Of 7005 citations identified in the database (n=6827) and grey literature (n=178) searches, we included 78 (54 peer-reviewed publications; 25 grey literature) (figure 1). The study characteristics are highlighted in online supplemental table 2A, B.
Definitions of OPR
Descriptions of OPR lacked clarity and consistency in definition and use. Nine primary research papers and one grey literature document provided explicit definitions of ‘readiness’ and/or ‘preparedness’ for infectious disease emergencies (online supplemental table S3).18–27 Of these, three18 21 24 explicitly defined ‘readiness’ while the others used the term ‘preparedness’ in a way that was congruent with our working definition of OPR. The term readiness was used interchangeably with concepts of preparedness, response and recovery. In other included articles, the concept of readiness was reflected implicitly, as per our working definition.
Some included articles suggested that preparedness indicators, using tools like the State Party Self-Assessment Annual reporting tool (SPAR), could be used to indicate gaps for the purposes of targeting OPR actions.24 28 Others suggested that a country’s OPR and response capacity depends on the strengths of its preparedness, with regular testing and updating of plans and capacities assessing country OPR.22 26 However, some authors noted that countries’ responses to COVID-19 highlighted an incongruence between IHR compliance scores and response performance; for example, some countries with lower IHR scores demonstrated a better ability to contain COVID-19 at the early stages of the pandemic.21 29 A lack of recently updated and tested plans and a lack of large-scale training and refresher courses or key actions for OPR, have been identified as reasons for inconsistency and weakness in previous responses.23 25 Others have identified the activities they had taken as a result of lessons learned from similar diseases as a reason for more successful responses.29 30 For example, rapid training and simulation exercises and leveraging specific expertise and experiences were considered important in preventing or mitigating an outbreak.20 28 31
The nature of the imminent threat also influenced the scale and speed of OPR actions, along with the proximity to the hazard.18–21 OPR could thus be considered the ‘operationalisation’ of hazard-specific capacities aimed at mitigation of a specific, identified risk. Triggering rapid action in response to an imminent threat was noted as a way to feedback and strengthen country capacities while effectively cutting costs of ‘firefighting’ public health emergencies.
While preparedness and OPR are used interchangeably by papers during this review, the reasonable abundance of literature dedicated to time-bound actions right before an event suggests they are different concepts. This observation prompts the necessity for a clear understanding of OPR and its differences from preparedness. Thus, OPR actions could build on overall preparedness levels but consist of time-sensitive activities focused on the imminent threat (eg, ensuring that the healthcare workforce has been recently trained for an imminent threat). These activities have been focused on ensuring that overall preparedness gaps are accounted for (eg, requesting international emergency medical teams (EMTs) to be ready to deploy if EMTs are unavailable in-country). In the following section, we detail the variety of OPR actions that have been taken in articles included in our review, in alignment with the HEPR subsystems.20 28 31
Critical capabilities for OPR
Collaborative surveillance
Previous emergencies highlighted the importance of a strong Early Warning System with capacity to improve disease outbreak detection for early action to localised health events.32–34 Strong surveillance systems at all levels, rapid feedback of results and accessibility of information were described as critical for risk management and decision-making.33 35 36 A critical review of epidemiological data linked with planning and decision-making to increase vigilance and real-time information sharing at all levels was viewed as critical to communicate changes in the incidence of disease, which could signal triggers.22 35 37–40
Key OPR actions embedded in surveillance systems included updating case definitions for consistency in identifying and reporting cases, early investigation, proactive contract tracing training for all staff and rapidly updating guidance for clinicians.18 19 23 41–44 Measures to rapidly ensure integration of various types of surveillance and to address gaps in information collection and sharing were noted.19 37 40 Integration of human and animal health surveillance systems was viewed as critical, as was the importance of interoperability of surveillance systems.38 40 The interconnectivity of surveillance systems has been stressed to ensure that actions taken, and information gathered in one part of the system are made aware to other parts.22 45 For example, it was stressed that the occurrence of viral haemorrhagic fever in animals should activate enhanced surveillance.38 The timely reconciliation of data from multiple sources has been noted as challenging without an escalation in trained staff, improved communication, information technology and accessibility to more remote locations.32 The need to have epidemic data be open and transparent for decision-making was emphasised.46
