Proceedings of a Symposium—in Brief

Exploring Actions for Epidemic and Pandemic Preparedness

Proceedings of a Symposium—in Brief

INTRODUCTION

Investing in pandemic preparedness ahead of disease outbreaks can greatly reduce the toll of epidemics and pandemics when they occur. Although several tools exist for assessing pandemic preparedness at an epidemiological and operational level, less information and fewer approaches are available to guide the prioritization of preparedness investments at the country level. To understand the current challenges, the National Academies of Sciences, Engineering, and Medicine convened experts and interested parties in global epidemic and pandemic preparedness from low-, middle-, and high-income countries in a virtual symposium titled Prioritizing Actions for Epidemic and Pandemic Preparedness held over 3 days (May 4, May 18, and June 9, 2023). This Proceedings of a Symposium—in Brief provides the rapporteurs’ high-level summary of the discussions at the symposium. This proceedings highlights potential opportunities for action but should not be viewed as consensus conclusions or recommendations of the National Academies.

The symposium, held around the same time the World Health Organization (WHO) declared that the COVID-19 pandemic was no longer a public health emergency, sought to explore possible strategies for strengthening the capacity for evidence-based prioritization of global health capabilities to prepare for future epidemics and pandemics. Specific objectives of the meeting were to discuss assessment tools and how, independently and together, they relate to national action planning; to gain insight into how countries and organizations currently select priorities in funding for epidemic prevention, detection, and response; to hear evidence for effective prioritization approaches to building disease surveillance and risk communication capabilities; and to explore governance structures that can support robust and reliable systems for global health investments. Within these objectives, participants discussed several actions, many of which did not focus only on tools and resources for prioritization. Examples of these actions are included in this proceedings.

CONTEXT FOR SUSTAINABLE INTERNATIONAL EPIDEMIC PREPAREDNESS

In the first symposium session, speakers and panelists from around the world highlighted research, programs, and perspectives on the political and economic context of epidemic and pandemic preparedness. This discussion

set the stage for a deeper exploration of potential actions moving forward.

Country Capacity for Action Planning

Speakers discussed a variety of considerations for assessing and enhancing country capacity for national action planning. One theme raised by many speakers was the importance of learning from real-world experience, which plays into the capacity of individual countries to invest in pandemic preparedness, and approaches to preparedness and response at the global scale. Describing health emergency planning and capacity in Brazil, for example, Jailson Correia (Instituto de Medicina Integral Professor Fernando Figueira) noted that the country’s previous experiences with Zika and chikungunya informed its response to COVID-19. He stressed the importance of having translators or “interpreters” who can understand multiple aspects of public health and bridge across disciplines and sectors. Expanding on this point, Saul Walker (Coalition for Epidemic Preparedness Innovations) said that during the COVID-19 response, the world drew upon the experience of countries in the Global South that regularly face disease outbreaks.

Infectious disease public health investments often follow a cycle of “neglect and panic,” in which focus and investments dissipate between crises. Walker stressed that sustained investments in-between epidemics are essential for laying the groundwork so that when a crisis emerges, the relevant partners already know how to work together and are poised to switch into response mode. He noted that the aspects of the COVID-19 response that went relatively well were those areas in which sustained investment in science and infrastructure existed ahead of time, such as in mRNA and other technology platforms that allowed vaccines to be developed, manufactured, and delivered at record speed.

For countries to make impactful investments in pandemic preparedness and response and reap the benefits of these investments, many speakers pointed to one essential ingredient: trust. On the part of leaders, trust is critical for generating the political will to invest in preparedness. As Lisa Hilmi (CORE Group) summarized, “It’s clear without country and regional leadership and buy-in, our efforts of preparedness and response will fail.” Conversely, the public’s trust in their leaders and institutions influences how successful the response will be. “In times of crisis, public trust is not just important; it is indispensable. It is a glue that holds societies together, the foundation upon which successful responses are built, and the light that carries us through the darkest of times,” said Ayoade Alakija (African Vaccine Delivery Alliance).

