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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Suggested Citation:"Appendix A: Commissioned Paper." National Academies of Sciences, Engineering, and Medicine. 2019. Exploring Lessons Learned from a Century of Outbreaks: Readiness for 2030: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25391.
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Appendix A Commissioned Paper Readiness for Microbial Threats 2030: Exploring Lessons Learned Since the 1918 Influenza Pandemic Elvis Garcia, M.P.H., M.P.A., M.Eng. Harvard T.H. Chan School of Public Health Liana Rosenkrantz Woskie, M.Sc. Harvard Global Health Institute 149

150 LESSONS LEARNED FROM A CENTURY OF OUTBREAKS ACRONYMS AND ABBREVIATIONS DG Director-General DON disease outbreak news DORS disease outbreak response system ED executive director EIS epidemic intelligence service EOC emergency operations centers ERF emergency response framework FAO Food and Agriculture Organization of the United Nations GHSA Global Health Security Agenda GOARN Global Outbreak Alert and Response Network HSS health systems strengthening IHR International Health Regulations ILAR Institute for Laboratory Animal Research IMF International Monetary Fund MERS-CoV Middle East respiratory syndrome coronavirus MOH Ministry of Health OIE World Organisation for Animal Health PHEIC public health emergency of international concern R&D research and development SARS severe acute respiratory syndrome SDG Sustainable Development Goal UHC universal health coverage UN United Nations UNGA United Nations General Assembly UNSG United Nations Secretary-General WHA World Health Assembly WHO World Health Organization WTO World Trade Organization

APPENDIX A 151 BACKGROUND The world has made dramatic strides in tackling infectious diseases over the past century, including smallpox eradication, significant progress on polio eradication, and widespread vaccination. However, new threats have emerged—including 30 new zoonotic diseases in the past two decades alone. This uptick in new diseases may be the result of many factors, includ- ing economic growth, global travel, the proximity of humans to animals, or climate change, and the trend does not appear to be slowing. One hundred years after the 1918 pandemic influenza, we remain at risk of pandemic spread—perhaps more so than ever before. This continued risk highlights the need to be globally prepared. While many lessons on preparedness were gleaned following the 2014 Ebola outbreak in West Africa, we still lack a more comprehensive summary of lessons from different outbreak and pan- demic events over the course of the past century. To address this gap, we reviewed reports outlining recommendations and lessons from major epidemics that have occurred since the 1918 influ- enza pandemic. Six major types of outbreaks were chosen by the Forum on Microbial Threats (FMT) to survey.1 We conducted a unique review of the literature for each outbreak to capture reports or studies published dur- ing, or in the years following, that pandemic (see reference list at the end of the commissioned paper). The subject of the review was what needs to be accomplished to make progress in epidemic and pandemic preparedness moving forward—or globally relevant lessons learned from each event. Where possible, we focused on global lessons (for more than one coun- try) from each specific outbreak. This ultimately included global lessons abstracted from 16 peer-reviewed papers or reports. The process was not meant to be exhaustive but rather representative of different periods, dis- ease types, and authorship (e.g., academic, practitioner, multilateral). We found significant overlap in content across the reports. This finding was consistent with themes summarized by both Gostin (2016) and Moon et al. (2017) in Toward a Common Secure Future: Four Global Commis- sions in the Wake of Ebola and Post-Ebola Reforms: Ample Analysis, Inadequate Action, respectively. Moon et al. (2017) categorized recommen- dations from the 2014 Ebola outbreak in West Africa as follows: 1. Bolster country-level core capacities and compliance with the International Health Regulations (IHR). 1  The following outbreaks were selected: (1) the 1957 and 1968 influenza pandemics, (2) the 2003 emergence of influenza A (H5N1) and severe acute respiratory syndrome (SARS), (3) the 2009 H1N1 influenza A pandemic, (4) the 2013 emergence of influenza A (H7N9), (5) the 2014–2016 Ebola outbreak in West Africa, and (6) the 2012–2015 Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak in Saudi Arabia and in Korea.

152 LESSONS LEARNED FROM A CENTURY OF OUTBREAKS 2. Improve knowledge sharing and research. 3. Strengthen the World Health Organization (WHO), the United Nations (UN), and broader global health or humanitarian systems. Below, we summarize highlights from the review using an adaptation of this same framework. Additionally, for each category, we provide sum- maries of recommendations and lessons (see Boxes A-1 to A-5), which are outlined in more detail in Tables A-1 to A-5. CATEGORY 1: COUNTRY-LEVEL CORE CAPACITIES Robust and sustainable health systems are a prerequisite for preventing, detecting, and responding to pandemics and to pandemic threats. The IHR are the current framework for country preparedness for infectious disease outbreaks and require 196 State Parties to develop and maintain core health system capacities in the face of acute public health risks such as infectious disease threats of international concern. Core capacities in this framework are organized into three categories related to prevention, detection, and response, which include subdomains (e.g., health workforce, laboratories, data systems, and risk communication), in order to identify and to con- tain threats before they cross national borders. While this review includes studies that were released prior to the development of the IHR, we use the IHR framework to organize recommendations and lessons from reviewed content (see Box A-1). Additional content was also reviewed on trade and travel, accountability mechanisms, and other suggestions to support coun- tries as they work to achieve adequate core capacities. BOX A-1 Recommendations and Lessons for Bolstering Country-Level Core Capacities Strengthening Capacity to PREVENT 1. Response frameworks should include better scenario planning and less rigidity, considering variation that occurs among diseases. Ministries of health should be familiar with different suites of measures so that they can deploy them flexibly. (H1N1) 2. Effective primary care can help alleviate the overloading of emergency departments. (H1N1) 3. Prevention goals within the International Health Regulations (IHR) should align with those in the universal health coverage (UHC) agenda, and accountability should be built into both frameworks. (Ebola)

APPENDIX A 153 BOX A-1 Continued Strengthening Capacity to DETECT 1. “Wide net” surveillance often makes sense in situations when there are nonspecific symptoms (H1N1), and nonhealth entities can support screening in places such as schools, businesses, and transportation sites. (SARS, H1N1) 2. National surveillance needs to be paired with rapid international verifica- tion, especially when a pandemic occurs in low-resource contexts with limited lab capacity. (H5N1) 3. Web-based search patterns can be used to identify potential risks early. (H1N1) 4. Surveillance efforts must be tied to animal health and focused on rural areas. (H1N1, H5N1) 5. “Timeliness of data management and risk assessment is essential for identifying unusual clusters (e.g., high death rates) and initiating ap- propriate responses” (Fisher et al., 2011). (H1N1) 6. When the disease is not fully understood, detection systems should include feedback loops on spread, so clinicians and other people who treat the disease can understand viral transmission and treatment ef- fectiveness. (H1N1) Strengthening Capacity to RESPOND 1. Strong health systems are key: “Underresourced, understaffed, and fragmented health services are unable to contain outbreaks of serious infectious diseases or to adequately respond to health emergencies” (Save the Children, 2015). (Ebola) 2. “Health care workers must be given priority for protection and treatment to enable them to perform their duties” (Lee et al., 2008). (H1N1) 3. Lack of epidemiological information on the disease hampers effective treatment. (H1N1) 4. Response plans, even those created for prior diseases, are effective and provide a blueprint for countries. However, there is need for practi- cal testing of these plans at both hospital and above hospital levels. (H1N1) 5. Containment, as a strategy, is highly dependent on the disease. When containment efforts do not work, the importance of communicating risk to the public increases. (H1N1) 6. Risk communication and engagement with communities throughout outbreak events were noted as critical for each outbreak. Specific efforts featured included dedicated government websites and use of social media. (Multiple)

