key: cord-341754-rr7ei8o2
authors: Aitken, Tess; Chin, Ken Lee; Liew, Danny; Ofori-Asenso, Richard
title: Rethinking pandemic preparation: Global Health Security Index (GHSI) is predictive of COVID-19 burden, but in the opposite direction
date: 2020-05-08
journal: J Infect
DOI: 10.1016/j.jinf.2020.05.001
sha: 
doc_id: 341754
cord_uid: rr7ei8o2

nan

In the wake of the Ebola outbreak in 2014, the Global Health Security Index (GHSI) was developed with the aim of gauging countries' capacity to deal with infectious disease outbreaks. 2 The GHSI highlights the shortcomings of existing pandemic policies and procedures, with the aim of spurring improvement of future practices. The index ranges from 0 to 100, and assesses six core elements: prevention, detection and reporting, response, health system, compliance with norms and risk of infectious disease outbreaks. 2 A higher GHSI indicates better preparedness.

In the present study, we examined the correlation between GHSI and various measures of COVID-19 burden across different countries. We hypothesised that higher GHSI was inversely associated with measures of COVID-19 burden.

Country-level data on COVID-19 as at 11 April 2020 were sourced from the 'worldometer'. 3 Countries without testing data, or those with no assigned GHSI score were excluded. Furthermore, we included only countries with at least 100 confirmed cases of COVD-19. Data on countries' median age and proportion of females in 2019 were sourced from the United Nations population database. 4 We analysed the association between GHSI and COVID-19 burden, represented by numbers of tests confirmed cases and deaths per million people per day since the first confirmed case in each country. First, we plotted GHSI against natural log transformed values of these outcomes (to provide more symmetrical distributions). Secondly, we used a generalised linear model (GLM) to determine the association between GHSI and confirmed cases and deaths per million people per day, with adjustment for testing rate, population median age and proportion of females.

We considered GHSI both as a continuous variable and as a categorical variable comprising four quartiles. In the latter analyses, the first (lowest) quarter of GHSI was considered as the reference category.

A total of 100 countries with complete data were included in the analysis (Supplementary Table S1 COVID-19 metrics (log transformed) plotted against GHSI are presented in Figure 1 . These suggest a positive correlation between GHSI and testing rate, as well as cases and deaths per million people per day since the first recorded case. Of note, the US was the highest ranked country in terms of GHSI of all 100 countries analysed yet had the largest number of COVID-19 cases worldwide at the time of analyses. 2,3 Secondranked UK was also bearing a large burden of disease.

The results from the GLM model are presented in Table 1 . There was no statistically significant association observed between GHSI and testing rate. After adjusting for testing rate, median age and the proportion of females, a positive association was also observed between GHSI and COVID-19 cases and deaths, with the biggest burden borne by countries at the highest quartile of GHSI.

The findings of our study were unexpected. First, no association was noted between GHSI and testing rate, despite that GHSI should serve as a surrogate for healthcare capacity, including COVID-19 testing. Effective pandemic response requires significant investment in testing, with adequate training of healthcare workers in testing, as well as sufficient supply of PPE and testing kits. 5 In addition, effective and widespread dissemination of information to the general population regarding testing criteria assists case detection. 5 Secondly, the associations between GHSI and COVID-19 cases and deaths were positive, meaning that the GHSI can reflect a country's capacity to deal with epidemics or pandemics, but in the opposite manner than intended. No doubt there was confounding by increased globalisation among more developed countries (with higher GHSI). Increased exposure to foreigners travelling for the purposes of tourism, business and use of healthcare is likely to increase the risk of new infectious pathogens being introduced. Similarly, mass migration contributes to disruption of local bacterial and viral environments. 2 Furthermore, the rarity of pandemics in conjunction with false reassurance from a high GHSI may have contributed to more lenient adherence to infection control mechanisms in recent years. 6 The intent of the GHSI is noble, and the findings of our study should not discourage future endeavours to gauge capacity to respond to pandemics. However, as the world becomes increasingly interconnected, the value of assessing the capacity of countries to manage infectious outbreaks individually is redundant. This interconnectedness extends beyond social, political, and business interactions to pathogenic environments. Consequently, identifying and controlling spread of newly arising infectious agents is only as effective as the practices within the poorest performing countries.

The COVID-19 pandemic has revealed insufficiencies in existing knowledge of pandemic preparedness and response. A more integrated global approach is necessary, as is further research into alternative factors related to infection control that have not yet been considered. Development of international response protocols and effective communication channels will permit coordinated global action. Furthermore, establishment of dynamic models and tools will ensure the world is better prepared for future outbreaks. 

Global COVID-19 fatality analysis reveals Hubei-like countries potentially with severe outbreaks

The Economist Intelligence Unit. Global Health Security Index

Worldometer COVID-19 Coronavirus Pandemic

United Nations, Department of Economic and Social Affairs

Evaluation of national pandemic management policies-A hazard analysis of critical control points approach

World Health Organisation. The world health report 2007 -A safer future: global public health security in the 21st century