Building trust is important at all levels, but several speakers emphasized that grounding trust in the community is most effective. “Pandemics begin and end in communities. Starting to build that trust at the community level, engaging communities in prevention, detection, containment [is] absolutely vital,” said Priya Basu (World Bank Group). Noting that nothing that is developed on a global scale can replace domestic activities fully, Sara Hersey (WHO) said that building trusted in-country resources is essential and added that global efforts also can be made more effective by tapping into existing trusted regional networks and organizations.

Investing in Pandemic Preparedness and Response

Speakers examined how different countries and organizations currently prioritize pandemic preparedness and response along with evidence relevant to prioritization approaches for strengthening disease surveillance and risk communication capabilities.

Several speakers emphasized the value of starting with existing capacities and capabilities and building from there. Irma Makaliano (University of the Philippines) highlighted how the Philippines took this approach in its response to the COVID-19 pandemic. For example, to fill gaps in disease detection laboratory equipment and infrastructure in its health care systems, the country was able to repurpose and use resources and expertise found in its research facilities and universities. In addition, Makaliano stressed the importance of strengthening primary care systems as a foundation upon which to add enhanced science, technology, and surveillance capacity.

Alakija described the PACTT framework for strengthening global health security, which involves five fundamental elements: prevention, access, countermeasures and tools, and trust.¹ Hersey highlighted how the WHO is working toward a global architecture for preparedness and response that builds capacity for collaborative surveillance, emergency coordination, community protection, access to countermeasures, and clinical care through its Epidemic and Pandemic Hub. In particular, the International Pathogen Surveillance Network, a recently launched global network bringing together pathogen genomic data to improve public health and decision-making, aims to coordinate existing systems, networks, and capacities.

Rather than thinking in terms of a short-term project, Hersey underscored the need for long-term investments to build institutional capacity, both domestically and internationally. In guiding these investments, she added that overcoming silos and attending to the interdependencies among different facets, such as on-the-ground surveillance systems and the laboratories needed to support testing, are important. Walker added that efforts to build institutional capacity ought to focus on long-term goals, but also deliver on the value of capacity-building in the near term by putting surveillance and response systems to the test to strengthen systems, provide positive feedback, and build trust.

Another common theme that several speakers raised is the value of thinking about the context of pandemics from multiple dimensions. As Alakija put it, “We cannot do epidemic preparedness in a vacuum.” Focusing too much on quantitative data points without understanding the social context for those numbers can lead to incorrect interpretations or risk missing crucial nuances. Building on this point, Marty Cetron (U.S. Centers for Disease Control and Prevention) noted that pandemics enter societies that constantly are being shaped by politics, conflict, and other public health contexts and challenges. He cautioned that although syndemics (i.e., two or more concurrent or sequential epidemics that synergize and exacerbate the disease) are increasing in frequency, duration, magnitude, geoscope, and speed, most countries and organizations have not established a model of pandemic preparedness and response that takes this context into account. Thinking about pandemics only from a pathogen-focused perspective overlooks the social context in which these events play out.

To enable decisions and actions that are responsive to context, Cetron suggested establishing ways to measure readiness that are appropriately multidimensional. Several speakers highlighted the importance of investing in integrated surveillance systems, laboratory capabilities, and high-quality data systems aligned with the “One Health” approach.² As Hersey highlighted, surveillance is valuable not only in health emergencies, but also for understanding how the emergence, management, and elimination of diseases interacts with complex contexts like conflicts and natural disasters. To capture this complexity, she suggested moving away from the traditional focus on linear, geographically constrained tracking of new cases and mortality rates and toward modes of collecting and analyzing data that capture multiple health, economic, and social contexts.

How people perceive the threat of pandemics is also important. Although familiarity with disasters like floods and earthquakes have led to greater understanding about their scale and scope, Larry Brilliant (Pandefense Advisory) pointed out that the risk of occurrence of a pandemic is in some ways incalculable. At the same time, having so recently experienced the COVID-19 pandemic can give people the erroneous impression that another pandemic is unlikely to happen for a while. Since the risks of a pandemic are both incalculable and increasing, he said resisting the temptation to let down our guard is crucial.