154 LESSONS LEARNED FROM A CENTURY OF OUTBREAKS In this review, we found that 16 out of 16 papers included content on core national capacities on outbreak reporting (if not specifically those outlined in the IHR). Some of this content was presented in the form of lessons for future outbreaks while other content was framed as reflections (often made by practitioners or policy makers who actively addressed an outbreak event). Recommendations and lessons regarding how the broader global health system could support countries’ efforts to develop core capacities were also mentioned throughout the reviewed papers but were less common than lessons aimed at countries themselves. Suggestions for WHO included content on supporting country preparedness in the absence of a current pandemic and on what WHO’s role should be during an actual outbreak (see Box A-2). BOX A-2 Recommendations and Lessons for Bolstering the Global System Support for Country-Level Core Capacities Role of the World Health Organization (WHO) in Supporting Country Capacity 1. WHO should prepare a template pandemic preparedness plan for coun- tries. (H5N1) 2. WHO should develop benchmarks for core capabilities and support countries’ efforts to achieve them. (Ebola) 3. WHO needs to “establish a more extensive public health reserve work- force” (WHO, 2005). (H5N1) 4. WHO is mandated to serve as the guardian of the International Health Regulations, and it may require involvement from multiple levels of the organization to accomplish this mandate (e.g., national country offices, regional offices, and headquarters). (H7N9) 5. WHO needs to “work with existing regional and sub-regional networks to strengthen linkages and coordination; the ultimate goal is to enhance mutual support and trust” (Sands et al., 2016). (Ebola) 6. WHO and other international guidelines cannot adapt as fast as local knowledge and should not eclipse clinical judgment. Adequate feedback loops are required so that guidelines are dynamic and respond to on- the-ground realities. (MERS-CoV)

APPENDIX A 155 BOX A-2 Continued Roles of Other Global Actors in Supporting Country Capacity 1. The UN Secretary-General should ensure a minimum level of health- system functionality in fragile and failed states. (H7N9) 2. “The International Monetary Fund (IMF) should include pandemic pre- paredness in countries’ economic and policy assessments” (Sands et al., 2016). (Ebola) 3. All development assistance for health should be contingent on pan- demic preparedness at the national level. (Ebola) Public Health Emergency of International Concern (PHEIC)a Reporting 1. The PHEIC reporting mechanisms should be used for the duration of a pandemic to communicate updates throughout the event. (H7N9) 2. An intermediate level prior to a formal PHEIC would incentivize coun- tries to express risk at earlier stages—without the risks associated with communicating a full PHEIC. (Ebola) a“A PHEIC is an extraordinary event that constitutes a public health risk to other State Parties through the international spread of disease and that potentially requires a coordinated international response” (WHO, 2016a). CATEGORY 2: RESEARCH, DEVELOPMENT, AND KNOWLEDGE SHARING There has been a persistent failure of timely vaccine deployment and lack of global knowledge/data sharing over time. The papers reviewed, con- sistent with prior work, recognize that for both effectively preventing and mitigating outbreaks timely sharing of information of research and health technology efforts is critical. While this topic was less well explored than national core capacities or global governance, several papers have outlined problems with vaccine readiness, sample sharing, and other issues related to the handling of epidemiological, genomic, or clinical data both during as well as after pandemics. In this review, we found that 8 out of the 16 papers contained content that addressed pharmaceutical research and development (R&D) or sample sharing and information sharing (see Box A-3).

156 LESSONS LEARNED FROM A CENTURY OF OUTBREAKS BOX A-3 Recommendations and Lessons for Improving Research, Development, and Knowledge Sharing Vaccine, Diagnostic, and Therapeutic Readiness   “Public health measures such as antivirals, vaccination, and 1. nonpharmaceutical interventions must be performed in concert to reduce the impact of a future pandemic” (Lee et al., 2008). (H1N1 1957–1968)  2. Very rapid and highly sensitive tests, which “substantially reduce the number of individuals that need to be quarantined without decreasing the effectiveness of the measure, need to be developed” (Tan, 2006). (SARS)   3. The development of a pandemic vaccine should be expedited: “Shorten the time between the emergence of a pandemic virus and the start of commercial production” (Behrens et al., 2006). (H5N1)   4. Scientific understanding and technical capacity need to be improved, because both are currently fundamental constraints on pandemic preparedness. (H1N1)   5. A comprehensive influenza research and evaluation program should be pursued. (H1N1)   6. “Investment in medical research and development (R&D) for diseases that largely affect the poor is deeply inadequate. Of the $214 billion invested in health R&D globally in 2010, less than 2 percent was allocated to neglected diseases” (UN High-level Panel on the Global Response to Health Crises, 2016). (Ebola)   7. Research and development (R&D) should not be left to market forces: The Ebola outbreak exemplified “how ill-suited the medical research and development model is for addressing the world’s health priorities” (Heymann et al., 2015). (Ebola)   8. Drug quality issues should be addressed: They pose “social, economic, and political challenges to health security by undermining capabilities to curb both infectious and noncommunicable diseases while eroding public confidence in governments and international institutions” (Heymann et al., 2015). (Ebola)   9. R&D “armory” should be built. It currently has “many gaps, which Ebola and other outbreaks have revealed, that span vaccine development and capacity, diagnostic tools, therapeutics, protective equipment, and anthropological research” (Sands et al., 2016). (Ebola) 10. Resources should be dedicated to “R&D on prioritized pathogens to ensure the greater availability of critical vaccines and treatments when they are most needed” (UN, 2016). (Ebola)

APPENDIX A 157 Delivery Capacity for Pharmaceutical and Medical Goods 1. An outbreak should be contained or delayed at the source. An international stockpile of antiviral drugs should be established, and mass delivery mechanisms for antiviral drugs should be developed. (H5N1) 2. There is a worldwide need for greater production capacity and for faster throughput. (H1N1) 3. Advanced agreements for vaccine distribution and delivery should be encouraged. (H1N1) 4. Significantly greater resources for medical products should be prioritized, mobilized, and deployed, and development and regulatory approval processes should be harmonized. (Ebola) Sample and Knowledge Sharing 1. “The exchange of epidemiological information on infectious diseases, especially the emergence of new infections, should be strengthened between the health authorities in Mainland China and Hong Kong” (Hung, 2003). (SARS) 2. It is important to reach an agreement on the sharing of viruses. (H1N1, Ebola) Synergies with One Health 1. Feedback loops should be developed between human and animal health. (Multiple) 2. “Most of the affected countries could not adequately compensate farmers for culled poultry, thus discouraging the reporting of outbreaks in rural areas where the vast majority of human cases have occurred” (WHO, 2005). (H5N1) 3. “Domestic ducks were able to excrete large quantities of a highly pathogenic virus without showing signs of illness. Their silent role in maintaining transmission further complicated control in poultry and made human avoidance of risky behaviors more difficult” (WHO Communicable Disease Surveillance and Response Global Influenza Programme, 2005). (H5N1) 4. More investment in “One Health research should be requested to enhance understanding of the emergence, prevention, detection, and control of pandemic influenza viruses” (Monath et al., 2010). (H1N1)

