The 74th World Health Assembly has just ended. All plenary sessions were open to be viewed on the WHO website. In this article Nigeria Health Watch's Kemisola Agbaoye revisits some of the discussions around pandemic preparedness and response, and the potential implications for Nigeria.
Given the COVID-19 pandemic and the impact it has had on the world, it has become critical that every citizen is aware of the International Health Regulations (IHR) 2005 and what it means for us. The IHR identifies health-related events that each State Party (country) signs up to and is bound by these regulations to report to the World Health Organisation (WHO). It provides guidance on prevention, detection, and response to public health emergencies with the potential for international spread to the 198 World Health Organisation (WHO) member states.
The IHR 2005 is a legally binding instrument that consists of 66 articles, including communication and coordination mechanisms and activities between WHO and states parties, roles and responsibilities of WHO and IHR National Focal Points (NFPs) in member states, and disease surveillance and responses activities required in-country and at points of entry. It also specifies the core capacities that countries must have to fulfil these functions. One of the major objectives of the IHR, is to control the spread of a severe public health threat, such as COVID-19, while avoiding unnecessary interference with international traffic and trade. Given the events of the last year and a half, it has come under immense scrutiny on its sufficiency to meet its desired objectives.
The COVID-19 pandemic has posed the most significant threat to human life and livelihoods in recent times. This has necessitated widespread restrictions to international traffic and trade with the institution of travel bans and lockdowns to mitigate its spread. How did the IHR 2005 function in this pandemic? How did countries and WHO adhere to the provisions of the IHR? Were the provisions in the IHR sufficient to prevent, detect and respond to the pandemic?
To answer these questions, the WHO convened two important committees to assess both the performance of the IHR, but also the performance of the WHO and its member states in responding to the pandemic. The first committee is the IHR expert review committee whose mandate was to review the functioning of the IHR during the COVID-19 response. The second committee is an independent panel of experts set up to review the spread, actions and responses to the COVID-19 pandemic. The panel was tasked with providing evidence-based recommendations to ensure that countries and global health institutions including the WHO, are better prepared to address health threats.
Key findings from the expert reviews
On preparedness, both reviews conclude that more could have been done to prepare for the pandemic, particularly since the world had already witnessed the devastating impact of novel viruses in recent times, including the 2003 SARS, 2009 H1N1 influenza, 2012 MERS and 2014 Ebola epidemics. For these epidemics, similar IHR review committees were instituted. However, the implementation of recommendations from these committees were slow and incomplete at best.
Following initial reports of cases of pneumonia of unknown origin in Wuhan, China, and despite reasonable assumptions that could have been made on the rapid nature of transmission of coronary viruses, many countries still failed to take deliberate steps to prepare. However, countries that had previously managed epidemics such as SARS and Ebola were better prepared, as they leveraged already established structures and were better positioned to contain the spread of the novel coronavirus.
The reports concluded that national pandemic preparedness activities have been grossly underfunded over the years. Many countries lacked multisectoral coordination and solid preparedness plans with demonstrable commitments by the highest level of leadership and multisectoral coordination. NFPs lacked adequate authority and capacity to carry out their functions, and preparedness scores determined by self-reported assessments and external evaluations such as the Joint External Evaluation did not reflect the relative performance of countries' response. The metrics for these evaluations did not adequately consider the impact of political leadership and trust in government institutions on response.
On response to public health threats, there was insufficient clarity on what states parties should do following the declaration of a Public Health Emergency of International Concern (PHEIC) as stipulated by the IHR. A PHEIC is the loudest alarm that can be sounded by the WHO Director General as provided in the IHR, predicated on the advice of an emergency committee drawn from the WHO roster of experts. The COVID-19 emergency committee was initially split as to whether to declare a PHEIC during its first meeting due to insufficient evidence but declared a PHEIC at its next meeting, following a WHO mission to China.
Following inaction by states parties after the declaration of a PHEIC, WHO declared COVID-19 a global pandemic. At this time, the virus had spread to 114 countries.
Three key approaches were employed by countries in responding to the pandemic; aggressive containment, suppression and mitigation. Successful measures included timely triage and referral of suspected cases, provision of designated isolation facilities, institution of socioeconomic support to promote widespread uptake of public health measures, and development of multi-level partnerships across sectors. They also included consistent and transparent communication, and engagement with community health workers, community leaders and the private sector.