Finally, several participants emphasized the benefits of investing in people and embedding equity in pandemic preparedness and response. “While we are thinking of advanced science and technology [and] infrastructure, we always, always have to remember to invest in

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people,” said Makalinao. This includes training the next generation of frontline health workers and preparing other groups and institutions that are not traditionally considered part of the public health system, such as, in the case of the Philippines, the police and army.

Effectively translating policy into practice may rely on equity in access, funding, decision-making, and power. Alakija described how inequities have undermined public health and crisis response, such as the history of religious and political tensions including a situation from northern Nigeria that delayed the global polio eradication effort back by a decade. To avoid missteps and increase the likelihood of success in public health, she stressed that people in communities most affected by health issues need to be included in the process of addressing them. “Trust cannot be an afterthought,” she said. “These conversations have to begin with those with the lived experience.”

Finance and Governance Structures

For global health investments to be robust, reliable, and sustainable, appropriate governance structures to support them likely are important. Speakers discussed considerations for political engagement, partnerships, and financing to support ongoing investments in pandemic preparedness and response.

Some speakers emphasized effective political leadership, a sense of shared responsibility, and a whole-of-society approach. Implementing pandemic preparedness is a journey that requires a long-term commitment at both the global and national levels, Basu stated, noting that the World Bank has seen an encouragingly strong level of commitment among low and middle-income country governments, which she hopes will be sustained at the national level as a complement to international financing. Several speakers pointed out that political engagement is helpful for sustaining investments, and Correia noted that political extremism and destabilization of democracies can undermine countries’ ability to respond to health emergencies. Wessam Mankoula (Africa Centers for Disease Control) described political engagement as an organic process of bridge-building in which parties learn to speak each other’s languages and acknowledge the needs and priorities of others. “We don’t buy political engagement; we build political engagement,” he said. This is true within countries and for harmonization between country and regional plans. Alakija described how the African Vaccine Delivery Alliance provides a good model for bringing multiple parties to the table, including international institutions such as the WHO, to coordinate actions around a shared goal. Walker added that focusing on enabling innovation, adaptability, and agility in pandemic preparedness such that the basic infrastructure and organizing principles are in place and can be built upon when crises emerge is important.

In addition to policy, funding allocations are important for pandemic preparedness and response. Duncan Selbie (International Association of National Public Health Institutes) said that budget allocations—not stated strategies—reveal a country or organization’s true priorities and level of commitment. He also stressed the importance of recognizing preparedness efforts not as a cost but as an investment that will reap returns by saving lives, saving money, and supporting healthy economies.

Basu said that harmonizing different investments and efforts can create a multiplier effect among funds provided by domestic and international organizations and help maximize their impact. Based on this notion, she said that in making grant decisions the World Bank looks for evidence that relevant institutions are complementing each other’s activities both in terms of technical expertise and co-financing. Walker reiterated the importance of complementarity between domestic, regional, and international actors. Although national and regional research and development (R&D) programs are often a locus of investment, he said they are necessary but not sufficient for pandemic preparedness and underscored the need to take a broader view of preparedness that recognizes the complexity and diversity within R&D and health services ecosystems.

ISSUES AND OPPORTUNITIES DISCUSSED IN BREAKOUT SESSIONS

Attendees further explored aspects of pandemic preparedness in a series of concurrent small group

discussions on issues and opportunities in five key areas: situational awareness; trust, transparency, and risk communication; governance, financing, and accountability; capacity and functionality assessment; and preparedness and response planning.

Situational Awareness in the Context of Health and Diseases

Brilliant summarized a discussion focused on situational awareness. Highlighting that disease outbreaks are inevitable—given human encroachment onto animal territories and the more than 300,000 uncharacterized animal viruses with zoonotic potential³—he said that early disease detection, continual surveillance, and situational awareness are critically important to containing outbreaks before they become widespread. Emerging digital and participatory surveillance techniques discussed by Mark Smolinski (Ending Pandemics) represent a significant improvement over routine clinician and government reporting, and some participants indicated that these tools could be used to identify new diseases and detect outbreaks more quickly.

