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response may be limited. National militaries may have experience in medical countermeasure research and development, transport elements, military health or other surveillance programs, or other initiatives that may prove relevant to outbreak preparedness and response. Challenges that could prevent or complicate engagement from the security sector include a possible lack of experience with biological or health-related emergency response in a given country’s security agencies; a mutual lack of understanding regarding the needs of the response and potential assets that could be brought to bear; a lack of training, equipment, or buy-in from military personnel; and the possibility that security sector involvement could, if improperly implemented, be at cross-purposes with efforts to provide communities with public health or medical interventions.83,84 On balance, in many countries the security sector could bring valuable expertise and assets to bear, both in terms of preparing for high-impact respiratory pathogens and in the response and in medical countermeasure research and development. Countries should seek to find mechanisms to incorporate the security sector, while planning on avoiding the possible complications of this kind of engagement. Surveillance, Monitoring, and Assessment Systems Surveillance Capabilities Reviews of past events have revealed limitations in global and national surveillance capacities. Current systems vary widely in their quality, and many under-resourced settings do not have surveillance systems that could adequately serve those purposes. Furthermore, existing surveillance systems are highly fragmented and local, with data that cannot easily be pooled and analyzed to direct a large-scale response. Enhancing (and, in some under-resourced settings, implementing) surveillance systems would improve capabilities to prevent, detect, and respond to an event from a high-impact respiratory pathogen. A commonly cited limitation is insufficient availability of laboratory testing.85 Laboratory information is essential for ensuring the availability of accurate and actionable surveil- 41 lance. In addition to assessing the availability of laboratories that can perform diagnostic testing, countries must also consider the capacity of laboratories to handle testing in the event that there is a large surge in demand. While laboratory networks and surveillance mechanisms including GISRS, FluNet, and WHO Collaborating Centers are vital components of current surveillance capacities, efforts should be made to further strengthen these mechanisms and improve laboratory testing. Surveillance capacity as measured by the JEE tool requires syndromic surveillance for 3 core syndromes (including severe acute respiratory syndrome) and regular analysis and reporting of surveillance data. Of the countries for which data is available, the average surveillance score is 3.3 out of 5 on the JEE, which suggests that there is room for strengthening the capacity of many countries to detect and monitor outbreaks.86 During large-scale events involving a respiratory pathogen, it will be critically important that countries and the international community have ready access to information to support decision making about how best to respond. A key question that is likely to emerge right away is how severe the event is in terms of health impacts (eg, percent ill, percent of cases resulting in death or severe outcomes). As demonstrated in the 2009 influenza pandemic, the answers to these questions are likely not readily available in traditional public health surveillance systems. Health officials should identify additional data sources that may provide insights to these questions and make plans for accessing and analyzing them.87 To enable this, countries should invest in developing surveillance systems that produce timely, accurate, and highly resolved data that can be easily analyzed and shared. Specific diagnostic information would be of great importance, and countries should have plans for the development or uptake of diagnostic tests. In an event involving a novel pathogen, PCR-based tests are likely to be the first to be available to aid in diagnosis and confirmation. In preparation for this, national public health laboratories and large commercial laboratories should develop a concept-of-operations for how to distribute test kits rapidly to relevant clinical sites and laboratories in areas affected by the outbreak. In instances in which demand exceeds capacity at available laboratories, policies for testing may change. For example, during the 2009 influenza pandemic, public health laboratories stopped confirming individual cases of influenza once transmission became widespread.88 Such changes in testing procedures would require pre-event planning to determine criteria for testing and communication about planned protocol changes with clinicians, public health practitioners, and the public. The information needs and sharing that may occur during deliberate events may vary greatly from a naturally occurring event. For example, there will be a need to assess the risk of subsequent attack—a consideration that is likely to be central in discussions about 42 how to utilize medical countermeasures. It has also been identified that there are insufficient mechanisms to enable rapid information sharing across sectors during a deliberate event response.37 Additional gains could be made by further developing modeling capabilities to enable the modeling of surveillance data to gain insights into its anticipated trajectory and potential future impacts of an event, as well as modeling around possible response strategies. Modeling can support public health decision making in a number of ways, including planning and comparing interventions, forecasting the trajectory of the epidemic, and simulating risk scenarios.89 Models can also transform diverse data streams into a mathematical representation of an outbreak that is more structured and informative than the input data individually. In order to be as useful as possible, modeling capabilities should be implemented in advance of an emergency and closely integrated with the public health decision-making team to facilitate rapid analyses and decision-