OPR actions taken for surveillance systems in anticipation of a disease outbreak were centred around detecting gaps and providing solutions,19 47 improving case detection via procurement of supplies, distribution of case definitions and the deployment of screening teams,28 44 47–49 improving reporting for Integrated Disease Surveillance and Response priority diseases28 48 and strengthening specimen transportation and analysis.47–49 Others included increased frequency of surveillance system results36 and rapid delivery of updated training and mechanisms for data sharing.28 29 50 Existing systems were leveraged for COVID-19 as a novel disease37 or the private sector engaged to provide surge capacity.31 Other efforts centred around digitising systems to improve flexibility of use and reporting times.32 46 Contact tracing systems were established as OPR actions,44 51 along with quarantine or isolation options, screening and referral pathways in community settings and dedicated transfers for suspect cases.44 47 52
OPR actions for increasing diagnostics and laboratory capacity for surveillance included prepositioning laboratory supplies in high-risk areas which was described as key to facilitating the investigation of suspected cases (eg, specimen transportation containers, triple packages and gloves, transportation vehicles for specimens).18 19 Electronic systems developed to improve laboratory results turnaround time,19 the quick detection of hotspots36 37 or digital contract tracing applications37 were important developments implemented by countries by way of OPR actions. Lessons learnt from the digitalisation of contact tracing highlighted the importance of scaling up laboratory capacity to account for the increased demand for testing and to timeously ensure sufficient capability to test and process tests.29 31 53 54 Mechanisms, if not available, should be rapidly instituted for sharing laboratory investigation data and establishing laboratory networks within and outside countries for timely diagnoses.18 38
Included sources also signposted OPR actions for a collaborative approach to successful surveillance. For the rapid confirmation of novel influenza strains, for example, countries were successful in collaborating with WHO collaborating centres in their region.35 Laboratory capacity in other countries were rapidly increased through the creation of laboratory networks.18 42 In scenarios where a neighbouring country had a disease outbreak, cross-border surveillance teams have been established and the sharing of information between border countries improved and highlighted as a reason for the limited spill.19 During COVID-19, surveillance was rapidly readied at the point of entries, including standard operating procedures for detected cases and awareness-raising sessions for personnel.55 56
Community protection
Included articles highlighted key actions to upscale for rapidly involving and engaging affected communities in anticipation of an imminent threat.22 57 These include rapidly providing updated information about the threat, including on identifying symptoms and any known public health and social measures, disseminated through numerous mechanisms and in a variety of languages to those at risk.19 23 31 33 46 These should be adapted for all literacy levels.58 Value was found in daily communications to build public trust.37 Community volunteers were trained to carry out communal and door-to-door health education19 32 or public websites containing epidemic reports to keep communities informed.46
Further recommendations highlighted risk communications and public health and social measures to be rapidly readied to contain any potential community transmission.18 21 48 51 59–61 These communications should allow the public to have a proper understanding of the perceived risk.35 Other recommendations included working with local influencers to disseminate trusted information47 and creating specialised focus messages for high-risk populations.26 62 Crucially, there should be strong efforts for engaging vulnerable populations.28 31 57
Plans and protocols should be in place for community-specific risk assessments to fill gaps in community OPR.28 These assessments should focus on community perception, knowledge, preferred and accessible communication channels and existing barriers preventing community members from adopting promoted behaviours.47 Plans should further account for resources for social security to support vulnerable communities.40 To support this, community-based measures such as leveraging the community health workforce and community-based actors should be considered.52 In this way, community needs and realities can be accounted for in the development of risk communication and community protection interventions. Misconceptions in the community should be identified and efforts made to dispel misinformation.44
Some papers highlighted the early identification of vulnerable and remote population groups to ensure that their unique needs are well understood and addressed both in the design of interventions and in mitigating the impact of response interventions.28 57 Accordingly, planning OPR should involve the input of communities, particularly organisations representing vulnerable groups, to inform community OPR.47 Plans for response action should additionally consider secondary impacts or unintended consequences. For example, a clear lesson from COVID-19 related to the need for social security policies to mitigate the impacts of restrictive public health and social measures.63 Policies for implementation should incorporate social security safety nets for communities, such as social health protection schemes or providing financial assistance for quarantined populations.40 Plans should further be supported by partners.64 Indirect health impacts should also be considered when OPR actions are implemented.65 For example, some countries rapidly scaled up their capabilities for mental health services by implementing psychiatric hotlines66 or providing stress management protocols.48 Other indirect health impacts could include food insecurity; to prevent this, doorstep delivery of daily essentials31 or provision of prepackaged meals39 were planned.
