Infectious disease outbreaks pose major threats to human health and security. Countries with robust capacities for preventing, detecting and responding to outbreaks can avert many of the social, political, economic and health system costs of such crises. The Global Health Security Index (GHS Index)-the first comprehensive assessment and benchmarking of health security and related capabilities across 195 countries-recently found that no country is sufficiently prepared for epidemics or pandemics. The GHS Index can help health security stakeholders identify areas of weakness, as well as opportunities to collaborate across sectors, collectively strengthen health systems and achieve shared public health goals. Some scholars have recently offered constructive critiques of the GHS Index's approach to scoring and ranking countries; its weighting of select indicators; its emphasis on transparency; its focus on biosecurity and biosafety capacities; and divergence between select country scores and corresponding COVID-19-associated caseloads, morbidity, and mortality. Here, we (1) describe the practical value of the GHS Index; (2) present potential use cases to help policymakers and practitioners maximise the utility of the tool; (3) discuss the importance of scoring and ranking; (4) describe the robust methodology underpinning country scores and ranks; (5) highlight the GHS Index's emphasis on transparency and (6) articulate caveats for users wishing to use GHS Index data in health security research, policymaking and practice.

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The value proposition of the Global Health Security Index.

Introduction The COVID-19 pandemic powerfully demonstrates the consequences of biothreats. Countries will want to know how to better prepare for future events. The Global Health Security Index (GHSI) is a broad, independent assessment of 195 countries’ preparedness for biothreats that may aid this endeavour. However, to be useful, the GHSI’s external validity must be demonstrated. We aimed to validate the GHSI against a range of external metrics to assess how it could be utilised by countries. Methods Global aggregate communicable disease outcomes were correlated with GHSI scores and linear regression models were examined to determine associations while controlling for a number of global macroindices. GHSI scores for countries previously exposed to severe acute respiratory syndrome (SARS), Middle East respiratory syndrome and Ebola and recipients of US Global Health Security Agenda (GHSA) investment were compared with matched control countries. Possible content omissions in light of the progressing COVID-19 pandemic were assessed. Results GHSI scores for countries had strong criterion validity against the Joint External Evaluation ReadyScore (rho=0.82, p Conclusion The GHSI shows promise as a valid tool to guide action on biosafety, biosecurity and systems preparedness. However, countries need to look beyond existing metrics to other factors moderating the impact of future pandemics and other biothreats. Consideration of anthropogenic and large catastrophic scenarios is also needed.

https://gh.bmj.com/content/bmjgh/5/10/e003276.full.pdf

Validation analysis of Global Health Security Index (GHSI) scores 2019.

BackgroundIn an influenza pandemic, the benefit of vaccines and antiviral medications will be constrained by limitations on supplies and effectiveness. Non-pharmaceutical public health interventions will therefore be vital in curtailing disease spread. However, the most comprehensive assessments of the literature to date recognize the generally poor quality of evidence on which to base non-pharmaceutical pandemic planning decisions. In light of the need to prepare for a possible pandemic despite concerns about the poor quality of the literature, combining available evidence with expert opinion about the relative merits of non-pharmaceutical interventions for pandemic influenza may lead to a more informed and widely accepted set of recommendations. We evaluated the evidence base for non-pharmaceutical public health interventions. Then, based on the collective evidence, we identified a set of recommendations for and against interventions that are specific to both the setting in which an intervention may be used and the pandemic phase, and which can be used by policymakers to prepare for a pandemic until scientific evidence can definitively respond to planners' needs.MethodsBuilding on reviews of past pandemics and recent historical inquiries, we evaluated the relative merits of non-pharmaceutical interventions by combining available evidence from the literature with qualitative and quantitative expert opinion. Specifically, we reviewed the recent scientific literature regarding the prevention of human-to-human transmission of pandemic influenza, convened a meeting of experts from multiple disciplines, and elicited expert recommendation about the use of non-pharmaceutical public health interventions in a variety of settings (healthcare facilities; community-based institutions; private households) and pandemic phases (no pandemic; no US pandemic; early localized US pandemic; advanced US pandemic).ResultsThe literature contained a dearth of evidence on the efficacy or effectiveness of most non-pharmaceutical interventions for influenza. In an effort to inform decision-making in the absence of strong scientific evidence, the experts ultimately endorsed hand hygiene and respiratory etiquette, surveillance and case reporting, and rapid viral diagnosis in all settings and during all pandemic phases. They also encouraged patient and provider use of masks and other personal protective equipment as well as voluntary self-isolation of patients during all pandemic phases. Other non-pharmaceutical interventions including mask-use and other personal protective equipment for the general public, school and workplace closures early in an epidemic, and mandatory travel restrictions were rejected as likely to be ineffective, infeasible, or unacceptable to the public.ConclusionThe demand for scientific evidence on non-pharmaceutical public health interventions for influenza is pervasive, and present policy recommendations must rely heavily on expert judgment. In the absence of a definitive science base, our assessment of the evidence identified areas for further investigation as well as non-pharmaceutical public health interventions that experts believe are likely to be beneficial, feasible and widely acceptable in an influenza pandemic.

