Early Action Review: Preventing local outbreaks from becoming pandemics

The COVID-19 pandemic was a wake-up call for governments and their global stakeholders to reform the management processes of infectious disease outbreaks.

Dr Stella Chungong and Dr Landry Ndriko Mayigane of the Health Security Preparedness Department of the World Health Organization’s Health Emergencies Programme are encouraging countries to implement early action reviews (EARs) for disease outbreaks to assess their vigilance and planning, the responsiveness of their health systems, and to better prepare for outbreaks.

Read more in Research Outreach

Read the original research: doi.org/10.1016/S2214-109X(23)00167-5

Transcript

Hello and welcome to Research Pod! Thank you for listening and joining us today. 

In this episode we look at the work of Dr Stella Chungong and Dr Landry Ndriko Mayigane of the Health Security Preparedness Department of the World Health Organization’s Health Emergencies Programme. Drs Chungong and Dr Mayigane are encouraging countries to implement early action reviews, also known as EARs, for disease outbreaks. EARs are based on a 7-1-7 metric that helps countries assess their vigilance and planning, the responsiveness of their health systems, and to better prepare for outbreaks. Simple though the metric may seem, its demands are not. But the lives of millions may depend on it.

The COVID-19 pandemic, which rapidly escalated into a global crisis that impacted millions of lives and disrupted economies worldwide, was a wake-up call for governments and their global stakeholders to reform the management processes of infectious disease outbreaks. While the pandemic hammered home numerous hard lessons, two were fundamental: first, the benefits of global connectivity come with costs; and second, there is significant value in international collaboration with a common agenda.

During the pandemic, governments worldwide were surprised by the rapidity with which the coronavirus spread by exploiting weaknesses in global supply chains, international travel, and both regional and intra-urban transportation networks. Nonetheless, scientists around the world swiftly collaborated to comprehend the virus and determine an effective strategy to combat it. While outbreaks and pandemics are inevitably bound to occur, future efforts must be focused on timely detection, notification, and rapid response to limit their impacts.

As part of the WHO’s Health Emergencies Programme, the Health Security Preparedness department, also known as the HSP department, supports countries to continuously assess, monitor, and build their national and sub-national International Health Regulation capacities using simulation exercises and action reviews, among other activities. Information resulting from these exercises and reviews facilitate the development and implementation of national action plans for health security. However, Drs Chungong and Dr Mayigane at HSP firmly believe that when outbreaks transcend international borders, we cannot afford to ignore the importance of a unified global response to effectively address international health security threats.

Early action reviews, or EARs, are a common and important public health tool that facilitate emergency responses to communicable diseases and other public health events. In general, an EAR should be performed as soon as possible after an outbreak is detected to allow for timely adjustments to response strategies. EARs can help mitigate the spread of an outbreak and strengthen readiness strategies by assessing a country’s detection, surveillance, and early warning systems. Moreover, early engagement with at-risk communities during EARs bolsters outbreak readiness. EARs can prevent local outbreaks from spreading and potentially becoming pandemics.

The WHO published The Guidance for conducting an early action review to offer countries a proactive assessment tool for evaluating preliminary strategies and actions associated with the early detection of outbreaks. Additionally, the tool aims to aid in identifying and addressing gaps or shortcomings and reinforcing best practices in a country’s response strategies. Timeliness and accountability are critical for this to happen, and a simple metric is needed to facilitate the preliminary review of response actions.

The new guidance provides granular, stepwise instructions for governments to implement EARs at different levels for various infectious disease contexts based on the several hard lessons the COVID-19 pandemic ingrained in emergency response practices.  Surveillance and monitoring must be ongoing, early detection is crucial, collaboration must be global, reporting systems should be robust, public health infrastructure must be operational, risk communication clear, and response strategies adaptive. 

The guideline details three time-based metrics, named the 7-1-7, which offer countries a simple, structured approach to outbreak management: (1) 7 Days to Detect, which measures how quickly a country can identify a suspected disease outbreak, with the aim being detection within 7 days of the emergence of an outbreak, and (2) 1 Day to Notify, which measures the time taken to inform relevant public health authorities and stakeholders about a detected outbreak, with the aim being notification within 1 day of outbreak detection. This outbreak notification goal is not new; it is consistent with the International Health Regulations of 2005 that require countries to notify relevant authorities within 24 hours of disease outbreak detection. Finally, (3) 7 Days to Respond, which measures how quickly a country can establish a response to an outbreak, with the aim being the instigation of effective response actions within 7 days of notification. 

