key: cord-0763164-i1jhtevc
authors: Khalifa, Banda A.; Abbey, Enoch J.; Ayeh, Samuel K.; Yusuf, Hasiya E.; Nudotor, Richard D; Osuji, Ngozi; Khan, Samiha; Nosakhare, Esosa; Oduwole, Modupe O.; Salia, Emmanuella L.; Lasisi, Oluwatobi; Karakousis, Petros C.
title: The Global Health Security Index is not predictive of vaccine rollout responses among OECD countries
date: 2021-09-20
journal: Int J Infect Dis
DOI: 10.1016/j.ijid.2021.09.034
sha: f6ed0f18b868e474058af819598f289da59ed476
doc_id: 763164
cord_uid: i1jhtevc

Objective We sought to evaluate the utility of the GHS index in predicting the launch of COVID-19 vaccine rollout by OECD member countries. Methods We collected country-level data on the preparedness to respond to infectious disease threats through vaccination rollout using the GHS index. OECD member countries were rank-ordered based on the percentage of their populations fully vaccinated against COVID-19. Rank-ordering was done from the lowest to the highest, with each country assigned a score ranging from 1 to 33. Spearman's rank correlation between the GHS index and the percentage of the population that is fully vaccinated was also performed. Results Israel, ranked 34th in the world on the GHS index for pandemic preparedness has the highest percentage of the population that was fully vaccinated against COVID-19 within 2 months of the global vaccine rollout. The Spearman rank correlation coefficient between GHS index and the percentage of population fully vaccinated was -0.1378, with a p-value of 0.43. Conclusion Our findings suggest an absence of correlation between the GHS index rating and the COVID-19 vaccine rollout of OECD countries, indicating that the preparedness of OECD countries for infectious disease threats may not be accurately reflected by the GHS index.

The ongoing coronavirus disease 2019 pandemic has revealed the ominous threat posed by emerging infectious diseases to human civilization. SARS-CoV-2 infection was first detected in Wuhan, China, in December, 2019 (WHO, 2020 , and on March 11, 2020, the WHO declared COVID-19 a global pandemic (WHO, 2020) . As of August 2021, SARS-CoV-2 has infected more than 200 million people and claimed more than 4.3 million lives, particularly in underserved populations. In addition to the heavy cost on human health, the COVID-19 pandemic has necessitated tight restrictions on movement and economic activities, discouraging investment and disrupting all levels of education. Global Economic Prospects of the World Bank envisions a 5.2% contraction in global gross domestic product (GDP) with a historic reduction in per capita income (World Bank, 2020) . The bleak economic outlook and the magnitude of the crisis caused by COVID-19 call for urgent steps to revive global economies, save lives and protect underserved populations.

Beyond temporizing interventions, such as masking, social distancing and hand hygiene, the most effective measure to end the pandemic is the development of herd immunity through mass vaccination. Through astounding scientific progress and robust financial backing, over 150 COVID-19 vaccines have entered clinical trials, with 8 gaining approval for clinical use (Zimmer et al., 2021) . Next, a coordinated strategy is needed to mass-produce and distribute vaccines to ensure that at least 75% to 90% of the target population is properly immunized to achieve herd immunity (Anderson et al., 2020) . Inequalities in vaccine distribution have resulted in faster vaccination rates in high-income countries relative to lower income countries (Bloomberg, 2021) . The highest proportion of vaccine utilization is by members of the Organization for Economic Cooperation Development (OECD), a 38-member organization consisting primarily of wealthy nations with increased energy expenditure and high GDP (OECD, 2021) . More robust economic recovery among OECD countries has been tightly linked with their ability to speed up the COVID-19 vaccine rollout. The projected economic growth among member nations is expected to differ among OECD countries markedly (OECD, 2021).