158 LESSONS LEARNED FROM A CENTURY OF OUTBREAKS CATEGORY 3: WHO AND THE GLOBAL SYSTEM Following the 2014 Ebola outbreak in West Africa, seven major reports agreed that reforms needed to be put in place to improve the global gov- ernance mechanisms within WHO and the broader UN and humanitarian systems to strengthen the global response capacity to these type of events. While the reports also agreed on maintaining the global preparedness and response functions for global disease outbreaks within WHO, they did not agree on how best to do this. Since Ebola, WHO has undergone a number of reforms—which we do not fully cover here. Rather, in this review, we look at what postpandemic reports have suggested as necessary changes. In line with prior work on this topic, we use sub-themes—for example, WHO’s specific role in outbreaks, as well as internal suggestions regard- ing leadership and human resources (see Box A-4). This includes issues related to WHO’s operational capacity to respond to disease outbreaks on the ground as well as broader institutional reforms to all multilateral organizations, such as financing, that may not be limited to emergencies or outbreaks (see Box A-5). There is some overlap with the category on national core capacities, but in that category we had focused on the role of WHO in supporting countries, while in this category, we take a systems view of the global governance mechanisms in place. We found that 7 of the 16 papers addressed broader issues of the global governance system (items that might be addressed by cross-national bodies, such as WHO or the UN). The inclusion of this topic, recommendations related to the global system (UN, WHO, or other multilateral organiza- tions), increased during and after the 2014 Ebola outbreak. Therefore, the majority of recommendations are from reports on, or following, the 2014 Ebola outbreak. Prior to this time, many reports were produced by agencies themselves with minimal inward-looking recommendations or critiques of the global health system, however defined.

APPENDIX A 159 BOX A-4 Recommendations and Lessons for Strengthening World Health Organization’s (WHO’s) Capacity WHO Actions and Internal Capacity for Future Outbreaks 1. WHO needs to develop operational capacity. (Ebola) 2. WHO should build capacity to support low- and middle-income ­ ountries c in the development of their own vaccine manufacturing capacity, and national pandemics preparedness plans. (H5N1) 3. Greater resources are needed to be able to improve WHO capacities, and this would require a profound organizational transformation. (Ebola) 4. WHO should establish a Program/Center for Health Emergency Preparedness and Response that is governed by an independent technical governing board. (H5N1, Ebola) 5. The role of WHO as a broker of knowledge—with the ability to respond more effectively when at odds with local, quickly developing knowledge—should be reinforced. (Ebola) 6. WHO should enhance cooperation with non-state actors while recalibrating relationships with member states and recognizing the distinct roles that each actor plays. (Ebola) WHO Leadership and Human Resources 1. The new Director-General’s critical role should be to refocus WHO’s purpose and structure, and remain accountable for incident management within WHO. (Ebola) 2. WHO should revise how elections are conducted for WHO officials and should specifically improve transparency and the democratic nature of elections. (Ebola) 3. WHO should invest in training health professionals, especially community health workers. (Ebola) 4. WHO staff need to be qualified to manage outbreaks and emergencies. Health workforces should include a broad range of actors from multiple sectors working at different levels, rather than a single global workforce of “white helmets.” (Ebola) 5. WHO should increase its staff. (Ebola)

160 LESSONS LEARNED FROM A CENTURY OF OUTBREAKS BOX A-5 Recommendations and Lessons for Strengthening System-Wide Capacity Operations (Internal and External to World Health Organization [WHO]) 1. Existing institutions should be leveraged rather than creating new ones. (Ebola) 2. Actors need to coordinate more effectively with each other and to establish clear lines of command. (Ebola) 3. During health crises, humanitarian actors should have access to guidelines and standard operating procedures. (Ebola) 4. Health cluster capacities and integration need to be developed along with the overall humanitarian system. (Ebola) Accountability 1. Regular independent assessments should be commissioned. (Ebola) 2. Sustainable Development Goals (SDGs) should be used to target indicators as a baseline for accountability. (Ebola) 3. WHO should be required to use existing resources more efficiently, report against specific outcomes, develop indicators to assess progress, and rigorously track expenditures. (Ebola) Financing and Aid 1. Investments need to increase for building robust health systems. (Ebola) 2. WHO should mobilize international financial support for IHR core capacities strengthening. (Ebola) 3. Contributions should increase for WHO, and WHO should establish a contingency fund for these type of emergencies. (Ebola) 4. Funding for WHO’s Emergency Program’s baseline capacity should be secured through predictable and reliable financing streams, including assessed contribution and different from funding for specific responses. (Ebola) 5. Effective mechanisms are needed to help countries in need through institutions like the IMF and World Bank. Initiatives need to provide budgetary support and rapid credit availability. (Ebola) 6. The creation of World Bank’s Pandemic Emergency Finance Facility should be supported. (Ebola)

APPENDIX A 161 CONCLUSION We found that country-level core capacities were the most common subject covered by the reports in this review. In earlier reports, recommen- dations on core capacities were more thoroughly explored, and targeted advice was provided at the country level. Later reports, particularly those following the 2005 IHR, focused on the effective implementation of IHR as opposed to its component parts. However, domains across the reports were similar (e.g., preparedness, detection, and response), which may reflect the incorporation of earlier recommendations into the IHR in 2005. Another notable difference in later reports was a shift toward taking a wider lens view (e.g., recommendations to strengthen capacities across countries) and examining the need to tie together global health agendas, such as the IHR and universal health coverage (UHC), as a primary component of the SDGs. This trend aligns with an increase in the number of global health actors over time, which, in turn, likely increases the relevance of dialogue on global coordination and accountability for country preparedness. While some reports covered issues such as health technologies, phar- maceutical readiness, deployment, or knowledge sharing (e.g., biological samples or results from trials), several others provided recommendations focused primarily on vaccine readiness. Specifically, many of the reports discussed the persistent failure of timely vaccine deployment and the lack of global knowledge-sharing norms around vaccines. Unlike their suggestions around country-level core capacities, recommendations on vaccine readiness resulting from outbreaks over time were generally consistent, which suggests broader challenges have yet to be addressed in this domain. There have, how- ever, been notable efforts to address these recommendations more recently (e.g., the Coalition for Epidemic Preparedness Innovations, the WHO’s R&D “Blueprint,” and other efforts summarized by Leigh et al. [2018]). Additionally, across reports, systems for the delivery of pharmaceuticals and other medical technologies were noted as impediments to effective response. However, authors offered few recommendations to improve deliv- ery capacity or to engage other actors, such as the private sector or military, in doing so. Content on R&D differed among reports depending on disease context. For example, following influenza outbreaks, discussions included a focus on One Health and on the need to better align human and animal R&D strategies. This was not true for Ebola reports, where the zoonotic nature of the disease was less well understood. In line with country-level capacity recommendations, this category may benefit from a more dynamic approach to readiness given the diversity of medical technologies needed. Such an approach could include familiarizing ministries of health and other key actors with multiple scenarios so that outbreak responses are adaptive to disease types.