The three-stage metric format has previously been applied to global initiatives against HIV and malaria. The United Nations established a 90-90-90 goal for tackling the HIV pandemic by 2020, which established that 90% of people living with HIV should know their status, 90% of people living with HIV who know their status should receive sustained life-saving antiretroviral treatment, and 90% of people living with HIV receiving antiretroviral treatment should attain undetectable HIV viral load levels. The 90-90-90 approach, ‘harmonised global action on solid, life-saving outcomes’, in part by generating enthusiasm and support; simple measures of progress are attractive to funders as they boast of clear, objective benchmarks. 

The vision of WHO and the global malaria community is a world free of malaria. As

part of this vision, the global technical strategy for malaria 2016 to 2030 set ambitious global targets for 2030, with milestones for measuring progress for 2020 and 2025. It envisioned a reduction in the global malaria incidence by 40%, 75% and 90% in 2020, 2025 and 2030, respectively, when compared to 2015. It also aimed for a reduction in global malaria mortality rates by 40%, 75% and 90% in 2020, 2025 and 2030, respectively, when compared to 2015. Moreover, the strategy aimed to eliminate malaria from at least 10, 20 and 35 countries in which malaria was transmitted in 2015 by 2020, 2025 and 2030, respectively, and the reestablishment of malaria in all countries that were malaria-free. The strategy, which is aligned with the sustainable development goals, has been gradually attained through a substantial expansion of malaria interventions.

EARs are supplemented by subsequent intra-action reviews, or IARs, which are conducted during a response employing real-time assessment methods, and after-action reviews – also known as AARs – which are a retrospective analysis of response actions. Together, the information from EARs, IARs, and AARs provides critical insight for on-going and future emergencies. Additionally, such information can be incorporated into national and regional policy strategies – such as Integrated Disease Surveillance and Response in Africa, the Asia Pacific Strategy for Emerging Diseases – to improve future responses.

EARs also support other WHO initiatives. For example, they provide a robust dataset to support the strengthening of the global health architecture for Health Emergency Preparedness, Response and Resilience, also known as the HEPR.

EARs also align with the One Health approach, which was established to improve the integration of work on human, animal, and environmental health. Several health issues, including outbreaks of certain infectious diseases, are linked with environmental factors and animal health – for example, zoonotic diseases, which can spread between animals and humans. 

As such, effectively addressing such health issues requires informed input from those working in human medicine, veterinary medicine, environmental science, and public health. With better communication and sharing of knowledge, more effective and timely surveillance systems, data sharing mechanisms, and coordinated responses can be established.

The 7-day detection target for infectious disease outbreaks is ambitious but doable. Africa is a case in point. Africa is ground zero for many outbreaks. It hosts less-resourced countries with limited access to reliable laboratories. According to Drs Chungong and Mayigane, between 2017 and 2021, the WHO African region reported 589 acute public health events – the highest among all WHO regions. With such a high number of public health events, Africa has become somewhat of an old hand at outbreak detection. A WHO review of 296 substantiated human and animal disease outbreaks in the African region over the same period showed a median time of 8 days to detection of public health events and 3 days to notification of public health events – time periods that closely align with the 7-1-7 metric.

Drs Chungong and Mayigane acknowledge that simple though the 7-1-7 metric may seem, achieving it may be challenging, especially for less-resourced countries. Identifying and tracking a potential outbreak in remote areas of countries with limited access to reliable laboratories for differential diagnosis can hamper detection. Fear of triggering a false alarm can delay notification, and the EAR outbreak response components are demanding. 

However, progress of any kind can build capacity and resilience. By providing countries with guidance that incorporates a straightforward, simple-to-communicate, and methodical metric for timeliness and accountability in detection, notification, and response, the World Health Organization is helping countries to become more adaptive, thereby preventing local outbreaks from spiralling into pandemics. 

As Drs Chungong and Mayigane conclude – ‘In a world that is increasingly susceptible to large-scale health emergencies, being proactive rather than reactive saves lives, resources, and preserves the integrity of our health systems’.

Drs Chungong and Mayigane wish to acknowledge the support and financial contribution of the USAID in creating awareness and further promoting their work on EAR.

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