In addition, several participants said that countries could build surveillance systems that fit their unique cultures and economic circumstances. For example, in Cambodia, which has a low smartphone penetration rate, the government created an analog phone reporting system to monitor and detect outbreaks. It was initially philanthropically funded and now has sustainable government support.

Finally, many participants reiterated the importance of building community trust. Communication strategies that listen, respond, and deliver benefits to the involved parties can create value and build trust, increasing the likelihood that communities will continue to voluntarily contribute health information. Voluntary participation at the community level is one strategy for moving from surveillance to a system of continuous situational awareness to monitor public health and detect crises.

Building Trust, Transparency, and Risk Communication Capabilities

Richard Garfield (U.S. Centers for Disease Control and Prevention) shared his group’s comments regarding trust, transparency, and risk communication. To prepare for and to respond to public health crises, many participants said supporting community engagement that prioritizes honesty, openness, and simplicity is just as important as providing funding for medical equipment. They stressed that continuous, bidirectional communication—an ongoing program of listening to key community groups and testing messaging strategies for mistakes and missteps—among public health organizations avoids seeming unprepared and disconnected from vulnerable communities during a crisis. “There’s always time to have some dialogue; there’s always time to listen back,” Garfield said.

Another example strategy that some participants mentioned is to separate risk communication from messaging about healthy or preventive behaviors, and to use different phrasing for these different types of health messages. Combining the two messages can be misinterpreted and seen as subjective, manipulative, or illegitimate.

Finally, during emergencies, Garfield said that researchers could practice market segmentation by defining the situation, identifying the impact on different groups (especially historically disadvantaged groups), and determining the most effective communication and engagement strategies before asking people to act.

Strengthening Global Health Security Through Strong Country-Level Infrastructure for Effective Governance, Financing, and Accountability

Julie Wahl (Resolve to Save Lives) summarized the discussion of governance, financing, and accountability considerations. The group discussed improved legislation, communication, public-private community coordination, and national and local monitoring and evaluation systems to improve countries’ preparedness, capabilities, and accountability in outbreak detection and prevention. Because access to resources can vary within countries, promoting equity and social protection

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within accountability systems may be beneficial. In addition, some participants thought that monitoring and evaluation systems could be linked to specific measurement tools that can aid regular accountability, capability, and financial needs assessments.

Some participants stated that providing adequate funding for domestic health security programs can improve accountability and coordination across government agencies, community groups, and the private sector. They described how financing of these programs in under-resourced nations, which typically rely on philanthropic donations, has been a significant challenge, but some countries have overcome these issues. For example, Ethiopia and Uganda have funded domestic preparedness teams and steering committees that support multisectoral coordination and governance and accountability demonstrating effective country-led ownership.

Finally, although most financial cases for disaster spending focus on the response costs, Wahl said that advocating for increased spending on effective preparedness could be bolstered by research quantifying the return on investment for these initiatives.

Global Health Capacity and Functionality Assessment

Jessica Petrillo (U.S. Agency for International Development) and Aamer Ikram (National Institute of Health, Pakistan) shared reflections from the discussion on global health capacity and functionality assessment. Prior to the discussion, participants listed and described existing assessment tools.⁴

Several participants highlighted the importance of engaging with local communities and ensuring that they have access to tools that provide timely, high-quality data for improving their capacity and functionality are important. They suggested that these tools could benefit from funding to overcome several challenges: potential language barriers, the overwhelming number and complexity of the tools, the need for training, and the lack of data interoperability, which results from different domestic and international data standards and overall data siloing. In addition, some participants suggested promoting partnerships across public and private sectors that are appropriate to the overall ecosystem and its capabilities.