162 LESSONS LEARNED FROM A CENTURY OF OUTBREAKS For reports following the 2014 Ebola outbreak, there was a notable increase in discussion of and recommendations regarding global governance mechanisms for health. As noted above, this may stem from diversification of the global health landscape over time and from the empowerment of additional global actors, such as those in academia, civil society, and the private sector, to assess and to comment on global performance—includ- ing WHO’s performance. This category, which addresses accountability at a multinational level, is particularly relevant given the current Ebola out- break in the Democratic Republic of the Congo. When faced with fragile or failed states, a focus on national core capacities alone becomes starkly inadequate. The global system should help countries as they develop and maintain core capacities on the ground but also should oversee global accountability, ensure clear and accurate knowledge transfer, and assume other roles that a single country cannot fill. This can be a delicate balance, and report recommendations highlighted the importance of ensuring that global guidelines do not eclipse local, real-time understandings of disease. This has been a consistent challenge to effective global and local response. Common recommendations included the need to better delineate roles and responsibilities, improve coordination, ensure accountability mechanisms, and consider drivers of trust in the relevant institutions. REFERENCES Behrens, G., R. Gottschalk, L. Gürtler, T. C. Harder, C. Hoffmann, B. S. Kamps, S. Korsman, W. Preiser, G. Reyes-Terán, M. Stoll, O. Werner, and G. v. Zyl. 2006. Influenza Report 2006. Flying Publisher. https://epdf.tips/influenza-report-200625f97a9a4de822cdfd- 4d527adc19657a35369.html (accessed April 2, 2019). Fineberg, H. V. 2014. Pandemic preparedness and response—Lessons from the H1N1 influenza of 2009. New England Journal of Medicine 370:1335–1342. Fisher, D., D. S. Hui, Z. Gao, C. Lee, M. D. Oh, B. Cao, T. T. Hien, K. Patlovich, and J. Farrar. 2011. Pandemic response lessons from influenza H1N1 2009 in Asia. Respirology 16(6):876–882. Global Health Crises Task Force. 2016. Protecting humanity from future health crises: ­ NSG’s high-level panel on global response to health crises. New York: United Nations. U Gostin, L.O., O. Tomori, S. Wibulpolprasert, A. K. Jha, J. Frenk, S. Moon, J. Phumaphi, P. Piot, B. Stocking, V. J. Dzau, and G. M. Leung. 2016. Toward a common secure future: Four global commissions in the wake of Ebola. PLoS Medicine 13(5):e1002042. Heymann, D. L., L. Chen, K. Takemi, D. P. Fidler, J. W. Tappero, M. J. Thomas, T. A. Kenyon, T. R. Frieden, D. Yach, S. Nishtar, A. Kalache, P. L. Olliaro, P. Horby, E. Torreele, L. O. Gostin, M. Ndomondo-Sigonda, D. Carpenter, S. Rushton, L. Lillywhite, B. Devkota, K. Koser, R. Yates, R. S. Dhillon, and R. P Rannan-Eliya. 2015. Global health security: The wider lessons from the West African Ebola virus disease epidemic. The Lancet 385(9980):1884–1901. Hung, L. S. 2003. The SARS epidemic in Hong Kong: What lessons have we learned? Journal of the Royal Society of Medicine 96(8):374–378.

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TABLE A-1 Category 1a: Country-Level Core Capacities—National Core Capacities 164 National Core Capacities Year of Publication Disease Outbreak Outlet Prevent/Prepare Detect Respond (Treat and Control) Twentieth Century H1N1 1957– Annals (R) Identify the onset of the (R) Give protection and treatment priority to Influenza Pandemics 1968 Academy of pandemic for early health care workers to enable them to in Singapore Medicine intervention (however, perform their duties Singapore influenza remains a difficult surveillance target because it manifests in a variety of non- specific symptoms) (R) Collect viral samples in a routine way. If a pandemic originates in less developed regions with high baseline mortality rates, the signal may be missed (R) Focus global surveillance efforts on frontline efforts in East Asian farms The SARS Epidemic SARS 2003 Journal of the (B) Inadequate epidemiological information in Hong Kong: What Royal Society about the disease hampered the prompt Lessons Have We of Medicine application of effective control measures Learned? (B) Lack of specified infectious disease hospitals led to difficulties in designating hospitals for the isolation and treatment of SARS patients (B) Deficient communication between the secretary (ministry) level responsible for health policy and the management level responsible for operation of hospitals SARS in SARS 2003 Annals (F) MOH adopted wide-net (F) Major containment efforts were Singapore—Key Academy of surveillance, isolation, and concentrated on hospitals (SARS was Lessons from an Medicine quarantine policy to detect all predominantly a nosocomial infection) Epidemic Singapore suspicious cases as early as (F) Early separation of potentially infectious possible and to isolate them patients (F) Temperature screening in (F) Enforced use of personal protective hospitals and in the equipment for all hospital staff and the community (e.g., preventing adoption of strict infection-control measures, the importation and including temperature monitoring of all exportation of SARS through hospital staff temperature screening at the (F) Designation of one SARS hospital airport and sea ports) allowed the clinicians at that site to develop strong clinical expertise

(R) Contain public anxiety and re-direct this energy into positive community bonding and action (R) Enact a strong and effective command, control, and coordination of responses Responding to the H5N1 2003 WHO (R) Use WHO, FAO, and OIE (R) Prioritize interventions in the backyard Avian Influenza Communicable jointly established Global rural farming system “wet markets” where Pandemic Threat Disease Early Warning and Response live poultry are sold in overcrowded and Surveillance System for trans-boundary often unsanitary conditions and Response animal diseases (R) Strengthen risk communication to rural Global (R) Develop infrastructure to residents Influenza complement national testing (R) Generate better knowledge on animal Programme with rapid international and human disease through WHO, in verification in WHO-certified collaboration with FAO and OIE, to make laboratories, especially as risk communication more precise and better each confirmed human case able to prevent risky behavior yields information essential to (R) Identify risk groups to guide preventive risk assessment measures and early interventions (R) Health authorities should start a continuous process of risk communication to the public as soon as pandemic is declared (R) Monitor the effectiveness of health and nonhealth interventions in real time Pandemic H1N1 2009 New England (R) Accelerate the implementation of the (F) Web-based search patterns Preparedness and Journal of IHR (2005) core capacities can yield valuable intelligence Response—Lessons Medicine that can give the world a head from the H1N1 start on the next emerging Influenza of 2009 pandemic 165 continued