The Global Health Security (GHS) index, released prior to the COVID-19 pandemic in 2019, was designed to provide a framework that assesses the ability of countries to prevent and mitigate emerging outbreaks, such as COVID-19 (Global Health Security Index, 2019). A 21member panel of international experts, in collaboration with the Johns Hopkins Center for Health Security, the Economist Intelligence Unit, and the Nuclear Threat Initiative ranked 195 countries based on their preparedness level, from most prepared to the least prepared (Global Health Security Index, 2019). The 140-question assessment is based on 34 indicators, 85 sub-indicators, and six categories related to prevention, detection, rapid response, health system, risk environment, and international norms compliance. Though the results revealed that none of the countries were adequately prepared for a major infectious disease outbreak, the United States (US), United Kingdom (UK), and Australia were ranked as the top 3 countries in preparedness (Global Health Security Index, 2019) .

Given that the vaccine supply chain and infrastructure for administering vaccine doses are critical components of the COVID-19 pandemic response, in the current study, we sought to evaluate the utility of the GHS index in predicting the launch of the COVID-19 vaccine rollout (i.e., during the first two months of vaccine availability) of OECD member countries for which data are available.

Participating countries used for this analysis include OECD member countries, each of which was assessed for inclusion. COVID-19 vaccine data are reported on a daily basis for all countries by Our World in Data (https://ourworldindata.org/). Four OECD member countries (South Korea, Japan, New Zealand, and Colombia) were omitted from the analysis due to unavailability of the start date for their COVID-19 vaccination programs. The latest country to join the OECD, Costa Rica (38 th member) was also not included in the analysis, since its membership status was formally recognized on May 25, 2021.

We collected country-level data on the preparedness to respond to infectious disease threats by way of vaccination rollout using the GHS index available from http://www.ghsindex.org/. Data relating to the cumulative COVID-19 vaccine doses and the percent population fully vaccinated per hundred were collected up to March 23, 2021 from https://ourworldindata.org/coronavirustesting (a collaborative effort between the researchers at the University of Oxford and a nonprofit organization, Global Change Data Lab) and https://github.com/CSSEGISandData/COVID-19 (a COVID-19 data repository by the Center for Systems Science and Engineering at Johns Hopkins University). Vaccination data for the Netherlands were collected up to March 21, 2021.

Variables collected in this study include the total number of COVID-19 cases/million persons, cumulative COVID-19 vaccines/hundred and the percentage of the population fully vaccinated (i.e., who received both doses of a two-dose vaccine, or a single dose of a one-dose vaccine) at 2 months after initiation of the vaccination program in each country. The percentage of the population fully vaccinated in each OECD country was the main variable of interest as an indicator of the success of each vaccination program. We rank-ordered the OECD member countries based on the percentage of their populations that had completed vaccination against COVID-19. Rank-ordering was done from the lowest to the highest, with each country assigned a score ranging from 1 to 33. The country (Israel) with the highest percentage (53%) of fully vaccinated population was assigned a score of 1, and that with the lowest percentage (0.6%) of fully vaccinated population was assigned a score of 33. By this approach, a lower score reflects relatively better performance, and a higher rating reflects poor performance. To determine the predictability of the GHS index for successful COVID-19 vaccination rollout, we performed a Spearman's rank correlation between the GHS index and the percentage of the population that is fully vaccinated. All statistical analyses were performed using STATA (Statistical Data Package version 16.0 IC, College Station, TX-USA).

According to the GHS index, the US ranks highest in preparedness, with a score of 83.5, a fivepoint difference from the next country, the UK. Specifically, the US ranks highest in four out of six areas: prevention, detection, health system capacity, and compliance with international norms. Luxembourg ranks at the 67 th position in the global ranking, with an overall score of 43.8. The 20 highest ranked countries are mostly OECD members, except for Thailand (6 th ) and

Malaysia (18 th ) ( Table 1) .

Israel, which is ranked 34 th in the world on the GHS index for pandemic preparedness, has the highest percentage of the population that was fully vaccinated against COVID-19 within 2 months of the global vaccine rollout, indicating a highly successful COVID-19 vaccination program ( Table 2) . On the other hand, the UK, which is ranked 2 nd on the GHS index, is ranked 23 rd among OECD countries with respect to percentage of the population that was fully vaccinated in the initial phase of vaccine rollout. It is worth noting that some of the high-ranking countries on the GHS index also ranked highly with respect to percentage of the population that was fully vaccinated (Figure 1 ).

