What Is Emergency Preparedness?

Emergency preparedness is defined by the World Health Organization (WHO) as the “knowledge and capacities and organizational systems developed by governments, response and recovery organizations, communities and individuals to effectively anticipate, respond to, and recover from the impacts of likely, imminent, emerging, or current emergencies” (1).

As the coronavirus disease (COVID-19) pandemic teaches us, infectious disease has the potential to represent a public health emergency.

Recognizing the need for an internationally coordinated approach to managing the spread of infectious diseases, a series of “international sanitary conferences” beginning in the mid-nineteenth century eventually led to the creation of the International Health Regulations (IHR; herein “the Regulations”) in 1969, a legal instrument that set up requirements for states to report events of public health importance to the WHO and defined criteria to determine whether or not a particular event constitutes a “public health emergency of international concern.”

According to the regulations, to minimize the risks posed by infectious diseases and to mitigate their impact, countries are requested to develop, maintain, and strengthen preparedness and response core capacities, which also implies the development of preparedness plans (2).

Applied to infectious disease outbreaks, preparedness aims to ensure that systems and plans are in place for early detection and subsequent implementation of an effective response. Furthermore, learning from this process informs preparation for strengthening the system in advance of next potential outbreaks (3). In fact, preparedness should be seen as a continuous quality improvement (CQI) process, including planning, the identification and prioritization of risks, training, simulation exercises, evaluation of lessons learned, and implementation of the organizational changes identified. Sound preparedness planning results in documented plans that provide a backbone structure for developing the core capacities to address health threats (4). Such plans represent guidance through which the roles and responsibilities of each sector involved are defined in order to ensure intersectoral collaboration and should be intended as dynamic “live” documents describing how an organization (authority, a state, etc.) will manage its response to emergencies (2).

Barriers to Preparedness Planning

According to the WHO, a challenge to emergency preparedness (including outbreak preparedness) is inconsistent and unsustainable financing (2). These include financial resources for preparedness and contingency funding for response, logistics mechanisms and essential supplies for health, as well as dedicated, trained, and equipped human resources for emergencies.

For outbreak preparedness, sustainable funding needs to be defined and adjusted to develop and maintain preparedness core capacities as surveillance, laboratory diagnostic capability, training, designated treatment facility, equipment and supplies, risk communication, human and logistics resources, etc. To quickly get ready for an imminent risk of outbreak, respond to alerts, and ensure that any spread is limited, early access to funding at the operational level remains crucial (2). All readiness actions, including scale-up of vaccination, risk communication, and health workforce readiness are all linked to contingency financing.

Another barrier to preparedness planning highlighted by the European Centre for Disease Prevention and Control (ECDC) refers to the process of including evidence in public health decision making for formulating an evidence-informed policy (5). As the COVID-19 pandemic teaches us, implementing coordinated evidence-informed actions is most challenging during a public health emergency, when time is limited, scientific uncertainties and political pressures tend to be high, and irrefutable evidence may be lacking. To strengthen the impact of evidence on decision making for public health emergency preparedness, it is necessary to better define mechanisms through which interdisciplinary evidence feeds into decision-making processes, and the context in which these mechanisms operate.

Community engagement in public health emergency preparedness has also been highlighted to be a limit for effective preparedness (Reference Ramsbottom, O'Brien, Ciotti and Takacs6), with uncoordinated risk communication and limited involvement of community in preparedness planning being the main barriers. COVID-19 is the first pandemic in history in which technology and social media are being used on a massive scale to keep people safe, informed, productive, and connected (7). On the other hand, the same technology is enabling and amplifying infodemics that continue to undermine the global response and jeopardize measures to control the pandemic. Outbreak preparedness plans should now address, develop, and include strategies to manage the infodemics by promoting the timely dissemination of accurate information, based on science and evidence, to all communities, and in particular high-risk groups, while at the same time employing, among other methods, fact checking to prevent the spread of mis- and disinformation, while respecting freedom of expression.

Overcoming Preparedness Barriers through Health Technology Assessment

Overcoming preparedness barriers needs a systematic approach through which evidence is identified and, with due consideration to implementation, transferred into preparedness plans, in order to guide the decision-making processes and develop each component of preparedness according to the best evidence and practice.

The WHO underlines that the development of emergency preparedness plans should be done through predefined indicators and with standardized, commonly shared tools and processes (2), whereas the ECDC highlights the need for strengthening knowledge transfer for decision making during public health emergencies (5).

As a CQI cycle, preparedness requires multiple assessments in each phase, from planning, including financing, to implementation and after-action review. Assessment should consider several aspects spanning contextual factors, but also the health technologies available to use, as vaccines, drugs (e.g., antimicrobials/antivirals), diagnostic tests (including point-of-care testing [PoCT]), medical devices (e.g., telemedicine, but also, masks), and surveillance and reporting mechanisms. Key nonmedical interventions, such as well-developed and regularly updated risk communication strategies, standard operating procedures (SOPs) for public health management of cases and contacts, measures to “increase social distance,” limiting domestic and international travel, etc., should also be included.

In this respect, the new definition of Health Technology Assessment (HTA) broadly describes health technology as “an intervention developed to prevent, diagnose or treat medical conditions; promote health; provide rehabilitation; or organize healthcare delivery. The intervention can be a test, device, medicine, vaccine, procedure, program, or system” (Reference O'Rourke, Oortwijn and Schuller8).