Influenza A (H1N1- H1N1 2009 Annals (F) When previous DORS framework (F) Local disease surveillance (F) National Influenza Pandemic Readiness 166 2009) Pandemic in Academy of was not applicable to H1N1-2009, both systems are critically and Response Plan developed for SARS was Singapore—Public Medicine MOH and its stakeholders had to reframe important to informing useful in responding to H1N1 Health Control Singapore and relearn the context of public health pandemic situations (e.g., (F) Framework for organizing/coordinating Measures control measures mid-response monitoring the progression of “whole of government” strategy and creation Implemented and (F) Stakeholders benefited from the the pandemic in the of crisis management groups Lessons Learnt flexibility to assess and take appropriate community, identifying the (F) Dedicated ambulance service created for measures locally start of sustained community suspected patients (R) Ensure better planning for multiple transmission, and guiding the (F) A dedicated government website on scenarios and less rigidity in plans step-down of containment influenza also facilitated the public’s easy (R) MOHs should familiarize themselves measures) access to information with different suites of measures, which (F) At-home learning or work- (R) Consider DORS as a guide for increasing could be implemented in a modular from-home options helped or scaling down response fashion decrease risk when (R) Have a core group of clinicians (R) Invest in an effective primary care transmission was high (comprising public health, infectious disease, response, which can prevent the (R) Work with clinics and microbiology, and respiratory medicine overloading of emergency departments in community, not only large specialists) meet regularly to review times of acute need hospitals, to assess true epidemiological and clinical information to prevalence of disease make decisions (R) Nonhealth care (R) Develop real-time, targeted public health establishments (e.g., schools “operational” research to determine the and businesses) should be effectiveness of specific public health involved in temperature and policies and control measures symptom screenings (R) Work toward building trust among stakeholders, as well as a degree of system discipline. This must be developed and built in peacetime (R) Generate creative personnel strategies that will help to build and maintain health care surge capacity in peacetime Lessons from H1N1 2009 ILAR Journal (R) Develop an effective (B) Misunderstandings of the relationship Pandemic H1N1 global, strategic, integrated between pigs and H1N1 led to unnecessary 2009 to Improve surveillance and response confusion and policy action, such as trade Prevention, system (which requires bans on the sale of meat Detection, and human, animal, and (R) Move away from naming flu strains Response to environmental health based on potential animal hosts Influenza Pandemics professionals to work together from a One Health for earlier detection and Perspective disease control) (R) Establish more comprehensive surveillance for infection and disease in occupational groups that work most closely with animals (i.e., poultry and swine workers, live market workers

and vendors, abattoir workers, veterinarians, and animal health technicians) Pandemic Response H1N1 2009 Respirology (R) Develop integrated analyses that (R) Strengthen timeliness of (B) Planning and hierarchy of intensive care Lessons from combine microbiological/virological, data management and risk and high dependency units across Asia were Influenza H1N1 immunological, clinical, epidemiological, assessments for identifying inadequate and slowed the response 2009 in Asia and genetic data for comprehensive unusual clusters (e.g., high (R) Need for practical and tested hospital assessment of host–emerging pathogen death rates) and initiating and inter-hospital level response plans for interactions appropriate responses public health emergencies and mass casualty events (R) Need for systems above the hospital level that allow for coordinated management of beds and other finite resources including equipment and manpower (R) Focus on risk communication when containment measures do not work (R) Establish a two-way communication system between administration and clinical providers to coordinate protocol dissemination and resources (R) Improve preexisting infection control practices Early Response to H7N9 2013 Bulletin of the (R) Strengthen coordination between (R) Strengthen the relevant the Emergence of World Health public health and veterinary services infrastructures, surveillance Influenza A (H7N9) Organization during an emergency by engaging in joint systems, and response Virus in Humans in preparedness planning beforehand capacity in preparation for China: The Central future emergencies caused by Role of Prompt emerging or existing disease Information Sharing threats and Public Communication Avian Influenza A H7N9 2013 WHO (F) Notable initiatives undertaken by (R) Leverage surveillance (F) Combined efforts of the human and (H7N9) Response: Publication China included enhancing public health capacity developed through animal health sectors through mutual sharing An Investment in emergency planning, establishing a Web- previous events (e.g., SARS) of information, close and timely Public Health based reporting system, and communication, and coordinated response Preparedness strengthening the National Influenza (F) Rumors spread faster than the virus Center as one of the six WHO itself, so a coordinated social media strategy collaborating centers was key to keeping the public up to date (R) Establish country–WHO partnerships, such as the China–WHO mission, to allow WHO to learn from people on the frontline and allow people on the frontline to 167 communicate information quickly to regional actors continued

Global Health Ebola 2014 The Lancet (F) Enhanced pharmacovigilance and Security: The Wider Global Health Ebola 2014 The Lancet (F) Enhanced pharmacovigilancebroad quality assurance composed two and Lessons from the 168 Security: The Wider qualityresponses that were essential to policy assurance composed two broad West African Ebola Lessons from the coordinate across governments policy responses that were essential to Virus African Ebola West Disease coordinate across governments Epidemic Virus Disease A Wake Up Epidemic Call: Ebola 2014 Save the (R) Make public commitments to (F) Under-resourced, understaffed, and A Wake from Ebola Lessons Up Call: Ebola 2014 Children Save the building universal health coverage, (R) Make public commitments to with fragmented health services are unable to (F) Under-resourced, understaffed, and for the World’s Lessons from Ebola Publication Children buildingno direct payments at the point of little or universal health coverage, with fragmented health of serious infectiousto contain outbreaks services are unable Health Systems for the World’s Publication littleandno direct payments at the point of use, or promote the accountability of diseases or adequately respond to health contain outbreaks of serious infectious Health Systems use, and promoteof health service of government and the accountability emergencies diseases or adequately respond to health providers government and of health service emergencies (R) Increase providers investment in comprehensive health services, starting (R) Increase investment in with primary care, and prioritize essential comprehensive health services, starting services, such as infectious disease with primary care, and prioritize essential outbreaks, and maternal and child health services, such as infectious disease outbreaks, and maternal and by raising (R) Increase public finances child health fair taxation, and clamping down on tax (R) Increase public finances by raising avoidance and evasion fair taxation, and clamping down on tax (R) Strengthen and invest avoidance and evasion in national (R) Strengthen and for possible outbreaks preparedness plans invest in national preparedness diseases. Plans should of infectious plans for possible outbreaks comprise public health surveillance, of infectious diseases. Plans should alert and referral systems, and supply chain comprise public health surveillance, alert and referral systems, andprocure chain systems that can rapidly supply and/or distribute medical equipment and drugs systems that can rapidly procure and/or in emergencies distribute medical equipment and drugs Middle East MERS- 2013 Journal of (B) Poor prognosis associated with in emergencies (R) Reinforce dynamics of (R) Update guidelines regularly, and Respiratory Middle East CoV MERS- 2013 Hospital Journal of MERS-CoV, especially in patients (B) Poor prognosis associated with with continuous vigilance and incorporate local knowledge from the (R) Reinforce dynamics of (R) Update guidelines regularly, and ground Syndrome Respiratory CoV Infection Hospital MERS-CoV, especially and the lack of multiple comorbidities, in patients with perseverance with diagnostic continuous vigilance and incorporate local knowledge fromof ground (R) Facilitate the communication the Coronavirus Syndrome (MERS- Infection effective antiviral therapy make multiple comorbidities, and the lack of perseverance of undiagnosed investigation with diagnostic (R) Facilitate the medical, and scientific epidemiological, communication of Coronavirus Lessons CoV): What (MERS- appropriate infection prevention effective antiviral therapy make and infectious diseases investigation of undiagnosed epidemiological, addition to presenting the developments in medical, and scientific Can We Learn? CoV): What Lessons diagnosis challenging appropriate infection prevention and public with factual material, timely updates, infectious diseases developments in addition to presenting the Can We Learn? diagnosis challenging and relevant advice public with factual material, timely updates, NOTES: DORS = disease outbreak response system; FAO = Food and Agriculture Organization of the United Nations; IHR = International Health Regulations; ILAR = Institute for and relevant advice Laboratory Animal Research; MERS-CoV = system; East respiratory syndrome coronavirus; MOH = Ministry Nations; IHR = = World Organisation for Animal Health; Institute for NOTES: DORS = disease outbreak response Middle FAO = Food and Agriculture Organization of the United of Health; OIE International Health Regulations; ILAR = SARS = severe acute respiratory syndrome;=WHO = World Health Organization. Laboratory Animal Research; MERS-CoV Middle East respiratory syndrome coronavirus; MOH = Ministry of Health; OIE = World Organisation for Animal Health; 13 of 16 severe acute had relevant findings for this = World Health Organization. SARS = publications respiratory syndrome; WHO category and were included. 13 of 16 publications had relevant findings for this category and were included. Key: (B) Barriers to pandemic preparedness and response. Key: (F) Facilitators pandemic preparedness and response. (B) Barriers to to pandemic preparedness and response. (R) Facilitators to pandemic preparedness and response. (F) Recommendations for implementation moving forward. (R) Recommendations for implementation moving forward.

