BMJ Glob Health: first published as 10.1136/bmjgh-2020-004227 on 25 January 2021. Downloaded from Practice Improving National Intelligence for Public Health Preparedness: a methodological approach to finding local multi- sector indicators for health security 1 1 2 3 Ngozi A Erondu , Afifah Rahman- Shepherd, Mishal S Khan, Ebba Abate, Emmanuel Agogo,4 Evelien Belfroid,5 Osman Dar,6 Angela Fehr,7 1 4 8 9 Lara Hollmann , Chikwe Ihekweazu, Aamer Ikram, Bjorn Gunnar Iversen, Alemnesh H Mirkuzie,3 Tayyab Razi Rathore,8 Neil Squires,10 Ebere Okereke11 To cite: Erondu NA, ABSTRACT Summary box Rahman- Shepherd A, Khan MS, The COVID-19 epidemic is the latest evidence of critical et al. Improving National gaps in our collective ability to monitor country- level ► Existing global frameworks to strengthen public Intelligence for Public Health preparedness for health emergencies. The global Preparedness: a methodological health core capacities lack indicators to measure frameworks that exist to strengthen core public health approach to finding local multi- several preparedness domains and do not provide capacities lack coverage of several preparedness domains sector indicators for health mechanisms to interface with local intelligence. and do not provide mechanisms to interface with local security. BMJ Global Health ► In collaboration with three National Public Health intelligence. We designed and piloted a process, in 2021;6:e004227. doi:10.1136/ Institutes (NPHIs) in Ethiopia, Nigeria and Pakistan, collaboration with three National Public Health Institutes bmjgh-2020-004227 we designed and piloted a rapid framework review (NPHIs) in Ethiopia, Nigeria and Pakistan, to identify and Delphi consultative process to identify, assess potential preparedness indicators that exist in a myriad Handling editor Seye Abimbola and prioritise non- traditional subnational indicators of frameworks and tools in varying local institutions. Additional material is to improve preparedness monitoring. ► Following a desk- based systematic search and expert published online only. To view, ► The demonstrated methodology can strengthen the consultations, indicators were extracted from existing http://gh.bmj.com/ please visit the journal online leadership role of NPHIs in health security without national and subnational health security- relevant (http:// dx. doi. org/ 10. 1136/ the added burden of developing new indicators or frameworks and prioritised in a multi- stakeholder two- bmjgh- 2020- 004227). collecting new data. round Delphi process. Eighty- six indicators in Ethiopia, 87 indicators in Nigeria and 51 indicators in Pakistan were Received 16 October 2020 assessed to be valid, relevant and feasible. From these, Revised 18 December 2020 14–16 indicators were prioritised in each of the three linked to a local seafood and wet animal on July 16, 2021 at Robert Koch-Institut. Protected by copyright. Accepted 23 December 2020 countries for consideration in monitoring and evaluation wholesale market, suggestive of zoonotic tools. Priority indicators consistently included private sector spill over.2 One thought experiment asks: metrics, subnational capacities, availability and capacity what would have happened if the vendors at for electronic surveillance, measures of timeliness for routine reporting, data quality scores and data related to the now-infamous Huanan Seafood Whole- internally displaced persons and returnees. NPHIs play an sale Market had to send a weekly report to a increasingly central role in health security and must have market inspector containing information on access to data needed to identify and respond rapidly to the health of each vendor? And what if one public health threats. Collecting and collating local sources indicator, ‘number of vendors with suspected of information may prove essential to addressing gaps; it illness’, was collected by local health authori- © Author(s) (or their is a necessary step towards improving preparedness and ties on a routine basis? Well, if this would have employer(s)) 2021. Re- use strengthening international health regulations compliance. happened and this ‘non-traditional’ indi- permitted under CC BY- NC. No commercial re- use. See rights cator was also monitored by a central public and permissions. Published by health authority, the outcomes for the 2019 BMJ. SARS- CoV-2 outbreak could have been very For numbered affiliations see INTRODUCTION different. end of article. In December 2019, a cluster of patients were The architecture of many traditional public Correspondence to admitted to hospitals in Wuhan, China, with health monitoring systems was not designed to Dr Ngozi A Erondu; an initial diagnosis of pneumonia of unknown detect non- human disease specific signals; but ngozierondu@ gmail. com