HTA, meant as “a multidisciplinary process that uses explicit methods to determine the value of a health technology at different points in its lifecycle (Reference O'Rourke, Oortwijn and Schuller8)”, can be of support in informing decision-making processes and also valuable in emergency preparedness planning. In fact, as a multidisciplinary, standardized, and evidence-based decision-making tool, HTA may represent an independent approach to overcome preparedness barriers and can be used as mechanisms to address, assess, and develop each component of preparedness (2) through each HTA domain (9).

Table 1 provides a conceptual framework, developed through consensus among experts working in HTA, infectious disease control, and preparedness within the European Public Health Association (EUPHA), to build a nonspecific outbreak preparedness plan through the HTA approach.

Table 1.

Conceptual framework to develop an outbreak preparedness plan through the health technology assessment approach

BLE, Bluetooth Low Energy; GPS, Global Positioning System; HCW, Healthcare workers; IPC, Infection Prevention and Control; NPV, Negative predictive value; PPE, Personal protective equipment; PPV, Positive predictive value; SOPs, Standard operating procedures.

Domains of HTA: CUR, Health problem and current use of technology; TEC, Description and technical characteristics of technology; SAF, Safety; EFF, Clinical effectiveness; ECO, Costs and economic evaluation; ETH, Ethical analysis; ORG, Organizational aspects; SOC, Patients and Social aspects; LEG, Legal aspects.

In this framework, each component of preparedness is linked to and addressed through an HTA domain following the EUnetHTA core model (9).

The “health problem and current use of technology (CUR)” domain can be used to develop the introductory part of a preparedness plan, providing evidence-based background information on actors and structures involved in preparedness, as well as on different types of surveillance systems for case detection, or on current diagnostic and treatment options.

The HTA domain “description and technical characteristics of technology (TEC)” finds its foundation in the identification and description of health technology. This could encompass infection prevention and control measures/procedures such as personal protective equipment and also vaccines or postexposure prophylaxis options, diagnostic and treatment technologies, and risk communication strategies.

Safety (SAF) and clinical effectiveness (EFF) domains can be used to address several issues, including the estimation of the benefit–risk ratio, unintended adverse events resulting from the use of a health technology, for example mental health consequences of isolation, safety risks for frontline workers, and factors influencing the safety and the efficacy of health technologies (e.g., vaccine effectiveness).

Resource utilization for case finding and management, and the cost-effectiveness of different health technologies, can be addressed by the costs and economic evaluation (ECO) HTA domain. In this way, it is possible to report different types of economic analyses, supporting evidence-based choices for diagnostics options, treatment technologies, and response tools.

Ethical, patient, and social aspects of preparedness, in terms of the impact of response procedures (e.g., isolation/quarantine, screening for asymptomatic case detection in the contact tracing process), and issues related to the equity in access, people autonomy, privacy, etc., can be addressed through the Ethical (ETH) and the Patients–Social aspects (SOC) HTA domains. These evaluations allow decision makers to have a 360° perspective of the social impact on the population of actions included in the preparedness plan.

Managerial issues can be addressed through the HTA domain “organizational aspects” (ORG) in order to allocate budget to each component of preparedness and define coordination mechanisms with the roles and responsibilities of each sector involved, and ways in which different resources need to be mobilized and organized to guarantee the system sustainability, including the maintenance of essential functions and services (business continuity planning) that might be disrupted in emergency situations.

Finally, the domain “Legal aspects” can be used to pinpoint the current legislative framework for the management of emergency situations, as well as authorization and regulation pathways for different health technologies, including data protection issues. This aspect emerged strongly in the context of COVID-19, as many legislative changes were made through emergency law, intended to tackle short-term emergency issues and threats rather than long-standing matters.

The Way Forward

Preparedness planning shares common principles with HTA as both encompass a multidisciplinary and multistakeholder approach, follow an iterative cycle, adopt a 360° perspective on the impact of intervention measures, and conclude with decision-making support.

As our conceptual framework illustrates, each HTA domain can address different component(s) of a preparedness plan that can indeed be seen as a container of multiple HTAs, which can then be used to populate the entire plan itself.

These HTAs can inform the preparedness planning processes by providing meaningful insights on the assessment of existing infrastructures, resources, and technologies, working as a bridge between scientists and decision makers, which ensures that evidence is effectively integrated in health choices; in this regard, the proposed framework also provides a practical solution to the need for evidence-based decisions in emergency situations, as stated by the ECDC (5).

Through HTA, all the technologies to be included in a preparedness plan can be assessed in a systematic, independent, and evidence-based way, which ensure a comprehensive evaluation of their value in the mitigation of the impact of the emergency. HTA could also be an important tool to identify needs for organizational reengineering and proper budgeting in order to respond effectively to emergencies and make it possible that the preparedness plan works.

Nevertheless, in order to move forward to an emergency preparedness plan developed through the HTA approach, several conditions should be brought about. The first one is the recognition of the importance of HTA in projecting the impact of health technologies at the international and national levels, by each country, health authorities, and institutions. Secondly, the timeliness on which a preparedness plan needs to be developed may not coincide with the timing of HTA, which is generally a time- and resource-consuming approach, as it is based on the collection of available evidence and data. In this respect, the use of the Rapid HTAs (10) can shorten time and can also be applied during emergencies, by addressing the elements of a preparedness plan through selected HTA domains (i.e., CUR, TEC, SAF, and EFF). Furthermore, an early and timely contact with decision makers and all stakeholders, as well an early identification of candidates for the assessment, could help the HTA be a timely one. Furthermore, a preidentification of the institutions involved and a predefinition of their roles are strategic measures to develop and implement rapid, coordinated, and evidence-based response activities, particularly for cross-border threats (as COVID-19), where an international body could strengthen cooperation and coordination between institutions based in different countries, in order to issue shared supranational assessments and facilitate their context-specific appraisal.