TABLE A-2 Category 1b: Country-Level Core Capacities—Core Capacity Enablers Year of Accountability and Regional and Non-WHO Publication Disease Outbreak Outlet PHEIC Reporting Role of WHO and HSS Global Actors Trade and Travel SARS in SARS 2003 Annals (F) Regular audits by Singapore—Key Academy of MOH teams, Lessons from an Medicine supplemented by internal Epidemic Singapore audits by hospitals, helped ensure a high level of compliance Responding to the H5N1 2003 WHO (R) Give risk-prone (R) WHO to establish a Avian Influenza Communicable countries an incentive to surveillance program for Pandemic Threat Disease collaborate antiviral susceptibility testing, Surveillance internationally modeled on a similar program and Response for anti-tuberculosis drugs Global (R) WHO to monitor the Influenza unfolding epidemiological and Programme clinical behavior of the new virus in real time (R) WHO to prepare a template pandemic plan, which will give many developing countries a head start in national pandemic preparedness planning Pandemic H1N1 2009 New England (R) WHO to ensure necessary (R) Reinforce evidence-based Preparedness and Journal of authority and resources for all decisions on international travel Response—Lessons Medicine national focal points and trade from the H1N1 (R) WHO to revise and Influenza of 2009 streamline the management of pandemic preparedness guidance (R) WHO to establish a more extensive public health reserve workforce globally Influenza A (H1N1- H1N1 2009 Annals (F) WHO created a model (R) Push nonhealth government 2009) Pandemic in Academy of country plan with the goal of sectors involved in mounting a Singapore—Public Medicine giving developing countries a “whole of government” Health Control Singapore framework to assess their status response to the H1N1-2009 Measures pandemic to include border 169 continued

Implemented and of preparedness and to identify control (temperature screening, 170 Lessons Learnt priority needs health declaration cards, and (R) WHO to provide support to health alert notices for countries in rehearsing these travelers), trade, and industry plans during simulation exercises Early Response to H7N9 2013 Bulletin of the (R) Release any results of (F) WHO and China’s National the Emergence of World Health risk assessments as well Health and Family Planning Influenza A (H7N9) Organization as other epidemic-related Commission jointly coordinated Virus in Humans in data promptly and the response mission by China: The Central publicly internationally recognized Role of Prompt influenza experts Information Sharing (R) WHO to strengthen relevant and Public infrastructures, surveillance Communication systems, and response capacity in preparation for future emergencies Avian Influenza A H7N9 2013 WHO (R) Establish transparent (F) WHO activated an (F) The Western Pacific (H7N9) Response: Publication and open channels of organization-wide mechanism regional office developed An Investment in communication with the involving the three levels of a framework for action Public Health global community, WHO from the country to for national health Preparedness including regular regional to headquarters offices authorities to highlight situation updates (F) The ERF provided guidance areas of public health (R) Support the in line with emergency emergency response that continued use of IHR management system and ensured may need specific action (2005) reporting adequate human resource surge for avian influenza A mechanisms throughout capacity for monitoring and (H7N9) the event in order to assessment provide timely updates (F) The EOC at the regional for relevant stakeholders office was the common platform and the public (e.g., EIS used to coordinate the response and DON) (R) As a guardian of IHR (2005) WHO to coordinate and support the H7N9 response Global Health Ebola 2014 The Lancet (R) Use GHSA to make (R) Address future threats Security: The Wider rapid progress in to health security Lessons from the strengthening collective comprehensively based West African Ebola health security through on deeper understanding country and inter-country of prevention and

Virus Disease capacities to prevent, remediation of human Epidemic detect, and respond to security infectious disease threats; (R) Broaden approach independent evaluations beyond the IHR (2005); are crucial to accelerate simply taking the IHR progress (2005) to a next step is too weak and narrow as an approach (R) Develop an initiative to drive better health within corporations The Neglected Ebola 2014 New England (R) Make all (R) Develop benchmarks for (R) World Bank to (R) The proposed WHO Dimension of Global Journal of development assistance core capabilities and support convene funders to Emergency Centre should create Security: A Medicine for health system countries in achieving them support lower-middle and protocols to dissuade member Framework for strengthening contingent (R) Work with existing regional low-income countries to states and the private sector Countering on country agreement to and sub-regional networks to achieve IHR (2005) core from implementing unnecessary Infectious Disease assessment strengthen linkages and capacities (these countries restrictions on trade and travel; Crises (R) Countries to develop coordination enhancing mutual should also develop plans WHA to implement and publish plans to support and trust, sharing of for eventual financial achieve benchmarks by information and laboratory self-sufficiency) 2020 resources, and joint outbreak (R) IMF to include (R) Create an investigations among pandemic preparedness in intermediate alert level neighboring countries countries’ Economic and before declaring a Policy Assessments PHEIC (R) UNSG to ensure (R) Develop a daily high- minimal health systems priority “watch list” of functioning in fragile and outbreaks with potential failed states to become PHEIC, summary to be published weekly A Wake Up Call: Ebola 2014 Save the (R) Civil society should (R) Ensure that aid and Lessons from Ebola Children engage with tax global support is for the World’s Publication processes and advocate increased and better Health Systems for progressive tax aligned to help build reforms and increased suitable and transparency comprehensive health (R) Civil society should services, and increase monitor domestic 171 continued

budgets to track resource public financing for 172 flows and advocate for health increased and more (R) Ensure the equitable revenue and multilateral initiatives— health expenditure such as the Gavi, the (R) The SDGs should Vaccine Alliance, the commit the world to Global Fund, and the new support UHC, alongside proposed Global priorities such as ending Financing Facility for preventable maternal, reproductive, maternal, newborn, and child and child health—are deaths aligned to support (R) The SDGs should comprehensive and aim (via target universal health services indicators) for universal and can demonstrate that coverage of key health they are doing this services and for financial (R) Implement domestic risk protection and and international reforms should ensure that targets to curb illicit financial apply to all social groups flows and tax avoidance (R) Strengthen and respect the IHR (2005) and support globally coordinated support for health emergencies Protecting Humanity Ebola 2014 UNGA (R) IHR Review (R) WHO to work with existing (R) World Bank should (R) IHR Review Committee to from Future Health Publication Committee to develop regional and sub-regional convene funders to develop mechanism to address Crises: UNSG’s mechanisms to rapidly networks to strengthen linkages support lower-middle and undue adoption of trade and High Level Panel on address violations of and coordination, and thus to low-income countries to travel bans Global Response to PHEIC temporary enhance mutual support and achieve IHR (2005) core (R) WTO and WHO to establish Health Crises recommendations trust, sharing of information and capacities; these countries a commission of experts to (R) All countries to fulfill laboratory resources, and joint should develop plans for increase coherence between the full IHR (2005) outbreak investigations among eventual financial self- IHR (2005) and the WTO legal compliance by 2020 neighboring countries sufficiency regime regarding trade (R) WHO to perform (R) WHO regional directors to (R) Regional and sub- restrictions imposed for public periodic compliance answer to WHO Emergency regional organizations to health reasons review through an Centre ED in emergencies develop or strengthen “independent field-based (R) WHO to lead efforts to standing capacities to assessment” mobilize international financial monitor, prevent, and respond to health crises

