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framework in place, the global quantity of medical countermeasures that can be produced quickly would fall short of the anticipated global demand during a severe pandemic influenza. 66 A significant concern is that the PIP framework and accompanying surveillance systems and capacity-building measures have focused solely on pandemic influenza. While some of these capacity-building measures (eg, laboratory capacity) are cross-cutting, other high-impact respiratory pathogens have not received a commensurate level of international attention, focus, and resources, despite their potential to cause significant harm. Difficult past experience in transferring Zika and Ebola virus specimens across borders have underscored continued challenges in countries’ abilities and/or willingness to sharing specimens in the middle of a crisis. Delays of this kind would have even greater consequences for a high-impact respiratory pathogen, such as a novel coronavirus. As the bilateral negotiations during the H1N1 pandemic in 2009 revealed, these negotiations are often fraught and time-consuming and unsuitable to carry out during an emergency. Pre-event negotiations could facilitate the rapid sharing of samples and epidemiologic data when a deadly new strain emerges, as well as the subsequent distribution of benefits across the globe, potentially saving millions of lives. More pre-event planning and negotiations are needed on the part of WHO Member States, public health, and industry to develop and prepare contractual agreements on the fundamental questions of access and benefit sharing for noninfluenza pathogens. It remains to be seen whether such a framework (or frameworks) should be modeled on PIP or whether an alternative mechanism is required. Frameworks will need to take into account the emergence of a broad range of respiratory pathogens with high-impact potential. Frameworks should be based on the principle of reciprocity and mutually reinforcing interests and conducted in collaboration with WHO Member States, industry, and civil society. 4. Countries and WHO need to assess and improve health systems’ readiness for infectious disease emergencies. To adequately prepare for and respond to outbreaks and pandemics of respiratory diseases, countries should assess the readiness of health facilities to effectively treat patients with a transmissible disease with high case fatalities. Health facilities would play a central role in mitigating or amplifying disease spread during communicable disease emergencies, but they have not been central to national efforts to develop core capacities to detect and respond to infectious disease emergencies. While the JEE provides for countries a well-defined list to assess the availability of core capacities, there has not been a similar international effort to define and evaluate the capacities for national health systems, and facilities need to respond to health emergencies, particularly infectious disease emergencies. WHO should work with member countries to develop a corresponding assessment tool for health systems and facilities, so that countries have a means of assessing the readiness of the broader health sector for infectious disease emergen- 67 cies. These efforts should be aligned with countries’ ongoing work to undergo JEEs and to advance universal health coverage and to improve the quality of care that is delivered at health facilities. WHO should lead an expert-informed process to develop technical guidance to inform the clinical management of patients with highly contagious respiratory diseases during a severe outbreak. This guidance should include recommended PPE, treatment courses, disinfection guidelines, and personnel training. Additionally, health systems may need guidance for allocating scarce resources, such as mechanical ventilators and medications, if the demand exceeds available supply. Given differences in countries’ health systems, this guidance may need to be tiered for low-, medium-, and high-resource settings. Countries should work to establish mechanisms for bi-directional information exchange between frontline healthcare providers directly treating patients and experts at external organizations, such as a national center for disease control or public health institute, who can provide critical subject matter expertise and guidance. Countries wishing to access additional clinical expertise should explore the feasibility of plugging into international networks. For example, the WHO Emerging Diseases Clinical Assessment and Response Network provides subject matter expertise—including from WHO, NGOs, and academic institutions—to frontline providers for the clinical management of patients with emerging infectious diseases. The success of these types of networks depends on the existence of mechanisms for frontline healthcare providers to relay clinical information to subject matter experts, and for those experts to quickly gather, analyze, and compile relevant information from multiple sources to devise best practices. National and/or international systems would be needed to turn this into clinical guidance that could be broadly disseminated to frontline providers and public health practitioners. Partnerships between public health officials and healthcare leaders should not be established ad hoc during a crisis but should be routine in advance of future emergencies. An incident command/incident management system (ICS/IMS) should be established at local, state/provincial, and national levels to help broadly coordinate a response. Additionally, emergency operations centers (EOCs) at national and local levels would be needed to coordinate efforts between public health and health services delivery organizations, and ideally these plans should be trained and exercised routinely. Countries should plan for the possibility of there being interruptions in the availability of essential basic supplies and equipment. Health facilities would need plans for continuing operations in the event that supplies are no longer available from their primary sources. Countries with sufficient resources should consider establishing stockpiles of critical or 68 high-volume products, including at the facility, local, regional, and national levels.
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