Non-pharmaceutical Public Health Interventions for Pandemic Influenza

Assessing public health emergency preparedness (PHEP) can help monitor and improve systems' capacities and capabilities Yet, measuring preparedness is a complex process and available assessment approaches have numerous limitations To review gaps and strengths of current assessment tools and methods, a scoping review was conducted based on peer-assessed and grey literature published between 2013 and 2019 describing PHEP assessments A total of 32 articles were selected, the majority being assessments implemented at national level (44%, N = 14) Assessments were mainly formatted as questionnaires/surveys (41%, N = 13), followed by checklists (25%, N = 8), interviews or group discussions (16%, N = 5), and tools that extracted information directly from data sources (13%, N = 4) The most frequent analytical approach adopted in the reviewed articles was quantitative analysis (N = 16, 50%), followed by qualitative analysis (N = 12, 38%) and mixed methods (N = 3, 9%) In most of the articles the assessment results were reported by listing gaps in preparedness (N = 9, 28%), a preparedness score with defined preparedness levels/margins (N = 6, 19%) or a preparedness score with descriptive figures (N = 6, 19%) The elements of preparedness incorporated in each assessment were also reviewed in this paper, the most common domains being “Pre-event preparation and governance” and “Event response management” Overall, from the reviewed articles, we identified important features and points of improvement that assessment approaches should undertake These suggestions include the need for assessments to identify and specify appropriate stakeholders to conduct and complete the evaluation; the importance of reaching a consensus on what preparedness standards to measure; and the need for further research on minimising the biases specific to each assessment format

Assessing public health emergency preparedness: A scoping review on recent tools and methods

Among the possible developments of the Covid-19 pandemic at the international and national levels is the advancement of the Global Health Security (GHS) agenda. On the one hand, GHS might be able to give priority to health problems on the political agenda-setting, on the other, however, it might open up space for public security actors in decision-making processes to the detriment of the power of health authorities. This article critically analyzes the concept and the progress of the GHS agenda seeking to demonstrate that there can be no security in matters of public health when sustainability in its multiple dimensions is not taken into account. At the end, sustainability has a twofold responsibility: to maintain the consistency and permanence of emergency response actions, especially with investments in public health systems, with universal access, and to minimize the structural causes of pandemics linked to the environment.

