Mpox as Two Global Health Emergencies: Altered Transmission, Genomics, Clinical Manifestation and Public Health Impact

Surveillance for SARS-CoV-2 variants of concern in the Australian context.

Is Africa prepared for tackling the COVID-19 (SARS-CoV-2) epidemic. Lessons from past outbreaks, ongoing pan-African public health efforts, and implications for the future

On 30 January 2020, the WHO declared a Public Health Emergency of International Concern (PHEIC) for the COVID-19 outbreak. On 7 March 2020, there were more than 100,000 confirmed cases in 88 countries. Telemedicine, otherwise known as telehealth, has been used at small scale in past outbreaks, including previous coronavirus outbreaks (SARS; MERS) and other PHEICs (Ebola; Zika). The objective was to describe the global larger scale use and practicality of telehealth in the COVID-19 outbreak.The 2015 conceptual framework of telemedicine during an outbreak for epidemiological assessment and clinical management (Ohannessian R.) was used to describe the use cases. A multi-country analysis from China, France, USA and UK was performed with a literature review using official institution websites, grey literature, media/business reports, as scientific articles were not yet published.Video and chat consultations were used for symptomatic patient assessments through private telehealth providers in all countries. In the USA, the Telehealth Services During Certain Emergency Periods Act of 2020 was voted by the Congress on 4 March 2020 to suspend restrictive rules of Medicare funding for telehealth home consultations. Triage via online auto-questionnaires were created by private providers and public authorities. In the UK, from 26 February to 2 March, 70,000 enquiries were made to a dedicated NHS111 online service. In China, teleradiology networks were also used for diagnostic of COVID-19 cases. Video consultation was used in France to monitor home isolated patients and non COVID-19 patients, to avoid risks of exposure.Telehealth has been useful to the COVID-19 outbreak but efforts to better describe cases and evaluate impact on the public health response should be promoted. National and international health authorities should be aware of the opportunities offered by telehealth during outbreaks, and may consider its integration in public health emergencies preparedness plans.Key messages Telehealth was useful for the public health response to COVID19 outbreak.Telehealth should be integrated into public health preparedness plans.

Policies in place throughout the world: action by the European Union

(This letter appears in response to the May 2007 PLoS Medicine Editorial: “How Is WHO Responding to Global Public Health Threats?” [1]) The travels of a patient with extensively drug-resistant tuberculosis (XDR-TB) from North America to Europe and back have heightened concerns about this growing global disease problem and the possibility of its international transmission through travel. The seriousness of this possibility raises the question of whether XDR-TB cases or outbreaks may constitute public health emergencies of international concern (PHEICs) under the 2005 International Health Regulations (IHR 2005), which became binding international law on June 15, 2007 [2]. XDR-TB may be the first case of a public health problem that tests how States Parties and the World Health Organization (WHO) apply the IHR 2005. We believe that cases or outbreaks of XDR-TB would meet the notification criteria of the IHR 2005 as events that may constitute a PHEIC because they trigger affirmative answers to at least two of the four questions in the IHR 2005's decision instrument (Annex 2, [3]). Thus, as of June 15, 2007, States Parties must report such cases or outbreaks to WHO pursuant to the IHR 2005. XDR-TB triggers an affirmative answer to the decision instrument's question: “Is the public health impact of the event serious?”, both because of the possibility of the event having a high public health impact and, in many instances, the need for external assistance in managing cases. XDR-TB cases would likely produce an affirmative answer to the question: “Is the event unusual or unexpected?”, because of the higher than expected case-fatality rates, particularly where XDR-TB occurs with high prevalence of HIV infection. The disease also may generate a positive answer to the question: “Is there a significant risk of international travel or trade restrictions?”, primarily because of the possibility of international media attention. At present, XDR-TB would arguably not produce a clearly affirmative answer to the question: “Is there a significant risk of international spread?”, because epidemiological data linking XDR-TB outbreaks and cases with the international movement of people are weak. Experience with TB, multi-drug-resistant TB (MDR-TB), and XDR-TB demonstrates, however, that cross-border spread is a very real threat. XDR-TB has already spread from one province to several provinces in South Africa, and has in all likelihood crossed African borders, but confirmation is delayed because of inadequate surveillance capabilities. It remains less certain whether the WHO Director-General would determine that XDR-TB cases or outbreaks notified to WHO would constitute a PHEIC. This would lead to the issuance of temporary recommendations to States Parties, which could include travel restrictions and use of compulsory measures such as quarantine or isolation. In February 2007, the WHO Global Task Force on XDR-TB argued against such a position because “the new regulations are aimed particularly to situations where there is a significant risk of international spread” and that temporary recommendations “are really intended for outbreaks of acute disease, rather than the ‘acute-on-chronic’ situation of MDR-TB and XDR-TB” [4]. The Global Task Force stated that, if international spread of XDR-TB were demonstrated, then standing recommendations should be considered. To some extent, the recommendations and alerts WHO has already issued on XDR-TB suggest that treating XDR-TB as a routine public health risk is not adequate. In addition, the IHR 2005 does not limit its scope of application to “acute disease” [5]. TB has never been an acute risk in the same manner as a pandemic strain of influenza, but history attests to TB's persistence as a lethal global threat, especially for vulnerable populations. As the global XDR-TB problem becomes more severe, more robust and drastic public health actions may be required nationally and globally, including a declaration from the WHO Director-General of the existence of a PHEIC. A window of opportunity may exist now for effective international action to control the spread of the disease, and the IHR 2005 may provide a mechanism to help achieve this objective. A narrow, limited reading of the IHR 2005's scope of application could undermine its ability to contribute to this global health crisis.

