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humanitarian system, including various UN agencies and the UN Secretary-General.42,52 In a large disease outbreak scenario, there may also be decreased international interest in supporting other countries’ responses as nations deal with the health crisis in their own borders The landscape of international response for a pandemic may look very different from what is seen for regional epidemics or locally contained outbreaks that are geographically limited. Where outbreaks are geographically more limited, international organizations, NGOs, and other governments can more readily provide personnel, equipment, and financial support to control the outbreak and limit the risk of spread. However, in the event of a high-impact respiratory pathogen causing a pandemic affecting numerous countries around the world, international organizations and NGOs are unlikely to have the capacity to provide support to all countries in need. The capacity of these organizations would likely be exhausted quickly, with little chance of replenishment due to high demand and scarcity of resources. Similarly, other countries would be focused on either combating the disease outbreak within their own borders or ramping up preparedness efforts to prevent the introduction of the disease into their territory. This may include decisions not to share vaccines with other countries until all domestic needs are met, as was seen in Australia during the 2009 H1N1 influenza pandemic when a manufacturing company was told that it had to fill all vaccine requirements for its host country before exporting to other places.75 With an expectation of more limited international support in a pandemic, a country would need to rely to a much greater extent on its own ability and resources. Challenges existing in epidemics and smaller disease outbreaks will be exacerbated in a large-scale pandemic, and the issue of scarcity of resources, coupled with high demand, needs to be considered ahead of time. An example of this issue was seen during the response to the 2009 H1N1 influenza pandemic. While information sharing occurred early in the outbreak, as the cases continued to rise and vaccine production was under way, concerns over equity of access to the vaccine arose. Countries initially announced their support of efforts to provide the vaccine for countries without access and declared they would share a percentage of their vaccine with low- and middle-income countries. However, as shown in Figure 2, the committed number of vaccines shared was considerably lower than the original pledged amounts. While various factors contributed to this actuality, including delay in vaccine production and pledges including amounts to be used in future emergencies, the large disparity between pledged and committed amounts drive home the concern that in a pandemic scenario, a country’s national capacity will be even more important as international support, particularly from other affected countries, will be limited and exhausted quickly.76 Figure 2: Vaccine Doses Pledged and Committed During 2009 Influenza Pandemic 37 Multisectoral Involvement and Coordination Preparedness for an epidemic or pandemic caused by a high-impact respiratory pathogen would require the involvement and coordination of multiple sectors. There is a high likelihood that a pandemic caused by a high-impact respiratory pathogen would cause harm that extends beyond the health sector, so it is crucial that other major sectors be involved in both preparedness planning and response efforts. The possibility of wide geographic spread and/or deliberate use of respiratory pathogens would mean that government human health resources alone would be insufficient to detect and respond to the spread of a novel respiratory pathogen. The continued development and sustainment of operational and effective OneHealth partnerships among human, animal, plant, and environmental health sectors is essential for preparedness. The collaboration among WHO, World Organisation for Animal Health (OIE), and Food and Agriculture Organization (FAO) has shown commitment to the OneHealth approach, and they have recently developed a guide outlining a OneHealth approach to zoonotic diseases.77 However, many reviews have underscored the continued lack of integration among the human, animal, plant, and environmental health sectors. One example of the consequence of a lack of such integration is the delayed ability of the human health sector to recognize Ebola as the cause of an outbreak in West Africa in 2014, which was in part due to the human health community’s belief that the virus was not present in the region—a finding that had been previously predicted by animal health experts.78 Preparedness for high-impact respiratory pathogens will also require involvement from nonhealth actors, including other government, private, and nongovernment organizations. This section highlights 3 specific sectors—financial, private sector, and security— that are critical in pandemic preparedness and response. Financial Financing for outbreak preparedness and response will require involvement of public, private, and NGO actors, supporting both international organizations and national health systems across multiple areas, including preparedness and response activities. Though funding for global preparedness has traditionally involved resources from national governments, there have been limits to government-centric approaches to financing, with inconsistent political commitments to funding for preparedness.7 Estimates from the World Bank suggest that the cost* of developing the core public health capacities needed to prepare for public health emergencies is well below the cost of responding to * The World Bank notes that for low- and middle-income countries that have costed their National Action Plans for Health Security, the investments needed to develop core public health capacities necessary to prevent, detect, and respond to potential public health emergencies may be less that US$1 per person per year (source: https:// www.worldbank.org/en/topic/pandemics). 38 such events, but governments continue not to make such investments in advance of an emergency. Many assessments
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