Moving forward, several participants suggested seeking out, celebrating, and emulating more examples of successful tools, communication strategies, and public health programs that empower community assessments. For example, the COVID-19 crisis has been a rich experience that could be examined for successes that can be used as models for a realistic global strategy of government-led sustainable practices to prevent future epidemics. Examples of successes include improving data interoperability and enhancing countries’ primary health care systems.

Country and Organization Experiences in Preparedness and Response Planning

Erwin Calgua (Universidad de San Carlos de Guatemala) summarized a discussion of the experiences of different countries and organizations in preparedness and response planning. One lesson from these experiences, he said, is the importance of addressing inaccurate or misleading information about biology or disease outbreaks. External assessments are only useful if communication strategies depict them as apolitical and legitimate; at the nexus of public health, decision-making, and policymaking; and connected with the well-being of all people.

He highlighted that although several regions and countries had specific networks in place that helped them respond to the COVID-19 pandemic, they had to operate in a dynamic and global context. Those that had increased laboratory facilities and capabilities were able to collect and analyze data more quickly, allowing them to have a more flexible response.

Calgua also reiterated that health emergencies are not only caused by pathogens, and they likely will never go away. The next pandemic is likely to combine with factors like climate change and conflict, underscoring the importance of a holistic and all-encompassing public health approach.

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EXAMPLE ACTIONS FOR EVIDENCE-BASED PRIORITIZATION OF GLOBAL HEALTH SECURITY CAPABILITIES

Throughout the symposium, speakers, moderators, committee members, and other attendees suggested a variety of actionable approaches to enhance pandemic preparedness and response. For the final session, planning committee members compiled the approaches that had been suggested during the first two sessions, and participants engaged in an interactive exercise and discussion to consider their relative urgency and feasibility. Committee members and participants also discussed ways to overcome obstacles, and specified some actors who could be involved in implementing the actions. Actions on assessments; data and information-sharing; and policy, frameworks, and planning were the focus of this exercise.

Global Health Security Capacity and Functionality Assessment

One theme throughout the symposium was the importance of tools and strategies for assessing pandemic preparedness that are relevant across different country contexts and levels. Table 1 at the end of this document lists the tools that Petrillo and Ikram prepared in advance of the symposium.

Several participants highlighted capacity and functionality assessments that are accessible and minimally burdensome, generate informative data, and are capable of influencing actions at the local, subnational, and national levels. Some participants suggested that assessment tools be available and accessible to all people. For this to be realized, involving language and communication experts can help to make tools understandable to users. Richard Seifman (World Bank) pointed out that a country’s official national language is not always the language spoken in the communities that will be important for surveillance, detection, and response, so considering how to use technology or other solutions to rapidly translate materials into relevant local languages will be important.

Real-world examples of successful implementation of actions can be highly informative, and many participants suggested incorporating such examples when developing plans for filling gaps and strengthening overall capacity. Some participants also suggested that assessment tools could be improved by focusing on specific activities, such as partnerships and collaboration, long-term investment, data collection capacity, use of language, and policy and government frameworks. Kavita Berger (National Academies of Sciences, Engineering, and Medicine) suggested that focusing on the country context when determining what data to collect may help, given that different types of data will be available or applicable in high-resource and low-resource countries.

Who is involved also matters. To effectively assess particular capacities and the overall system, several participants said including many sectors and diverse actors in the development and use of assessment tools are important. Many participants stated that this is urgent, but disagreement existed about its practicality.

Throughout the symposium, some participants expressed concern about balancing the objective of assessing preparedness and the burden of collecting data for those assessments. Speaking to this issue, Garfield stressed the need to focus on what information truly is needed. Every tool uses data, which is then provided, collected, and analyzed. As a result, trying to “learn everything” imposes a large burden on people and organizations and can hinder progress. Rather, he said the focus could be on determining what is actually needed for decision-making, and success could be measured by whether assessments help people do a better job. Sometimes, he added, this will mean identifying assessment tools or data that could be retired or moved into the realm of academic research rather than playing a more integral role in public health systems.