How Do Data Bolster Pandemic Preparedness and Response? How Do We Improve Data and Systems to Be Better Prepared?

Solidarity in the wake of COVID-19: reimagining the International Health Regulations

ObjectiveThe purpose of this project is to demonstrate the progress in development of a standardized public health (PH) emergency preparedness and response data ontology (terminology) through collaboration between the Centers for Disease Control and Prevention (CDC), Division of Emergency Operations (DEO), and the Logical Observation Identifiers Names and Codes (LOINC) system.IntroductionThe U.S. Department of Homeland Security National Incident Management System (NIMS) establishes a common framework and common terminology that allows diverse incident management and support organizations to work together across a wide variety of functions and hazard scenarios1. Using common terminology helps avoid confusion and enhances interoperability, particularly in fast-moving public health (PH) emergency responses. In addition, common terminology allows diverse incident management and support organizations to work together across a wide variety of functions and scenarios1. LOINC is one of a suite of designated standards for the electronic exchange of public health and clinical information. Implementation of LOINC facilitates improvement of semantic interoperability, including unified terminology2. More than 68,100 registered users from 172 countries use LOINC to move interoperable data seamlessly between systems3. The CDC Division of Emergency Operations (DEO) leads development of standardized PH emergency preparedness and response terminology to improve effective and interoperable communications between national and international partners. Realizing the scale of LOINC support and implementation across the global public health arena, CDC DEO collaborates with LOINC to further enhance and harmonize the current PH emergency response terminology and to attain critical PH emergency management and preparedness and response requirements.MethodsDEO analyzed 87,863 LOINC terms that were included in LOINC version 2.64, released on 06/15/20183. Access to this LOINC version was obtained through the Regenstrief LOINC Mapping Assistant (RELMA). RELMA is a Windows-based LOINC utility developed by the Regenstrief Institute (Indiapolis, USA) for searching the LOINC database and mapping local codes to LOINC codes4. The relevance of LOINC terminology to PH emergency preparedness and response was assessed through evaluating existing LOINC terminology against terminology specified by the World Health Organization PH Emergency Operation Centers (EOC). The following functions were evaluated: 1) Managing and Commanding; 2) Operating; 3) Planning/Intelligence; 4) Logistics and 5) Finance/Administration5. LOINC terminology was also evaluated against the CDC PH EOC Minimum Data Set (MDS)6 that contains 315 standardized terms. Analysis of fully specified LOINC terms was conducted through assessment of such LOINC term parts (attributes) as the code, name (component), system, method and class. Recommendations of gaps and enhancements were coordinated with LOINC management for inclusion of the new terminology in the release of version 2.65 .ResultsA new LOINC method, “CDC.EOC”, is under development. Currently, the “emergency management incident” terminology presented by LOINC is limited by such characteristics as event type, event location and event name and requires amplification regarding to PH operations (i.e., communication, logistics etc.).As a result of this investigation, emergency management terms are now being classified according to the type of incident or event (i.e., hurricane, outbreak, etc.) under LOINC code 80394-0. Similarly laboratory and clinical terms are being classified under a provisional LOINC code (89724-9). Two panels were created: 1) The emergency medical systems from the National Emergency Medical Services Information System (NEMSIS) was added under the NEMSIS.Panel (n= 177 terms) and 2) the Data Elements for Emergency Departments Systems (DEEDS) panel (n = 152 terms) was added with two subpanels: Attach.ED and Panel.ED.Assessing existing LOINC taxonomy and codification, DEO is working with the LOINC management team on evaluating additional options for reconciliation the PH emergency preparedness and response common information exchange reference model and LOINC standard. This process aims to further improve semantic interoperability of PH emergency preparedness and response information.ConclusionsThe LOINC terminology standardization is essential for improving PH preparedness and response data exchange and semantic interoperability. Collaboration with the Regenstrief Institute (LOINC) allows CDC to meet the terminology needs of PH emergency management and defines new opportunities for reconciliation data exchange between NIMS partners. This collaborative effort incorporates critically needed PH emergency and preparedness terminology and hierarchical structure in the LOINC standard.