(R) Global community to support for building IHR (2005) perform country reviews core capacities on rotating basis (R) Mobilize domestic and international funding to support IHR (2005) core capacity compliance NOTES: DON = disease outbreak news; ED = executive director; EIS = epidemic intelligence service; EOC = emergency operations centers; ERF = emergency response framework; GHSA = Global Health Security Agenda; HSS = health systems strengthening; IHR = International Health Regulations; IMF = International Monetary Fund; MOH = Ministry of Health; PHEIC = public health emergency of international concern; SARS = severe acute respiratory syndrome; SDG = Sustainable Development Goal; UHC = universal health coverage; UNGA = United Nations General Assembly; UNSG = United Nations Secretary-General; WHA = World Health Assembly; WHO = World Health Organization; WTO = World Trade Organization. 10 of 16 publications had relevant findings for this category and were included. Key: (B) Barriers to pandemic preparedness and response. (F) Facilitators to pandemic preparedness and response. (R) Recommendations for implementation moving forward. 173

TABLE A-3 Category 2: Research and Development 174 Delivery Capacity for Sample Sharing Year of Vaccine, Diagnostic, and Therapeutic Pharmaceutical and Medical and Knowledge Synergies with One Publication Disease Outbreak Outlet Readiness Goods Sharing Health Twentieth Century H1N1 1957– Annals Academy (R) Use the increased knowledge of Influenza Pandemics 1968 of Medicine influenza, and the availability of in Singapore Singapore antivirals (and possibly prepandemic vaccines), to further reduce the impact of a future pandemic by combining pharmaceutical and non- pharmaceutical interventions based on available evidence (R) Perform public health measures, such as antivirals, vaccination, and non-pharmaceutical interventions, to reduce the impact of a future pandemic (R) Develop vaccines that can improve heterotypic immunity, better techniques for vaccine production, and more effective antiviral therapies which may reduce the pandemic’s spread The SARS Epidemic SARS 2003 Journal of the (R) Strengthen the exchange in Hong Kong: What Royal Society of of epidemiological Lessons Have We Medicine information on infectious Learned? diseases, especially the emergence of new infections, between the health authorities in Mainland China and Hong Kong SARS in Singapore— SARS 2003 Annals Academy (R) Develop very rapid and highly Key Lessons from an of Medicine sensitive tests for SARS infection, Epidemic Singapore which would substantially reduce the numbers of individuals that need to be quarantined without decreasing the effectiveness of the measure

Responding to the H5N1 2003 WHO (R) Expedite the development of a (R) Contain or delay spread (R) Compile and (B) Most affected Avian Influenza Communicable pandemic vaccine (shorten the time at the source by establishing compare clinical countries were not Pandemic Threat Disease between emergence of a pandemic an international stockpile of data on human able to adequately Surveillance and virus and the start of commercial antiviral drugs, developing cases in order to compensate farmers Response Global production, and increase the supply of mass delivery mechanisms elucidate modes of for culled poultry. Influenza influenza vaccines) for antiviral drugs, and transmission, This discouraged Programme (R) Improve approaches to conducting surveillance of identify groups at reporting of environmental detection of the virus antiviral susceptibility risk, and find better outbreaks in rural (R) Assist developing countries that treatments areas where the plan to manufacture their own majority of human vaccines cases occurred (B) Domestic ducks were able to excrete large quantities of pathogenic virus without showing signs of illness. Their silent role maintained transmission and further complicated control in humans and poultry Pandemic H1N1 2009 New England (R) Ensure better antiviral agents and (R) Develop better antiviral (R) Reach an Preparedness and Journal of more effective influenza vaccines, agents and more effective agreement on the Response—Lessons Medicine greater production capacity, and faster influenza vaccines, greater sharing of viruses, from the H1N1 throughput production capacity, and access to vaccines, Influenza of 2009 (R) Pursue a comprehensive influenza faster throughput and other benefits research and evaluation program (R) Recommend encouraging (R) Improve scientific understanding advance agreements for and technical capacity (beyond vaccine distribution and institutional, political, and managerial delivery difficulties) Influenza A (H1N1- H1N1 2009 Annals Academy (F) Frequent 2009) Pandemic in of Medicine information Singapore—Public Singapore reviews guided Health Control local decisions on Measures the implementation 175 continued

Implemented and of public health 176 Lessons Learnt control measures Lessons from H1N1 2009 ILAR Journal (R) Invest in One Pandemic H1N1 2009 Health research to to Improve enhance Prevention, Detection, understanding of the and Response to emergence, Influenza Pandemics prevention, from a One Health detection, and Perspective control of pandemic influenza viruses Avian Influenza A H7N9 2013 WHO (R) Ensure that the (H7N9) Response: An Publication timely release of Investment in Public data does not Health Preparedness jeopardize future publication of the data in scientific journals Global Health Ebola 2014 The Lancet (R) Address issues of drug quality, Security: The Wider which pose social, economic, and Lessons from the political challenges to health security West African Ebola by undermining ability to address Virus Disease diseases while eroding public Epidemic confidence in governments and international institutions (R) Prevent market forces from being the only driver of medical research The Neglected Ebola 2014 New England (R) Need to address the many gaps in (R) Enhance our scientific Dimension of Global Journal of our R&D armory, as Ebola and other armory against infectious Security: A Medicine outbreaks have shown, which range disease, including Framework for from vaccine development and prioritization, mobilization, Countering Infectious capacity, diagnostic tools, and deployment of Disease Crises therapeutics, and protective equipment significantly greater to anthropological research. Relying resources and harmonization on the disparate efforts of the R&D of development and community—academia, government, regulatory approval industry, and civil society—has not processes worked

Protecting Humanity Ebola 2014 UNGA (B) Investment in medical R&D for from Future Health Publication diseases that largely affect the poor is Crises: UNSG’s High deeply inadequate. Of the $214 billion Level Panel on Global invested in health R&D globally in Response to Health 2010, less than 2 percent was Crises allocated to neglected diseases (R) Dedicating resources to R&D on prioritized pathogens will ensure the greater availability of critical vaccines and treatments when they are most needed NOTES: ILAR = Institute for Laboratory Animal Research; R&D = research and development; SARS = severe acute respiratory syndrome; UNGA = United Nations General Assembly; UNSG = United Nations Secretary-General; WHO = World Health Organization. 11 of 16 publications had relevant findings for this category and were included. Key: (B) Barriers to pandemic preparedness and response. (F) Facilitators to pandemic preparedness and response. (R) Recommendations for implementation moving forward. 177