Participants explored various ways to reduce the burden of assessments and enhance their value. Evaluating the effectiveness of assessment tools at the local level was viewed positively by many participants, and some participants also highlighted the importance of better integrating local data into local, subnational, and national assessment and decision-making. Jennifer Lasley (World Organisation for Animal Health) pointed out that people who provide their data want to see that it is being used to inform decisions or generate some

benefit, particularly when the tools are in analog form. Often, information is used one time and then lost. “We’re not leveraging the effort that it takes for countries and stakeholders to provide that information, which probably was really hard to get in the first place,” Lasley said. To make better use of data for assessments, some participants said that digitizing data and enhancing capacity and systems with appropriate staffing, expertise, data systems, and political support, among other capacities can be important. However, they acknowledged that some of these may pose challenges. Lasley posited that the onus is on organizations that create and use assessment tools to stop using single-use and analog approaches and invest in sustainable, long-term digital data.

Several other strategies for improving assessments were seen by many symposium participants as being of lesser immediacy even though they may be practical to implement. These strategies include using independent peer review processes and locally relevant criteria to assess country capacity; collecting existing capabilities that are available through academic, government, and healthcare systems; and incorporating an understanding of the context for integration of the tool across levels, including consideration for factors such as trust, resource allocations, and information and communications technology infrastructure. Some participants stated that use of assessments to compare capabilities among countries is not helpful.

Data and Information-Sharing

Several suggestions related to data collection and use were discussed. One goal was to develop data standards for assessments. Several participants highlighted that this is an important goal, but several disagreed about its feasibility. For example, Emily Ricotta (National Institutes of Health) noted that implementing data standards is complicated by language and cultural differences among different countries and contexts. Another suggestion was to conduct proof of concept demonstrations to show how information and processes involved in assessments could be digitalized into data that can help make future assessments more useful.

Another suggestion was to improve the interoperability, interconnectedness, and integration of assessment tools and data at multiple levels, from facilities to countries. One practical measure this could involve is to establish agreements to assist in data sharing, availability, and use. In the same vein, some participants stressed the value of integrating and balancing information-sharing platforms, resources, and other mechanisms of cooperation across sectors and multi-levels of governance to build equity and surveillance.

These activities are not without challenges. Cetron noted that the ability to monetize data creates incentives to make them proprietary and hoard it, rather than sharing them freely. A further complication is that different actors do not always share the same core values regarding what types of data can be owned and which are communal resources for the common good. Resolving these issues likely involves participatory processes that recognize the values of many different parties, but that is difficult to achieve. Petrillo added that many challenges from a technological perspective also exist. Facilitating connections among different data systems may benefit from significant investments in data integration architecture, which in turn involves political will, appropriate financing, and mechanisms for bridging between silos, such as facilities that handle human data and those that handle animal data.

Some participants stressed the importance of having access to quality, actionable data in a timely manner to help assess capacity and functionality gaps, and to analyze the data to inform decision-making and develop evidence-based policies. Recognizing that assessments can impose burdens on local actors, many participants suggested better defining what data will be informative and available, although some noted that this could be challenging. Some participants also emphasized incorporating measurements of capabilities that look across sectors and are more intuitive, in contrast to a traditional emphasis on linear and more siloed approaches. Other ideas discussed included (a) reframing preparedness and investment in ways that recognize the interdependence of capabilities, and (b) considering the causal relationships among actions.

Policy, Frameworks, and Planning

Policy is one crucial tool in the response to public health threats. Several participants discussed two potential actions for informing policy decisions: (1) establishing active monitoring within any rapid policy changes that happen during disease outbreaks; and (2) following up with policy impact evaluations to understand the effectiveness of policy and financial investments. Other potential strategies are to use implementation research and case scenarios to inform policy advice, and to align country and regional plans. Strategies seen as practical include breaking broader strategy plans into smaller, more manageable activities based on a country’s current capacity to reduce bottlenecks and considering the synergies between noninfectious diseases and infectious disease outbreaks in preparedness planning.

