World Health Organization (WHO) reported human cases of swine influenza A/H1N1 occurring in the USA and Mexico.1 The number of recorded cases increased rapidly, there was clear human to human transmission,2 and it appears that the outbreak originated in Mexico in mid-March or earlier.3 This prompted WHO on 27th April to raise its pandemic preparedness from phase three, where it had been for some time as a result of the ongoing H5N1 virus epizootic, first to phase 42 and then 2 days later to phase 5.4 Countries with national pandemic plans responded accordingly. It might be argued that by the end of May the spread of this new virus has been sufficient for WHO to declare that phase 6, a pandemic, had been reached. However, most of the recent pandemic preparedness planning has been initiated and refined in the face of the perceived threat of a severe outbreak due to a virus such as the H5N1 subtype. In fact most such plans have an introduction or preamble explaining, for those less familiar with influenza, that there are two types of antigenic variation in human influenza, ‘antigenic drift’, due to small ongoing mutational changes and ‘antigenic shift’ when a novel influenza A subtype successfully enters and transmits in the human population and that this is when pandemic influenza results. True to the frequent description of influenza as enigmatic or unpredictable this new outbreak represents neither antigenic shift nor antigenic drift and whether this should truly be considered a pandemic is not yet clearcut.5 In this issue of Influenza and Other Respiratory Viruses there are a number of articles related to the current outbreak and to pandemic preparedness and response. Tracking the virus is clearly important in attempts to contain spread and the article by Hurt et al.6 provides a preliminary assessment of rapid point of care tests for the detection of the novel H1N1 virus. Kelly et al.7 demonstrate that the age distribution of outbreaks due to this virus to date, in the USA and Europe, is similar to that of seasonal A(H1N1) when compared with recent outbreaks in Australia and suggest that this may be an inherent property of A(H1N1) viruses. McCaw et al.8 speculate that a variety of factors that influence both the susceptibility of populations and the fitness of circulating influenza viruses could explain the varying mortality rates experienced in the 1918–1919 pandemic. These may be important in responding to the current outbreak as continued out of season activity in the Northern hemisphere and ongoing geographic spread may be an indication that this novel H1N1 has true pandemic potential. As we move into the Southern hemisphere winter it remains to be seen whether season may influence the impact of the virus and whether certain populations are at increased risk as suggested by the initial, apparently greater severity in Mexico. While WHO is yet to recommend commercial manufacture of a vaccine against the novel H1N1 virus, news reports indicate that many European countries, the USA and Australia have already placed orders for vaccine. The article by Hessel on behalf of the European Vaccine Manufacturers9 reviews current progress in meeting the challenges of pandemic influenza vaccine manufacture, however, as has been frequently emphasised in the past and again recently in the context of the current outbreak,10, the lead-time for influenza vaccine manufacture and global production capacity seem destined to fail global demands for both timeliness and quantity of supply for a pandemic occurring in the immediate future. The Holy Grail for influenza scientists has long been a vaccine that could produce heterotypic protection across all influenza A viruses. An encouraging approach targeting T-cell immunity with lipopeptide vaccines that may reduce the severity of disease and supplement the antibody-based approach to vaccination is reported by Ng et al.11 If such vaccines are effective in practice their value globally will clearly be dependent on a number of factors including cost, duration of immunity and availability, particularly for developing countries. The World Health Organization recommends that all countries should develop a pandemic preparedness plan as part of the implementation of the International Health Regulations.12 However, web-based documents13,14 provide evidence of only 45 such plans and it appears that some countries, particularly developing countries, have yet to complete a pandemic plan. Clearly, for those countries with little capacity to directly source vaccines or antivirals as a part of their pandemic response, preparedness planning requires special considerations15 including an emphasis on non-pharmaceutical interventions.16 The current emergence of a novel virus, be it a pandemic virus or not, places additional emphasis on the need for pandemic preparedness planning and the article by Azziz-Baumgartner et al.17 provides a valuable overview of a process for drafting a plan. In his review article, in this issue,18 David Fedson observes that ‘most of the world’s people will not have access to affordable supplies of vaccines and antivirals’ and that ‘In the 21st century, science ought to be able to provide something better’. He proposes that understanding the system-wide effects of influenza on the host that are responsible for the severe consequences of pandemic influenza, particularly the increased mortality in younger adults, may provide a basis for ameliorating these effects with inexpensive generic agents that are readily available even in developing countries. The current outbreak may provide an ideal opportunity to test these and other approaches to minimising the impact of a pandemic. And we must remember that while we are distracted with the H1N1 outbreak the H5N1 epizootic continues and the number of human cases continues to rise, particularly in Egypt. Wouldn't it be a terrible irony if H5N1 suddenly achieved the ability to transmit readily in humans, possibly aided by widespread infection of H1N1 and increased opportunity for reassortment, with much of our resources already committed to H1N1. Influenza may yet hold more surprises. As the World Health Organization and the scientific community ponder whether the current outbreak constitutes a pandemic and the appropriate level of response to it, an additional area of confusion has become apparent – how should we refer to it, particularly as it doesn’t represent a novel subtype? Official communications and scientific reports, including those included in this issue of this journal, already contain a confusing array of nomenclature. These include ‘swine influenza’, ‘novel swine-origin H1N1 influenza’ and ‘human-swine influenza’. Recently it seems that it is considered inappropriate to include the word ‘swine’ in referring to the virus and it has become ‘novel influenza A(H1N1)’ and currently ‘influenza A(H1N1)v’ (v for variant). The latter gives no hint as to its origin or uniqueness, is very bland and seems unlikely to resonate with the popular media many of whom, probably by analogy with referring to H5N1 as ‘bird flu’, continue to use ‘swine flu’ or ‘pig flu’ when reporting this outbreak. From a scientific standpoint there is, of course, nothing novel about the circulation of ‘variant’ influenza viruses. The journal will continue to fast-track reports related to the current outbreak, the global response and pandemic preparedness and response generally, as it has for this issue and welcomes contributions.

