Introduction
COVID-19 makes it both possible and necessary to review lessons learnt from recent
epidemics, re-evaluate approaches, and develop a framework that accelerates progress
to make the world safer from epidemics. Every country and every community must be
able to rapidly detect, report, and respond effectively to any potential major new
health threat. Notably, wide variation in capacities exist across countries.1, 2 To
improve early detection and rapid control of health threats, clear performance targets
need to be set, cross-country variations need to be better quantified, factors responsible
for these variations need to be identified, and speed and quality of detection and
response need to be improved.
3
Since the west Africa Ebola epidemic of 2014–16, several frameworks have been developed
to measure readiness capacity. These frameworks focus on discrete components of health
systems (eg, laboratory, surveillance4, 5 and universal health coverage
6
) rather than overall system performance, and do not adequately account for less easily
measurable capacities, such as access to rapid financing and logistics, transparency,
governance, leadership, or overall system fairness.
7
How fast a system detects and responds effectively to a threat is the optimal measure
of performance.8, 9 Continuously evaluating and improving timeliness can identify
performance bottlenecks and help to accelerate progress, improving detection speed
and response quality.8, 9, 10, 11 Timeliness metrics have been integrated into the
WHO after-action review process
12
and the Triple Billion targets for its 13th General Programme of Work (GPW13).
13
However, clear targets for time to detection and response have not yet been described.
These metrics can supplement existing capacity measurements of the International Health
Regulations (2005), including the Joint External Evaluation, which have been shown
to be useful but not sufficient to predict effective response to COVID-19.
2
The COVID-19 pandemic provides a galvanising moment to set clear and ambitious goals
to promote accountability and to align stakeholders, including communities, countries,
global health institutions, and donors. Ambitious but achievable goals are an essential
communication tool to improve the identification and control of health threats. Establishing
objectively verifiable benchmarks will give countries clear guidance, will give partners,
civil society, WHO, and donors a clear pathway forward for measurement, accountability,
and improvement, and will help governments and civil society to focus attention and
resources.
Part of the reluctance to fund health preparedness stems from the absence of simple
measurements of progress. One reason for broad support for the global initiatives
against HIV and malaria has been the appeal, to politicians and voters alike, of clear
metrics: the number of people treated, the bednets distributed, and the lives saved.
For HIV, the 90-90-90 goal established by the UN
14
—ensuring that 90% of people infected with HIV know their status, 90% of those diagnosed
receive sustained treatment, and 90% of patients receiving treatment have undetectable
viral load—translated evidence of the benefits of antiretroviral therapy into targets
for harmonised global action on solid, life-saving outcomes.
15
Generating enthusiasm and support for a public health programme is easier if it has
a performance metric that is straightforward, easily remembered, and will catalyse
progress on the problem being addressed.
We suggest a new global target of 7-1-7 (panel
) whereby every suspected outbreak is identified within 7 days of emergence, reported
to public health authorities with initiation of investigation and response efforts
within 1 day, and effectively responded to—as defined by objective benchmarks—within
7 days (appendix p 1). This 7-1-7 target can provide a global basis for accountability,
be applied at country level to assess and improve performance, and can also be applied
locally to promote equity in detection and context-appropriate response capabilities.
Panel
7-1-7 target for outbreak detection, notification, and response
Suspected outbreak detection (time to target: 7 days)
Required capacities and response components:
•
Access to medical care and treatment
•
Health workers trained on case definitions with the ability to detect suspected outbreaks
•
Laboratory diagnostic capacity for differential diagnosis
Public health authorities are notified and the investigation is initiated (time to
target: 1 day)
Required capacities and response components:
•
Clear reporting structures
•
Data systems and training for reporting from clinical and laboratory facilities to
public health
•
Public health workforce receives alerts and initiates investigation and response
Effective response measures are put in place (time to target: 7 days)
Required capacities and response components:
•
Component 1: response initiation
•
Component 2: epidemiological investigation
•
Component 3: laboratory confirmation
•
Component 4: medical treatment
•
Component 5:* countermeasures
•
Component 6:* communications and community engagement
•
Component 7:* response coordination
Detect within 7 days and notify, investigate, and begin response within 1 day
Setting a performance standard of 7 days from the emergence of an outbreak to recognition
and 1 day for notification, investigation, and initiation of response allows for the
assessment of the performance of surveillance, reporting, investigation, and response
systems. A 2010 study that examined timelines for 281 WHO-verified outbreaks reported
between 1996 and 2009 showed that the timeliness of outbreak start to outbreak discovery
improved from a mean of 29·5 days to 13·5 days.
10
With most outbreaks and delays recorded in Africa, WHO reviewed timeliness metrics
for 296 substantiated outbreaks in the African region that were reported using the
Integrated Disease Surveillance and Response strategy during 2017–19.
16
There was a median of 8 days (IQR 2–28) for time to detection and 3 days (IQR 0–9)
for time to notification. During these 2 years, timeliness for detection improved
substantially, indicating advances in surveillance systems, although time to disease
notification increased.