The Spearman rank correlation coefficient between GHS index and the percentage of population that was fully vaccinated was -0.1378, with a p-value of 0.43. Also, the Spearman rank correlation between rapid response to and mitigation of the spread of an epidemic (both components of the GHS index scoring system) and percentage of the population that is fully vaccinated is -0.0190, with a p-value of 0.91. The Spearman correlation affirms that, though there is a negative trend, it is not statistically significant; as such, there is no monotonic relationship between the GHS index, or the rapid response to and mitigation of the spread of an epidemic, and the percentage of the population that was fully vaccinated within two months of the global vaccine rollout.

Our findings demonstrate that the GHS index is a poor predictor of vaccine rollout or the general response to the COVID-19 pandemic by OECD countries. Overall, there is no correlation between the GHS index rankings and the vaccine rollout based on the percentage of the population that is fully vaccinated. The US and the UK, which rank first and second, respectively, on the GHS index, also represent two of the three countries with the highest number of vaccine doses administered/hundred population. Of these two countries, the US also accounts for the largest number of persons that have been fully vaccinated (i.e., who received both doses of a two-dose vaccine, or a single dose of a one-dose vaccine). In contrast, the UK is ranked 23 rd among OECD countries for percentage of the population that was fully vaccinated in the early phase of the global COVID-19 vaccine rollout. This discrepancy has been explained by the differing vaccination strategies adopted by each country. Whereas the US prioritized the vaccination of groups with the highest risk and poorest COVID-19 outcomes (healthcare workers and the elderly) and emphasized the completion of vaccine doses (two doses of the Pfizer-Biontech and Moderna vaccines) in its rollout process (Bubar et al., 2021) , the UK adopted a mass vaccination strategy, primarily focusing on the administration of at least a single vaccine dose to as many people and as quickly as possible (Baraniuk, 2021; Harnden and Earnshaw, 2021) . It is important to note that this approach "penalizes" the U.K. in our study, since the definition of full vaccination we utilized is the receipt of two doses of a two-dose vaccine. Israel, which is ranked in the 54 th position globally and 34 th among OECD countries by the GHS has had the most effective COVID-19 vaccine rollout globally. As of March 2021, more than 60% of the Israeli population had been fully vaccinated, nearly double the rate of vaccination in the next country. The success of vaccination in Israel is ascribed to its comparatively advantageous population size of 9.3 million people, a viable health care structure, and a solid vaccine rollout plan (McKee and Rajan, 2021).

In contrast, certain countries ranked highly by the GHS index have shown significant deficiencies in their vaccination campaigns. For example, although rated in the top 5 countries by the GHS index, Australia had a comparatively poor vaccine rollout. While the reasons for this discrepancy are unclear, it is possible that the comparatively small number of reported COVID-19 cases in Australia may have diminished enthusiasm for a vigorous vaccination campaign there. Nevertheless, many people in the highest risk category for COVID-19 infection have expressed an interest in receiving the vaccine, despite its relative inaccessibility within the country (Seale et al., 2021) .

Given the obvious discrepancies between the GHS index ranking and the initial COVID-19 vaccine rollout among OECD member countries, its use in assessing country level vaccination efforts is limited. These shortcomings can be explained by the failure of the GHS index scoring framework to collect relevant information explicitly related to vaccine rollout in the categories assessed (Global Policy Journal, 2021). Furthermore, the GHS index does not take into consideration the important role of centralized health systems and the complex nature of political decisions regarding public health, particularly for country-wide vaccination programs (Lafortune, 2020). Additional reasons for the differences between vaccination matrices evaluated in our study and the GHS index are related to the methodology of data collection and its sole dependence on data provided by the countries assessed without engaging the specific country level authorities and key stakeholders. This approach has the potential to mask any relevant existing weaknesses in a country's health system and overestimate their ability to efficiently conduct their vaccination efforts. Additionally, relevant vaccination parameters, such as the cumulative number of vaccines administered in each country, are largely reflective of the complex interplay of socioeconomic determinants of health at the population level, which may not be completely captured by the GHS index. Countries with high vaccine hesitancy rates and government mistrust will inevitably report lower vaccination rates irrespective of GHS index (Tjada, 2021). As stated earlier, the GHS index inevitably fails to represent vaccination efforts in countries like Australia, with an early robust response to the COVID-19 pandemic and lower infection rates, resulting in a less robust vaccine rollout.