Ideas from participants related to prioritization frameworks include developing a maturity framework to inform ad hoc responses to epidemics; developing a framework for translating capability gaps into tangible actions within different cultural contexts, along with methods for assessing progress toward implementation; and promoting alternative structures to facilitate plans for countries that are missing governance structures to support preparedness activities.

OTHER EXAMPLES OF ACTIONS FOR STRENGTHENING EPIDEMIC PREPAREDNESS CAPABILITIES

Several other examples of potential actions were mentioned during the discussions.

Risk Communication and Public Engagement

Two suggestions in risk communication and public engagement were highlighted by some participants: (1) pursuing people-centered, community-led engagement and partnerships; and (2) engaging the public in an ongoing manner with mechanisms for direct and indirect avenues of communication. In terms of risk communication strategies, some participants suggested communicating frequently using multiple media venues; incorporating research-based strategies for communicating around uncertainties; and translating key pieces of information into straightforward content that can be easily digested and communicated by trusted messengers.

Several participants emphasized some helpful example approaches: investing in communication strategies before an outbreak so that systems are in place ahead of time; conducting formative evaluations to test messages; collecting communication success stories within countries that have a decentralized health system; and establishing standards that inform the evidence and data, communication, and decision-making in an emergency. Having more translators who understand the relevant cultural complexities can help to build community trust, and some participants suggested that these trusted messengers could be armed with lessons learned from what was effective in previous public health actions. Finally, some participants noted that addressing misinformation and fake news and understanding the channels through which false information spreads are vital.

Preparedness and Response Capability-Building

In building capacity for pandemic preparedness and response, several participants highlighted the importance of building capacity at the country level and in communities and across regions. Infrastructure also was highlighted as a critical part of capacity-building. Some participants suggested that countries could develop plans to scale up core infrastructure and organize programs such as epidemiological surveillance teams, laboratory services, and communication teams ahead of time. In addition, several participants pointed out that these capabilities could be tested in outbreak settings, and that preparedness efforts overall could benefit from continually being evaluated and monitored.

To advance these general capacity-building goals, some participants mentioned potential strategies: leveraging existing structures and partnerships; building relationships and communication around local cultural practices; closing gaps in formal and structural supervisory performance capacity to increase multisector coordination; and taking a systems approach to both creating resilient and sustainable health

systems and assessing those capacity-building efforts. Several participants also highlighted the importance of considering climate and environmental health in strengthening pandemic preparedness capabilities.

Symposium discussions also surfaced opportunities in the specific areas of surveillance, response, and vaccine deployment. For surveillance, some participants said that countries could enhance training of community workers, especially in remote settings. In addition, implementing surveillance plans and combining surveillance across social and environmental factors can help to increase data use and sharing for pathogen surveillance efforts. In terms of response capacity, several participants underscored the importance of including mental health in preparedness planning and suggested creating teams that are equipped to serve multiple purposes, responding not only to health emergencies and potential pandemics, but also to crises arising from climate change, natural disasters, conflicts, and displacement.

To leverage vaccines more effectively in pandemic response, some participants suggested countries could learn from organizations and countries with experience in quickly mobilizing vaccine delivery and procurement systems using global supply chains for vaccines, drugs, and diagnostics. These can be made more resilient to shortages by investing in local manufacturing opportunities to support vaccine dissemination and lessen response time. The discussions also underscored concerns about vaccine hesitancy among different populations.

Commitments and Financing

To make headway and sustain preparedness activities, several participants mentioned political will, accountability, and funding. Some participants stressed the importance of ownership of these efforts at the country level, and others noted that including local needs and capabilities in national and regional level response decisions involves ownership and coordination across all levels and sectors. Several participants noted the value of capacity strengthening, including with technology and coordination, to support governance at country and regional levels, and added that alternative structures may be needed to facilitate planning in countries without governance structures suitable for supporting preparedness activities.

Monitoring the status of pandemic preparedness and capacity is important to ensuring interested parties are accountable to the commitments they make. Many participants suggested employing tracking tools and other resources, developing a certification process for data analysis, and openly sharing monitoring systems to increase cooperation and amplify health safety measures across countries and regions.