TABLE A-4 Category 3—Global Governance 178 System Wide WHO Cooperation and Year of Operational New Bodies and Actions Leadership/Human Publication Disease Outbreak Outlet Response Accountability Financing/Aid for Future Outbreaks Function and Role Resources Avian H7N9 2013 WHO (F) The WHO Western Influenza A Publication Pacific regional office (H7N9) developed a framework for Response: An national health authorities Investment in to highlight areas of public Public Health health emergency response Preparedness that may need specific action for avian influenza (the framework was based on the Asia Pacific Strategy for Emerging Diseases [2010], which covered the key technical areas [e.g., command and control, surveillance, risk assessment, etc.]) The Neglected Ebola 2014 New (R) WHO and (R) (R) IMF to develop (R) WHO to establish a (R) WHO to take (R) Next DG should Dimension of England UN to establish Commission capacity to provide WHO Centre for Health the lead in the reenergize and refocus Global Journal of clear an budgetary support to Emergency Preparedness global system to WHO on core Security: A Medicine mechanisms for independent governments that raise and Response governed by identify, prevent, priorities and on Framework for coordination assessment in outbreak alerts independent technical and respond to relationship building Countering and escalation in 2017 and then through the existing governing board potential pandemics with other actors, such Infectious health crises every 3 years Rapid Credit Facility (R) WHO Emergency (R) WHO to as other multilateral Disease Crises (R) Use existing following (R) Develop a World Centre to coordinate global increase its agencies and non-state institutions 2017 Bank Pandemic health emergency capability and actors; rather than Emergency Facility workforce by resources while (R) Next DG needs creating new strengthening and demonstrating stature and courage to bodies (e.g., expanding GOARN better leadership engage with other United Nations across actors global leaders, accept Mission for (R) WHO to accountability, and Ebola enhance means of hold countries Emergency cooperation with accountable Response) non-state actors, including local and

international civil society organizations, the private sector, and the media A Wake Up Ebola 2014 Save the (R) Develop (R) Use SDG (R) Ensure that aid (R) WHO to revise Call: Lessons Children disease target and global support is how elections are from Ebola for Publication surveillance indicators to increased and better conducted for WHO the World’s systems with hold globe aligned to help build officials, specifically: Health Systems strong regional accountable to suitable and improve transparency networks for UHC (key comprehensive health and democratic nature better health services, and increase of elections forecasting and services) and public financing for control for financial health risk protection (R) Ensure that (R) Ensure multilateral initiatives that SDG are aligned to support targets apply comprehensive and to all social universal health groups in a services and can country and demonstrate that they are not just are doing this reported as (R) Implement national domestic and averages (e.g., international reforms “no target met to curb illicit financial unless met for flows and tax all”) avoidance (R) Civil society to monitor domestic budgets to track resource flows and to advocate for increased and more equitable revenue in 179 continued

global health 180 expenditure Protecting Ebola 2014 UNGA (R) Reinforce a (R) Increase assessed (R) WHO to establish a (R) WHO to serve (R) WHO to increase Humanity from Publication clear line of contributions to WHO WHO Centre for as the single global investment in training Future Health command by at least 10 percent Emergency Response with health leader, health professionals at Crises: throughout the with a share a multisectoral advisory determining and national level UNSG’s High UN system mandatorily directed board executing global (especially community Level Panel on (e.g., WHO DG to support the (R) WHO Emergency health priorities health workers) Global reports to proposed Emergency Centre and Inter-Agency (R) WHO to build Response to UNSG, WHO Centre Standing Committee to unified and Health Crises regional (R) Build a establish Standard effective directors report “Contingency Fund” Operating Procedures for operational capacity to WHO of at least $300 humanitarian actors in (R) WHO to work Emergency million by 2016 that is health crises closely with Centre ED, ED financed according to (R) WHO Emergency development actors to become assessment scale and Centre to incorporate to ensure UNSG’s managed by the GOARN and foreign complementarity Emergency proposed Emergency medical team programs in between Coordinator) Centre (to be coordinating the global development (R) Integrate immediately health emergency programs and UN health and replenished when workforce efforts to build humanitarian depleted) health care systems crisis trigger (R) Guarantee that aid and public health systems e.g., is disbursed according (R) WHO to ERF Grade 2 or to Paris Declaration establish a culture 3 heath crisis principles, especially of emergency automatically alignment of support, response and to triggers an harmonization, and develop the interagency mutual accountability capacity and multisectoral (R) Support the instinct to lead assessment creation of a World major operations Bank Pandemic Emergency Financing Facility (national governments should decide how funds are spent in-country)

Report 2: Ebola 2014 WHO (R) WHO to (R) Fund Emergency (R) WHO to develop the (R) WHO to (R) Next DG should Advisory work with Program baseline internal capacity to develop the remain accountable for Group on health cluster capacity through function as an operational capacity to function incident management Reform of partners to build predictable and organization as and position within WHO WHO’s Work dedicated reliable financing (R) WHO to define and itself as an (R) Ensure that in Outbreaks capacity for streams, including promote acceptance of operational WHO’s mandate to and coordination, assessed contributions common professional organization since work in outbreaks and Emergencies planning, (this money should be standards on health working in emergencies is information different from interventions, on sharing outbreaks and reflected in the management, emergency funds information and handling emergencies is part capabilities of its staff and deployed in specific personal health data, and of WHO's core (R) WHO to facilitate communications responses) on building robust capacity mandate the diversification of (R) Integrate (R) Maximize the use for systematized (R) Reflect WHO’s the health workforce: cluster partners’ of existing funding information management mandate (working engaging multiple capacities in mechanisms, such as and protocols for in outbreaks and actors from multiple emergency the Central information sharing emergencies) in the sectors and at multiple operations Emergency Response focus of its levels, rather than a (R) Articulate Fund, to support governing bodies single global linkages emergency operations (R) Demonstrate workforce of “white between the (R) Seek full that WHO is helmets” Emergency capitalization of the independent and (R) WHO to increase Program, the Contingency Fund impartial while its staff Health Clusters, reviving and and overall improving humanitarian relationships with system member states and partners (R) Engage in a profound organizational transformation rather than piecemeal reform (i.e., a single merger of organizational units within WHO will not suffice; it will need new organizational 181 continued

structures and 182 procedures) Middle East MERS- 2013 Journal of (R) Global (R) WHO to act as a Respiratory CoV Hospital system to knowledge broker: WHO Syndrome Infection ensure guidelines should not Coronavirus adequate prevail over clinical (MERS-CoV): assessment of judgment during a What Lessons patients pandemic because such Can We Learn? presenting guidelines are inevitably with febrile based on incomplete illness prior to evidence international air travel NOTES: DG = director-general; ED = executive director; ERF = emergency response framework; GOARN = Global Outbreak Alert and Response Network; IMF = International Monetary Fund; MERs-CoV = Middle East respiratory syndrome coronavirus; SDG = Sustainable Development Goal; UHC = universal health coverage; UN = United Nations; UNGA = United Nations General Assembly; UNSG = United Nations Secretary-General; WHO = World Health Organization. 6 of 16 publications had relevant findings for this category and were included. Key: (B) Barriers to pandemic preparedness and response. (F) Facilitators to pandemic preparedness and response. (R) Recommendations for implementation moving forward.

Next: Appendix B: Workshop Statement of Task »
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In November 2018, an ad hoc planning committee at the National Academies of Sciences, Engineering, and Medicine planned two sister workshops held in Washington, DC, to examine the lessons from influenza pandemics and other major outbreaks, understand the extent to which the lessons have been learned, and discuss how they could be applied further to ensure that countries are sufficiently ready for future pandemics. This publication summarizes the presentations and discussions from both workshops.

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