Our study contains some limitations. The GHS index, a relatively new tool that provides a comprehensive assessment of global health security and level of preparedness of OECD member countries, uses only publicly available data sources from each country and published governmental information. There is a possibility of over-or underestimation of capabilities due to inaccurate data reported by each country. The variability in capacity of COVID-19 testing, number of deaths, recovered, vaccine administered, and type of vaccine received by individuals might have an impact on the scoring system. Using aggregated and composite data in an ecological study can introduce collection bias. Furthermore, there remains a concern that the international preparedness for epidemics and pandemics is low collectively but skewed towards the priorities of high-income countries. However, like any other cross-sectional study, it is difficult to establish a causal inference in this study. Of note, the GHS index is complex and does not account for all factors impacting global health security. As a result of continuously evolving knowledge from the pandemic, it is expected to see variation in GHS index performance over time.

Inequities in vaccine administration have the potential to impede global economic recovery and compromise global health security. The top five ranked OECD countries based on the GHS index have 65% of their population receiving at least one dose of the vaccine compared to about 7% of the population in the bottom five countries on the GHS index ranking, which are primarily in Africa. As of September 2, 2021, only 2.9% of the African population has been fully vaccinated compared to 48% and 42% of the population in Europe and North America, respectively (https://ourworldindata.org/covid-vaccinations). The world is highly interconnected, which is an important factor in pandemic preparedness as infectious diseases know no boundaries. The GHS index considers the broader context for biological risks within each country, identifies considerable potential gaps in global health security capabilities, including financing in preparedness, and illuminates those gaps by providing recommendations to counter those threats. It also helps to understand the emergence and spread of pathogens at national and international levels, the use of existing resources to predict, prevent and promptly respond to public health emergencies, and take collective action to build stronger national and global health security. However, to better prepare for future events and consequences, it is important to consider several other factors broadly beyond the GHS index indicators, such as social, political, economic, environmental measures, public health services, universal health coverage, social inequities, clinical severity of infections, pre-existing comorbidities and existing validated metrics. A more integrated global approach with international response protocols, coordinated global action and effective communication is crucial in pandemic preparedness and response.

Our study underscores the lack of correlation between the GHS index ranking and the real-world response of OECD countries based on COVID-19 vaccine rollout. Future assessment of countries' preparedness should consider reassessing the GHS index frequently, including the potential incorporation of the effect of politico-cultural differences in countries' responses to national health emergencies. Finally, a country's vaccine hesitancy and the population's mistrust of governmental institutions should be taken into consideration when developing a framework of this nature.

All authors have no conflict of interest to disclose.

Ethical approval was not required for this work. 

Challenges in creating herd immunity to SARS-CoV-2 infection by mass vaccination. The Lancet

Covid-19: How the UK vaccine rollout delivered success, so far

Model-informed COVID-19 vaccine prioritization strategies by age and serostatus

Johns Hopkins Coronavirus Resource Center

much do we know about countries preparedness to respond to pandemics? Insights from two countrylevel indices

Opinion: For COVID-19 vaccines to succeed, we must build trust. Devex

What can we learn from Israel's rapid roll out of COVID 19 vaccination?

Pneumonia of unknown cause -China

Examining Australian public perceptions and behaviors towards a future COVID-19 vaccine

The Global Economic Outlook During the COVID-19 Pandemic: A Changed World

The need for speed: faster vaccine rollout critical to stronger recovery -OECD

Coronavirus Vaccine Tracker. The New York Times