The Joint External Evaluation tool is a World Health Organization-recommended method for evaluating countries' capacities under the International Health Regulations (2005) (IHR). It encompasses a national preparedness assessment process for public health threats and offers a structured framework for planning and implementing effective response measures. A tailored approach is necessary for Nigeria's federated system of government, in which most constitutional requirements for public health and associated issues are decentralized to the state level. The Nigeria Centre for Disease Control and Prevention (NCDC) developed an assessment tool to identify state-level health security gaps and support the development of improvement plans. With input from state and national public health leaders and legal experts, a legislative evaluation was conducted to determine specific IHR activities that could be implemented within the state's legal framework to accelerate the implementation of the Integrated Disease Surveillance and Response strategy and IHR. The resulting assessment instrument was piloted in Kano, Enugu, and Kebbi states, followed by a consensus meeting to identify additional areas for improvement. The revised tool contains 14 technical areas and 35 indicators tailored to implementing improvement plans. By recognizing the unique characteristics of subnational entities and their implications for pandemic preparedness, the tool provides an innovative approach to health security for countries with multilayered governance structures or geographic diversity. Conducting a subnational health security assessment is a crucial step in ensuring preparedness for public health threats and enhancing health security in Nigeria's federated system of government.

The United States takes a federalist approach to pandemic responses while the bulk of pandemic powers sits at the state level. Thus, comprehensive accounts of how state health officials managed the crisis and how the federal government affected those efforts are needed to better understand the governmental response to the COVID-19 pandemic. This article reports the results of semistructured interviews with 29 state-level policy actors from 16 US states. Interviewees discussed multiple aspects of the US federal COVID-19 response that affected the response in their states, including communications with the public, intergovernmental communications, and federal actions regarding various aspects of health service preparedness including emergency funding, procurement, testing capacity, vaccine development and distribution, and data systems. This research enriches the discussion about US pandemic preparedness and response, and indicates that alignment of public communications across government levels, enhanced intergovernmental communication, inclusion of rural perspectives, and federal investment in and sustainment of health service preparedness are key factors that can improve future US pandemic responses.

The COVID-19 pandemic has revealed the need for nations to prepare more effectively for emerging infectious diseases. Preparing for these threats requires a multifaceted approach that includes assessing pathogen threat, building flexible capabilities for rapid medical countermeasure (MCM) development, and exercising, maintaining, and improving those response capabilities. The Biomedical Advanced Research and Development Authority (BARDA) promotes the advanced development of MCMs in response to natural and manmade threats. In this article, the authors describe a BARDA threat assessment tool that, in conjunction with other factors, facilitates portfolio management and decisionmaking related to the advanced development of MCMs for emerging infectious diseases. The tool was designed to use readily accessible public data and information related to the threat posed by pathogens. It can be adjusted to modify the specific areas of interest (eg, removal/addition of parameters) to facilitate cross-pathogen analysis and can be updated to reflect changes (eg, new outbreak) that may impact the overall threat assessment. Finally, assessment of certain pathogens is included.

Hospital patient boarding in emergency departments has reached unprecedented crisis levels over the past 4 years. Boarding and crowding has been demonstrated by prior literature to have adverse effects on patient care as well as increased associated costs. Importantly, the increase in hospital patient boarding has created critical shortcomings in disaster preparedness by limiting the capacity of emergency departments to respond to mass casualty incidents due to space and staffing constraints. Multiple concurrent threats exacerbate these challenges, including increases in the incidence of both natural and unnatural disasters over the past decade and decreases in the numbers of US hospitals, hospital beds, and employed healthcare staff. "Emergency department boarding" must also be renamed "hospital boarding" given that the fundamental challenge lies with hospital and health system leadership and does not stem from emergency departments. In this commentary, the authors share a call to action to increase support and funding for research to alleviate the demands of hospital boarding, greater recognition among hospital leadership of the threat that hospital boarding poses to disaster scenarios, and widespread development of hospital-based, regional plans for mass casualty incident response that are more effective in the context of excessive boarding.