16
A study of timeliness intervals for outbreaks in fragile states from 2000 to 2010
showed a similar median delay of 29 days (range 7–80) for outbreak discovery.
17
The 7-day target for detection is ambitious and varies by pathogen; however, as shown
with the data from Africa, it is possible to detect events within 7 days. Notification
of a Public Health Emergency of International Concern within 1 day (24 h) is already
required under the International Health Regulations (2005);
18
delays in notification must be reduced substantially to provide timely awareness of
new and unfolding potentially serious public health events. The initiation of investigation
and response within 1 day is a mark of a responsive public health system. Measurement
of the time from outbreak emergence to detection often requires a retrospective analysis
after an outbreak has been fully investigated. Although not all emerging threats merit
an urgent response, starting the investigation and response in 1 day is indicated
because the extent and cause of suspected outbreaks, and therefore the potential that
these will be catastrophic, is not known until the investigation is undertaken. Although
some pathogens (eg, Neisseria meningitidis) need detection and response in less than
7 days, and others (eg, Mycobacterium tuberculosis) might not be detected in this
time frame, establishing a single metric is a route to standardised assessment and
comparisons across countries and over time; stratified analysis might provide for
a refined indicator as more data become available, with standard definitions and data
collection.
Mount an effective response within 7 days
After notification, the outbreak response should begin immediately. The proposed target
to establish effective control measures includes seven response components; each of
the applicable measures should be completed within 7 days (panel, appendix pp 2–4).
In comparison with data on detection and reporting, fewer retrospective data are available
for the timeliness of response actions because there are uncertainties about what
constitutes a response action. The WHO GPW13 methods describe the “earliest date of
any public health intervention to control the event”, which can include the time the
field investigation started, the time the incident management system was established,
the time the vaccination campaign started, the time the rapid response team was established,
the time the vector control programme was launched, the time the food product was
recalled, or the time that risk communications were started.
13
The 7-1-7 target makes clear that multiple response components must be in place for
a response to be considered effective, and that the relevant components should all
be in place within 7 days of notification to public health authorities. Although different
pathogens require different paces and types of intervention, the seven components
are broadly applicable. Obtaining detailed epidemiological and laboratory information
is foundational in any outbreak response. The provision of medical treatment and supplies,
including personal protective equipment and other appropriate countermeasures, is
required for most outbreaks, as is effective communication and community engagement.
In any large event, the establishment of an incident management system is essential
to ensure effective coordination of stakeholders across sectors. If any one of the
applicable steps has not been taken, the 7-day metric would not be considered met.
This clear, simple yes-or-no approach increases accountability and provides a roadmap
for initiating early and effective responses. More details are provided in the appendix
(pp 2–4).
The 7-1-7 target provides a common benchmark to assess the effectiveness of clinical,
laboratory, and public health detection and response systems. Although this 7-1-7
target is ambitious and exceeds the performance levels of some recent outbreaks, including
the initial emergence and cross-country spread of COVID-19, it is feasible, even if
this approach is not achievable in every instance. Synthesising data into the 7-1-7
metric will integrate and improve the use of data collected through existing systems,
including Integrated Disease Surveillance and Response reporting, laboratory information
management systems, and various surveillance platforms, including District Health
Information Software 2-based systems. Event management systems could serve as an efficient
platform to integrate data from across departments and sectors.
9
WHO should consider adopting the 7-1-7 target as part of its reporting to establish
a standard measure of how well countries are detecting and responding to outbreaks.
Countries would be able to simply and regularly assess their performance as well as
identify areas for improvement. The 7-1-7 target would also improve global preparedness
accountability and could further catalyse action and funding from donors and entities,
including the World Bank and other international financial institutions. Formal adoption
of the 7-1-7 metric by WHO (eg, as part of its Triple Billion initiative) could increase
funding for national and international epidemic response agencies, as well as increase
financial commitments from countries.
Although the 7-1-7 metric is a global target, implementation of and accountability
for this target must be accomplished by countries, where national public health institutes
or ministries of health have primary responsibility for collecting data and routinely
assessing performance to identify lessons learnt, best practices, and areas for improvement.
National public health institutes can accelerate progress towards the 7-1-7 target,
19
as shown by the Nigeria Centre for Disease Control and others,
20
if these institutes are well integrated into the overall public health system, including
at the subnational level, and have sufficient autonomy and protection from political
interference. Although countries will vary in their performance on the targets, a
global target can help identify priorities for donor investments and technical assistance
as well as allow all countries to identify system bottlenecks and align health security
goals among stakeholders.
We are at a now-or-never moment to improve global readiness for disease threats. We
cannot know the character or timing of the threats ahead, but we can be certain that
such threats are inevitable. The urgent need to improve speed and completeness of
detection and reporting, and quality and timeliness of response, is clear. Establishing
the 7-1-7 target will provide impetus and accountability to make the substantial financial,
technical, and political investments needed to strengthen global health protection
by improving our capacity to find, stop, and prevent future pandemics.
Declaration of interests
We declare no competing interests.