Pandemic influenza preparedness has contributed significantly to building, strengthening and maintaining countries' core capacities to prepare for health emergencies. The Pandemic influenza preparedness framework for the sharing of influenza viruses and access to vaccines and other benefits (the PIP framework) was adopted by the World Health Assembly in 2011. The experiences and lessons learnt from the implementation of the PIP framework have provided insights that can be used to strengthen preparedness for epidemics of other priority high-threat pathogens in the World Health Organization (WHO) South-East Asia Region in line with obligations under the International Health Regulations, 2005 (IHR). Implementation has established policies, strategies, action plans, strengthened systems and operational readiness to promptly diagnose influenza virus strains with pandemic potential and ensure timely event notifications and management in compliance with the IHR. WHO collaborating centres and the annual bi-regional meeting of national influenza centres and influenza surveillance have strengthened the influenza laboratory diagnostic knowledge network in the region. After action reviews following influenza outbreaks have documented best practices, strengths, constraints and areas for improvement in pandemic preparedness. The pandemic in 2009 and recent seasonal influenza outbreaks have offered real-life scenarios for testing national pandemic influenza preparedness plans and deploying vaccines. The successful implementation of the PIP framework, along with strengthening of health systems and operational procedures and continued technical collaboration with global centres of excellence, should be tapped into to strengthen preparedness to respond to epidemics of other high-threat pathogens based on the influenza model. The political commitment reflected in the Delhi Declaration on Emergency Preparedness, signed by all ministers of health in September 2019 and supported by the Five-year regional strategic plan to strengthen public health preparedness and response - 2019-2023, should be a catalyst for guidance and support in developing a broad, long-term strategic plan for preparedness and response to high-threat pathogens in the region.

Since first being detected in Wuhan, China in late December 2019, COVID-19 has demanded a response from all levels of government. While the role of local governments in routine public health functions is well understood-and the response to the pandemic has highlighted the importance of involving local governments in the response to and management of large, multifaceted challenges-their role in pandemic response remains more undefined. Accordingly, to better understand how local governments in cities were involved in the response to the COVID-19 pandemic, we conducted a survey involving cities in the Partnership for Healthy Cities to: (i) understand which levels of government were responsible, accountable, consulted, and informed regarding select pandemic response activities; (ii) document when response activities were implemented; (iii) characterize how challenging response activities were; and (iv) query about future engagement in pandemic and epidemic preparedness. Twenty-five cities from around the world completed the survey and we used descriptive statistics to summarize the urban experience in pandemic response. Our results show that national authorities were responsible and accountable for a majority of the activities considered, but that local governments were also responsible and accountable for key activities-especially risk communication and coordinating with community-based organizations and civil society organizations. Further, most response activities were implemented after COVID-19 had been confirmed in a city, many pandemic response activities proved to be challenging for local authorities, and nearly all local authorities envisioned being more engaged in pandemic preparedness and response following the COVID-19 pandemic. This descriptive research represents an important contribution to an expanding evidence base focused on improving the response to the ongoing COVID-19 pandemic, as well as future outbreaks.

Objective: To describe the experience of engaging senior clinical nurses as surge staff in a pandemic public health response and determine the effect of an on‑line training package and exercise participation on these individuals’ perceptions and confidence of being deployed during an influenza pandemic. Design: After action reviews, end of exercise surveys, and pre‑ and post‑training risk perceptions questionnaire completion. Setting: The study was conducted within the operational aspects of a public health exercise response to an influenza pandemic. Subjects: Clinical nurse consultants, nurse educators and nurse managers sourced from areas defined as not clinically critical during the early containment phase of an influenza pandemic response. Interventions: Four hour on‑line training package and a four day influenza pandemic exercise. Main outcome measures: Expert observation and self‑perceived appropriateness of surge staff and measured changes in risk perception. Results: Observers’ comments and after action reviews indicated that by the end of the deployment, day surge staff were able to perform public health surveillance functions competently. The end of day survey showed that the on‑line training package served as a useful reference document but alone was an inadequate means of equipping staff for deployment. Exercise pre‑ and post‑perceptions surveys found that self‑perceived knowledge and confidence in performing duties increased following the exercise from 46% to 93% (p<0.01) and from 46% to 90% (p<0.01), respectively. Conclusion: Clinical nurse consultants, nurse educators and nurse managers working within a health authority are an appropriate surge workforce during public health emergencies if provided with appropriate training and support.