A new day for African public health

Dr Tedros Adhanom Ghebreyesus, the Director-General of the World Health Organization (WHO), declared the Ebola outbreak in the Democratic Republic of Congo a Public Health Emergency of International Concern (PHEIC) on 17 July 2019. This announcement came after months of discussion about when and if he should call a PHEIC for this outbreak. What was interesting about the debate was the apparent disconnect between the political and economic purposes of declaring an emergency, which were in complete contradiction to the medical and scientific view that declaring a PHEIC would not serve to enhance the medical and public health response. Of course, now that the PHEIC has been declared, it will be interesting to see whether its presumed levers work, especially in terms of increased donor and political support to halt the spread of the disease. What is certain, however, is that this Ebola outbreak, like west Africa's in 2014, is challenging the medical and scientific community's conventional understanding of the conditions conducive to the spread of the disease. The virus itself is well understood; the social, environmental and political factors that fuel the outbreak are harder to grasp. The pandemic century reveals the necessity for the scientific community to come to terms with the interplay between social, environmental and political factors and infectious disease aetiology—and the difficulties they will face in attempting to do so.

What does it mean to declare monkeypox a PHEIC?

Global pandemic perspectives: public health, mental health, and lessons for the future

In today's environment of an increased need to demonstrate the value of the federal investment in public health preparedness and response (PHPR), it is encouraging to see the results of the research conducted by the Preparedness and Emergency Response Research Centers (PERRCs), which were funded by the U.S. Centers for Disease Control and Prevention (CDC).1 The research generated by the PERRCs represented in this special supplement of Public Health Reports, “Outcomes from the Federal Investment in Public Health Systems Research to Strengthen Preparedness and Response,” is not only impressive but also vital in adding to the evidence base for our PHPR efforts. The PERRCs have demonstrated the value of public health research that collectively advances our thinking and understanding of how to improve our public health system's preparedness for and response to disasters. Investigators share a wealth of practical insights to help bolster the continuing development and refinement of the public health system contribution to emergency preparedness and response. The research reported in this supplement reflects a confluence of three disciplinary trends in the field: (1) the application of methods, frameworks, and analytical strategies from the evolving field of public health systems and services research (PHSSR) to the specialized practice domain of PHPR; (2) a move, generally, toward more rigorous study design within the field of public health emergency preparedness and response research; and (3) the influence of themes and analytical strategies from more established fields, such as social science-oriented disaster research, psychometrics, and operations research.

BackgroundAn infodemic is an overflow of information of varying quality that surges across digital and physical environments during an acute public health event. It leads to confusion, risk-taking, and behaviors that can harm health and lead to erosion of trust in health authorities and public health responses. Owing to the global scale and high stakes of the health emergency, responding to the infodemic related to the pandemic is particularly urgent. Building on diverse research disciplines and expanding the discipline of infodemiology, more evidence-based interventions are needed to design infodemic management interventions and tools and implement them by health emergency responders.ObjectiveThe World Health Organization organized the first global infodemiology conference, entirely online, during June and July 2020, with a follow-up process from August to October 2020, to review current multidisciplinary evidence, interventions, and practices that can be applied to the COVID-19 infodemic response. This resulted in the creation of a public health research agenda for managing infodemics.MethodsAs part of the conference, a structured expert judgment synthesis method was used to formulate a public health research agenda. A total of 110 participants represented diverse scientific disciplines from over 35 countries and global public health implementing partners. The conference used a laddered discussion sprint methodology by rotating participant teams, and a managed follow-up process was used to assemble a research agenda based on the discussion and structured expert feedback. This resulted in a five-workstream frame of the research agenda for infodemic management and 166 suggested research questions. The participants then ranked the questions for feasibility and expected public health impact. The expert consensus was summarized in a public health research agenda that included a list of priority research questions.ResultsThe public health research agenda for infodemic management has five workstreams: (1) measuring and continuously monitoring the impact of infodemics during health emergencies; (2) detecting signals and understanding the spread and risk of infodemics; (3) responding and deploying interventions that mitigate and protect against infodemics and their harmful effects; (4) evaluating infodemic interventions and strengthening the resilience of individuals and communities to infodemics; and (5) promoting the development, adaptation, and application of interventions and toolkits for infodemic management. Each workstream identifies research questions and highlights 49 high priority research questions.ConclusionsPublic health authorities need to develop, validate, implement, and adapt tools and interventions for managing infodemics in acute public health events in ways that are appropriate for their countries and contexts. Infodemiology provides a scientific foundation to make this possible. This research agenda proposes a structured framework for targeted investment for the scientific community, policy makers, implementing organizations, and other stakeholders to consider.

Desperate Times: Protecting the Public From Research Without Consent or Oversight During Public Health Emergencies.