aetiology.1 The cluster was epidemiologically it is exactly these signals that can be collected Erondu NA, et al. BMJ Global Health 2021;6:e004227. doi:10.1136/bmjgh-2020-004227 1 BMJ Glob Health: first published as 10.1136/bmjgh-2020-004227 on 25 January 2021. Downloaded from BMJ Global Health at a local level and then reported upward—that need to be must be underpinned not only by essential technical assessed for their utility as part of national preparedness capacities but also local multi- sectoral public health efforts. Without the systems in place to bridge national intelligence and behavioural health data, which must be and subnational capacities for better preparedness, local- accessed and analysed in order for governments to take ised health events will remain undetected until the signal early action to respond to acute threats and crises.8–12 becomes loud enough to be picked up by the existing public health infrastructure. Strengthening early detec- Local data and National Public Health Institutes tion is essential for the public health entities responsible The International Association for National Public Health for preventing, detecting and responding to infectious Institutes (IANPHI) includes membership from National disease outbreaks; having robust and timely data are the Public Health Institutes (NPHIs) in 99 countries.13 In only way to benefit from the extra weeks or days that may many contexts NPHIs were first established because of, be gained from earlier detection and that are so critical and in response to, public health challenges typically to controlling an infectious disease outbreak. There is a related to infectious diseases and house the capaci- wealth of data routinely collected across a range of indi- ties to effective monitoring of national health security cators and using a variety of monitoring and evaluation and preparedness, including surveillance, evaluating tools and programmes. These data are not readily acces- and analysing health information, and epidemiological sible and the mechanisms to understand and effectively research.14 In recent times, the breadth of programmes analyse and use the data in decision- making for national and activities undertaken by NPHIs globally has expanded health security and preparedness is lacking. as they confront new threats and risks to public health, evolve their vision and mandate, and respond to leader- Limitations of the Joint External Evaluation tool for assessing ship and political priorities.14 Thus, NPHIs are increas- country preparedness ingly being positioned as the main agency to monitor, With wide participation from 113 WHO Member States, evaluate and report on various aspects of national and the Joint External Evaluation (JEE) has become a mean- subnational preparedness, playing a critical role in global ingful exercise to attune national interests and promote health security.15–17 cross- sectoral coordination to strengthen International The structures of NPHIs vary, with many NPHIs existing Health Regulations (IHR) capacities. IHR monitoring within Ministries of Health; yet, many have limited access framework includes the State Party annual reporting to non- health emergency related data. Even when a process and voluntary external evaluation using the JEE national integrated disease system exists, there is still tools, after- action reviews and simulation exercises.3 A key potentially useful data that stays within disease- specific tool within the WHO’s IHR monitoring framework, the programmes and information systems. The siloed JEE uniquely convenes national actors across sectors and nature of data and the limitations of data sharing are is externally validated by peer country experts. While it often mirrored subnationally and amplified at the inter- http://gh.bmj.com/ elevates the visibility of health emergency preparedness, sectoral level. For example, organisations that manage it is a large resource-intense multi- sectoral exercise that humanitarian crises can provide important information is logistically difficult to perform annually—the recom- on internally displaced persons, as well as refugee move- mended frequency is every 4–5 years.4 The challenge is ments.18 19 that outbreaks do not stop. Very few NPHIs have access to these data. In part due The JEE indicators have been found to accurately to lack of a mechanism in place to enable the effective on July 16, 2021 at Robert Koch-Institut. Protected by copyright. measure essential public health functions, such as use of this data for decision-making. 20 COVID-19 has disease surveillance and laboratory capacity as well as shown us that this fragmentation is a problem for even health threats stemming from communicable disease at the best resourced NPHIs, as insufficient