From influenza to COVID-19, emerging infectious diseases have taken a heavy toll on lives and resources. Emerging infectious diseases represent one of the largest threats to national security. The primary mission of the Center for Biomedical Advanced Research and Development Authority (BARDA), within the US Administration for Strategic Preparedness and Response, is to support the advanced development of medical countermeasures (MCMs) for public health security threats, including select infectious diseases. Given the number of potential emerging infectious diseases, it is not feasible to develop a suite of MCMs necessary for a full response, including vaccines, therapeutics, and diagnostics. In this article, the authors describe BARDA's 3-step strategy to address emerging infectious diseases: (1) prioritize the development of MCMs for BARDA's priority pathogens with an increased focus on "platform technologies" with rapid development capabilities; (2) develop response capabilities including specific licensed medical countermeasures and flexible, rapid MCM development infrastructure; and (3) improve those response capabilities, so they are finely tuned and ready when needed.

In early 2020, to halt the spread of SARS-CoV-2, the state government of Rio Grande do Sul in Brazil established a public health assessment and response framework known as a "controlled distancing model." Using this framework, the government divided the state into 21 regions and evaluated them against a composite index of disease transmission and health service capacity. Regions were assessed using a color-coded scale of flags that was updated on a weekly basis and used to guide the adoption of nonpharmaceutical interventions. In this study, we aimed to evaluate the extent to which the controlled distancing model accurately assessed transmission and the effectiveness of its responses throughout 2020. We estimated the weekly effective reproduction number (Rt) of SARS-CoV-2 for each region using a renewal equation-based statistical model of notified COVID-19 deaths. Using Rt estimates, we explored whether flag colors assigned by the controlled distancing model either reflected or affected SARS-CoV-2 transmission. Results showed that flag assignments did reflect variations in Rt to a limited extent, but we found no evidence that they affected Rt in the short term. Medium-term effects were apparent in only 4 regions after 8 or more weeks of red flag assignment. Analysis of Google movement metrics showed no evidence that people moved differently under different flags. The dissociation between flag colors and the propagation of SARS-CoV-2 does not call into question the effectiveness of nonpharmaceutical interventions. Our results show, however, that decisions made under the controlled distancing model framework were ineffective both at influencing the movement of people and halting the spread of the virus.

The COVID-19 pandemic has underscored the importance of the International Health Regulations (IHR) (2005) in addressing global health emergencies. This review aims to improve healthcare system capabilities, future preparedness, and actions in the Eastern Mediterranean Region, particularly in low-resource areas. The IHR, established in 1969, initially focused on 6 diseases but has since expanded to include a wider range of public health threats. These rules establish a globally recognized legal framework that is applicable to all 196 states parties, including all 194 World Health Organization member states. The IHR prioritize the prevention, protection, and control of global disease transmission while minimizing unwarranted disruptions to international travel and commerce. Nonetheless, the response to COVID-19 in the Eastern Mediterranean Region revealed a range of deficiencies despite the regulatory strengths. Some countries encountered challenges in fully complying with their IHR obligations, particularly in terms of preparedness, and occasional geopolitical tensions obstructed international collaboration. The pandemic experience underscores the need for improved trust, resource allocation, and regulatory revisions to address upcoming global health challenges. This case study highlights positive aspects of the pandemic response, including the swift exchange of information and global cooperation, while also recognizing shortcomings, such as delays in reporting and unequal vaccine access. In summary, the COVID-19 pandemic underscores the urgency of subsequent updates to the IHR or comparable accords, such as the IHR amendments and the pandemic treaty, to rectify these deficiencies. Updates should place a greater emphasis on transparency, cultivating trust, enhancing preparedness, and establishing mechanisms that incentivize comprehensive compliance among all participating nations.

This case study describes findings from an exercise conducted in April 2023 to assess the readiness of the National Quarantine Unit (NQU) and identify opportunities for improvement. The exercise is part of a multiyear effort to assess the readiness of quarantine and transport capabilities at the NQU through annual workshops, discussion-based exercises, and functional and full-scale exercises. The April 2023 exercise tested interagency coordination and decisionmaking, transport of individuals for monitoring, quarantine unit operations, and escalation of care for symptomatic individuals out of quarantine to high-level isolation units in the United States. Findings showed that collaboration and engagement of local, state, and national organizations increases awareness of novel and emerging high-consequence infectious disease pathogens and enhances capabilities and capacity for patient transport. It also improves timely and efficient diagnostic testing and increases the availability of dedicated assets to support activation and mobilization of the NQU, the Regional Emerging Special Pathogen Treatment Center network, and the future national special pathogen system of care. Given the changing landscape of emerging special pathogens, an objective evaluation of the state of readiness is an essential element of preparedness and response.