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governments in their preparedness planning and benefit responding agencies in streamlining activities such as procurement processes. In addition, the World Economic Forum report that addresses the risk and impacts of future epidemics strongly advocates for public-private collaboration and provides potential models to optimize private-sector engagement. The World Economic Forum recommends building connections between in-country operators and the public sector; expanding expert-based groups, such as the UN Clusters, to include private sector partners; and developing a platform to improve information flow and increase coordination between the private and public sectors.50 In summary, preparedness for a high-impact respiratory pathogen has received little specific focus in these high-level reviews, notwithstanding hundreds of useful recom- * Reports include the National Academy of Science, Lessons Learned from a Century of Outbreaks; the World Economic Forum, Managing the Risk and Impact of Future Epidemics: Options for Public-Private Cooperation; the International Vaccines Task Force report, Money & Microbes: Strengthening Clinical Research Capacity to Prevent Epidemics; the International Working Group on Financing Preparedness report, From Panic and Neglect to Investing in Health Security: Financing Pandemic Preparedness at a National Level; and the Independent Commission on Multilateralism, Global Pandemics and Global Public Health. 27 mendations related to strengthening and increasing preparedness systems and structures generally, or specifically related to other forms of outbreak threat. While there has been some focus on improving international and national capacity for pandemic influenza—specifically after the 2009 H1N1 pandemic and subsequent Fineberg Report— there have been few (if any) high-level reviews or recommendations focusing on the possibility of other high-impact respiratory pathogens with pandemic potential.19,60,61 The lack of global attention to and consideration of this threat illustrates the vital need to address preparedness for epidemics and pandemics that might be caused by high-impact respiratory pathogens. HOW CAN THE WORLD BETTER PREPARE FOR OUTBREAKS CAUSED BY HIGH-IMPACT RESPIRATORY PATHOGENS? Global Preparedness Mechanisms Global preparedness mechanisms, which encompass international treaties, frameworks, and agreements, articulate the international roles and national capacities required to prevent, detect, and respond to a high-impact respiratory pathogen event. Published guidance documents, standard operating procedures, and frameworks denote international outbreak emergency response capacities and processes, as well as considerations for data sharing, travel and trade restrictions, and other aspects of the international response. As many of these international frameworks have been conceived only within the past 20 years, they remain untested during a high-impact respiratory pathogen event that causes serious illness or death in tens or hundreds of millions of people or more. Though not an example of a high-impact respiratory pathogen as defined in this report due to its lower mortality, the emergence and global spread of a novel influenza A H1N1 virus in 2009 provided an opportunity to test modern preparedness mechanisms. The ultimate health impacts of the 2009 influenza pandemic may have been lower than initially feared; however, international conflicts arose about the development and sharing of vaccines and other medical countermeasures and what actions should be taken to limit transmission.19,45 It remains to be seen the extent to which the global preparedness system will be prepared to respond to an epidemic or pandemic event caused by a high-impact respiratory pathogen. But as observed in the 2009 pandemic, individual country needs might quickly outstrip international resources and capacities, and national interests might overtake the imperative to adhere to international agreements on sample sharing, vaccine access, and emergency medical assistance.60 During a high-impact scenario, the limitations of current international frameworks would come into immediate focus. The International Health Regulations The International Health Regulations (2005), an international treaty that outlines WHO’s and Member States’ responsibilities in disease preparedness and response efforts, represents an important and useful framework for building consensus and aligning global health stakeholders on questions of disease prevention, detection, and response. The revision of the IHR in 2005 can be largely attributed to the emergence and international spread of SARS in 2003. Though the initial call to revise the IHR came during the 1998 World Health Assembly and more there had been an international push to modernize 29 the IHRs for many years, SARS highlighted critical gaps in the authority and scope of the IHR itself, the obligations of WHO and other international bodies, and the duties of countries, specifically their national reporting commitments. The revised IHR requires States Parties to develop core public health capacities to prevent, detect, prepare for, and respond to any disease outbreaks. Unlike its predecessor, the revised IHR includes a focus on novel pathogens that have the potential to spread beyond borders, threaten other countries, and may be considered as a potential Public Health Emergency of International Concern (PHEIC).56,62 The capacities that have been identified as core to the IHR are not only useful for the detection of and response to rare events, but, rather, they have day-to-day benefits in helping to identify, measure, and respond to routine health events. For example, a robust national process and a system to enable the collection, analysis, and dissemination of surveillance data is an essential tool for identifying and understanding patterns and drivers behind a wide range of health threats. Similarly, all countries need to be able to communicate with their populaces about health issues and protective actions that they can take. The processes and systems used to conduct risk communication and national surveillance can
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