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Lessons from the Covid-19 pandemic: Sustainability is an indispensable condition of global health security

Since the 2014–2016 West Africa Ebola epidemic, the concept of measuring health security capacity has become increasingly important within the broader context of health systems-strengthening, enhancing responses to public health emergencies, and reducing global catastrophic biological risks. Efforts to regularly and sustainably track the evolution of health security capabilities and capacities over time – while also accounting for political, social, and environmental risks – could help countries progress toward eliminating sources of health insecurity. We sought to aggregate evidence-based principles that capture a country’s baseline public health and healthcare capabilities, its health security system performance before and during infectious disease crises, and its broader social, political, security, and ecological risk environments. We conducted a scoping review of English-language scholarly and gray literature to identify evidence- and practice-based indicators and proxies for measuring health security at the country level over time. We then used a qualitative coding framework to identify recurrent themes in the literature and synthesize foundational principles for measuring global health security. Documents reviewed included English-language literature published after 2001 until the end of the research period—September 2017—to ensure relevance to the current global health security landscape; literature examining acute infectious disease threats with potential for transnational spread; and literature addressing global health security efforts at the country level. We synthesized four foundational principles for measuring global health security: measurement requires assessment of existing capacities, as well as efforts to build core public health, healthcare, and biosecurity capabilities; assessments of national programs and efforts to mitigate a critical subset of priority threats could inform efforts to generate useful metrics for global health security; there are measurable enabling factors facilitating health security-strengthening efforts; and finally, measurement requires consideration of social, political, and ecological risk environments. The themes identified in this review could inform efforts to systematically assess the impacts and effectiveness of activities undertaken to strengthen global health security.

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Establishing a theoretical foundation for measuring global health security: a scoping review

Biosecurity and biosafety measures are designed to mitigate intentional and accidental biological risks that pose potentially catastrophic consequences to a country's health system, security, and political and economic stability. Unfortunately, biosecurity and biosafety are often under-prioritized nationally, regionally, and globally. Security leaders often deemphasize accidental and deliberate biological threats relative to other challenges to peace and security. Given emerging biological risks, including those associated with rapid technological advances and terrorist and state interest in weapons of mass destruction, biosecurity deserves stronger emphasis in health and security fora. The Global Biosecurity Dialogue (GBD) was initiated to align national and regional donor initiatives toward a common set of measurable targets. The GBD was launched by the Nuclear Threat Initiative (NTI), with support from Global Affairs Canada's Weapons Threat Reduction Program and the Open Philanthropy Project, and in coordination with the government of The Netherlands as the 2018-19 Chair of the Global Health Security Agenda (GHSA) Action Package Prevent-3 (APP3) on Biosafety and Biosecurity. The GBD provides a multisectoral forum for sharing models, enabling new actions to achieve biosecurity-related targets, and promoting biosecurity as an integral component of health security. The GBD has contributed to new national and continent-wide actions, including the African Union and Africa Centres for Disease Control and Prevention's new regional Initiative to Strengthen Biosafety and Biosecurity in Africa. Here we present the GBD as a model for catalyzing action within APP3. We describe how the benefits of this approach could expand to other GHSA Action Packages and international health security initiatives.

Accelerating Action in Global Health Security: Global Biosecurity Dialogue as a Model for Advancing the Global Health Security Agenda

The NTI Nuclear Security Index (NTI Index) is a first-of-its-kind public assessment of nuclear security conditions on a country-by-country basis in 176 countries. Initially launched in 2012 (a fifth edition is planned for release in June 2020), the NTI Index helps spark international discussions about priorities required to strengthen security and most important, encourages governments to provide assurances and take actions to reduce risks. Developed with the Economist Intelligence Unit (EIU) and with input from a respected international panel of nuclear security experts, the NTI Index draws on NTI’s nuclear expertise and the EIU’s experience in constructing indices, and the reach of the EIU’s global network analysts and contributors. This chapter examines whether the NTI Index methodology could apply to the state-level concept (SLC) in the nonproliferation and arms control verification context, including a discussion of the benefits and constraints of developing an index tool for assessing a country’s compliance with nonproliferation and arms control commitments. For further details on the NTI Index, please see the NTI Index website: www.ntiindex.org.

Michelle Nalabandian

Papers

Establishing a theoretical foundation for measuring global health security: a scoping review

Accelerating Action in Global Health Security: Global Biosecurity Dialogue as a Model for Advancing the Global Health Security Agenda

NTI Nuclear Security Index: A Model for State-Level Approaches to Nonproliferation and Arms Control