Participants offered a range of suggestions to support funding for pandemic preparedness activities, noting that different models may be needed in different countries and regions. Several participants suggested focusing investment on institutional capacity-building. Other, more specific examples include establishing sustainable funding for financing the health sector and securing funds to facilitate health communication. Many participants suggested that public-private partnerships can be helpful, as can working with philanthropies to reduce the financial risk that governments take on. Noting that preparedness financing is frequently subject to boom-and-bust cycles, Brilliant underscored the need to establish sustainable funding models, even in lower-resource countries. As an example, he pointed to Thailand’s use of taxes from specific sectors—namely, alcohol, cigarettes, and prostitution—to create the Thai Health Promotion Foundation, which supports many aspects of the “One Health” approach to public health improvement along with pathogen surveillance and situational awareness. Although the same model would not necessarily be appropriate for every country, he suggested that “the action item is to look at each country’s ability to deal with being able to uniquely develop the mechanism for having sustainability, reliability, and assurance that money and resources will be there when they’re needed.”

Partnerships, Equity, and Education

Pandemic preparedness is a multifaceted issue that involves and affects all sectors and communities. Many participants underscored the importance of building partnerships with communities—including diverse

and historically marginalized groups—and upholding commitments made to them. To embed equity in preparedness activities, some participants said linking institutions and capacities to community benefits and working to ensure equitable access throughout implementation of preparedness investments and collaborations are important. Finally, several participants suggested working with academic researchers and relevant organizations to conduct research on the implementation of preparedness measures and strengthen guidance, and to provide opportunities for students and employees to gain experience and maintain knowledge and skills in public and international health.

TABLE 1
Examples of Preparedness Assessment Tools Currently in Use^a

^a This table lists examples of actions shared by workshop participants. This table does not include all ideas mentioned by participants and should not be interpreted as consensus conclusions or recommendations of the National Academies.

DISCLAIMER: This Proceedings of a Symposium—in Brief was prepared by Kavita Berger, Anne Johnson, Julie Pavlin, and Nam Vu as a factual summary of what occurred at the symposium. The statements made are those of the rapporteurs or individual symposium participants and do not necessarily represent the views of all symposium participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.

REVIEWERS: To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Symposium—in Brief was reviewed by Larry Brilliant, Pandefense Advisory; Erwin Humberto Calgua Guerra, University of San Carlos de Guatemala; Klara Henderson, Department of Foreign Affairs and Trade, Australia. Lauren Everett, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.

SYMPOSIUM PLANNING COMMITTEE MEMBERS Lisa M. Hilmi (Chair), CORE Group; Larry Brilliant, Pandefense Advisory; Erwin Humberto Calgua Guerra, University of San Carlos de Guatamala; Arminder Kaur Deol, Coalition for Epidemic Preparedness Innovations; Richard Garfield, U.S. Centers for Disease Control and Prevention; Soawapak Hinjoy, Ministry of Public Health, Thailand; Aamer Ikram, National Institutes of Health Pakistan; Joshua Kayiwa, Ministry of Health, Uganda; Jessica Petrillo, U.S. Agency for International Development; Gisela Scaglia, Former Member of Parliament, Argentina; Julie Kathleen Wahl, Resolve to Save Lives.

STAFF Kavita Berger, Board on Life Sciences; Julie Pavlin, Board on Global Health; Nam Vu, Board on Life Sciences.

SPONSOR This symposium was supported by the National Academies’ Presidents.

SUGGESTED CITATION National Academies of Sciences, Engineering, and Medicine. 2023. Exploring Actions for Epidemic and Pandemic Preparedness: Proceedings of a Symposium—in Brief. Washington, DC: The National Academies Press: https://doi.org/10.17226/27226.

For additional information regarding this activity, visit https://www.nationalacademies.org/our-work/science-based-approaches-for-prioritizing-capabilities-for-preventing-detecting-and-responding-to-infectious-disease-outbreaks-epidemics-and-pandemics-a-symposium

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