What can be done to improve emergency preparedness and response?
Recommendations from both reviews cut across global, regional, and national structures and include both recommendations from WHO and countries. They specify measures both to improve response to the current pandemic as well as prevent and prepare for the next one. At the global level, for instance, the independent panel review recommended that leadership be elevated to the highest levels to ensure just, accountable and multisectoral action. The panel specifically recommended the establishment of global health threats council consisting of the highest level of leadership across countries.
Both reviews recommend a pandemic framework convention that aims to address gaps in the current IHR by specifying structures and actions to prevent, prepare for and respond to pandemics. It was also recommended that the governance, financing and functioning of WHO be strengthened to fulfil its mandate in implementing the IHR and coordinating public health responses, including ensuring predictable and sustainable financing for emergency preparedness and response activities. With this in place, countries will be more inclined to invest in a faster, more effective surveillance, alert and notification system, early investigation, and risk assessment of outbreaks. In turn this would set new targets and benchmarks for pandemic preparedness and response capacities and establish a pre-negotiated platform for tools and supplies, including vaccines, to ensure equitable access.
To bridge the gaps identified in the COVID-19 response and implementation of the IHR 2005 in states parties, both reviews emphasise a need for whole-of-government and whole-of-society approaches to public health Emergency Preparedness and Response (EPR).
Key recommendations for countries include:
Integration of EPR efforts into larger disaster risk reduction mechanisms and economic planning
Explicit one-health planning -- integration of animal and environmental health systems into EPR
Regular funding for preparedness and fast funding for response to reduce dependence on development assistance
Gender equality in EPR
Establishment of the highest-level national coordination for EPR
Strengthened approaches and capacities for information management and community engagement to build public trust.
What recommendations can Nigeria prioritise? Why and how?
Nigeria's initial response to COVID-19 focused on prevention, containment and mitigation strategies and included measures tailored to each strategy, depending on the level of spread at the time. Key interventions included the establishment of a high-level national coordination structure, the Presidential Task Force (PTF), now Presidential Steering Committee, rapid mobilisation of funds from government and private sector, and rapidly improved capacity for testing and management of cases, including the establishment of molecular laboratories. In addition, training and deployment of rapid response teams, targeted community engagement and information management, availability of a digitalised event-based surveillance system, were notable successes.
To build on these successes, Nigeria could implement the following five recommendations from the reviews in the immediate and short term:
Ensure sustainable and predictable financing for EPR: While funds were successfully mobilised to respond to the COVID-19 pandemic, there is a need to ensure dedicated budget lines for preparedness activities such as regular simulation exercises, after action reviews, self-assessments, medical countermeasures, and a rapidly accessible contingency fund to be mobilised in the event of a public health emergency.
Ensure integration of EPR structures into larger disaster management and economic structures, employing a whole of government approach and improve point of entry core capacities: EPR should be seen as the responsibility of the whole government not just the NCDC as the IHR NFP, and overseen by the highest level of government. Also, given the three-tiered government system, state and local governments should be included in high level decision making for EPR. Ensure sufficient legal and financial instruments for point of entry preparedness and response and the ability of competent health authorities to sufficiently implement travel restrictions where necessary.
Strengthen integration of EPR with animal and environmental health: Resources should be made available for rapid optimisation and improvement of animal and environmental health structures and better integration with human health.
Strengthen NCDC's IHR coordination capacities: Provide adequate authority and resources to effectively coordinate EPR activities and improve collaboration among responsible Ministries, Departments and Agencies (MDAs), including digitalisation of communication channels, and improving molecular testing capacity.
Strengthen EPR capacities at sub-national levels: EPR activities should be embedded in existing public health systems, which include structures at the state and local government levels. Nigeria needs to strengthen health systems at these levels to ensure equitable, effective, and efficient EPR structures. There would also need to be purposeful gender representation in decision making bodies for EPR at the national and sub-national level.
As countries deliberate on the ongoing COVID-19 pandemic and the reports of these reviews, Nigeria needs to act decisively and rapidly to improve her capacity for Epidemic Preparedness and Response, to bring this pandemic to an end and prevent the next one.