Numerous papers highlighted the need for public health and social measures to be available rapidly and as early as possible, such as (for respiratory disease outbreaks) mask usage in public places when the risk level was high31 36 46 52 63 and access to water, sanitation and hygiene,44 48 with additional measures in place for individuals at risk of complications at the household level, such as using physical barriers, proper wearing of masks and environmental cleaning.52 If non-existent, a strategy should be in place to assist in accelerating the containment of disease through imposing various public health and social measures, such as limits on local and international travel, the wearing of masks in public places,37 social distancing,67 bans or limits on mass gathering events33 48 and closing educational institutions.36 48 These measures were all implemented to a varying degree during COVID-19, with analyses finding that the earlier efforts of containment generally resulted in better containment early in the pandemic.21 The measures taken should be weighed against the possibility of improving detection and spread through other methods, such as a rapid expansion of laboratory testing.63 Public health and social measures should additionally take into account other likely risks—for example, countries with hurricane-prone areas during COVID-19 had to quickly revise their strategies to ensure social distancing in shelters.39 If vaccines are available, a prioritisation policy should be developed to avoid ethical and political conflicts.23
Safe and scalable care
For the health service to function during an emergency, they need a baseline quota of adequate staffing to perform core functions.68 Included articles stressed OPR to surge additional healthcare personnel.31 The healthcare workforce needs updated case definitions, transmission, clinical presentation, infection prevention and control (IPC), community surveillance and case management for the threat.19 Capacity assessments can guide OPR to estimate the ability of health systems to contain the imminent threat36 37 41 and to identify gaps.29 36 Additional recommendations highlight that capacity modelling should integrate risks to the workforce during the response—previously, health workforce absenteeism has not always been considered in the development of staffing plans, leading to reduced response capacities.57 When scaling up healthcare worker OPR for a threat, actions should also be taken to scale up the services to support them.64 Health systems gaps have been addressed by increasing the space of intensive care unit beds in relevant facilities, human resource training and mobilisation20 36 48 49 63 69–71 and reducing the workload (eg, patients with mild symptoms were managed at home in isolation).46 Referral systems and safe pathways should be established.36 42 52
COVID-19 highlighted the importance of maintaining essential health services during an emergency. Many studies under review did not immediately prioritise this when considering OPR for the imminent threat. Measures taken proactively to maintain essential health services and to reduce the stress on the health system were described, such as giving patients with chronic diseases a stockpile to prevent them from coming to the hospitals31 72 and use of telemedicine.31 40 It was recommended to establish referral systems and safe pathways to designated local isolation facilities and enhance case detection in healthcare facilities and the community.47 Others emphasised their learnings from response to diseases before COVID-19 and maintaining the continuum of care36 40- for example, Korea created two systems (COVID-19 health system vs non-COVID-19 health system) to ensure continuity of non-COVID-19 needs and diverted the flow of patients through triage centres.36 Measures were taken to safeguard hospitals not identified as part of the response, for example, using temperature checks or encouraging the use of masks.33 40
Included articles also noted that staff protection and welfare should be strongly included in OPR planning, for example, to anticipate provision of personal protective equipment (PPE) and supplies for staff protection.73 74 An IPC programme should be implemented before an outbreak.33 38 63 Prepositioning of PPE supplies in high-risk districts has been recommended to enable a more rapid response,19 or if the risk level is low, the availability of a regional reserve of PPE.75 Where PPE was unavailable, production was quickly ramped up to be able to maintain inventory before the response76 - others who did not do this noted that they suffered shortages during the response.46 Regular training and simulation exercises were conducted for case management teams.19 38 Psychosocial support and other interventions necessary to support staff welfare were also emphasised.26 40 Others quickly put legislation into place to protect healthcare workers engaged in response from being attacked.31
Access to countermeasures
There were fewer descriptions of OPR in this HEPR subsystem in comparison with others. When gearing up for response, countries have increased production and procurement by procuring from local industry, working with manufacturing companies to increase supply by, for example, adapting manufacturing facilities or establishing warehouses and transportation.18 31 Numerous studies noted that they had extreme difficulty in obtaining the supplies they needed,40 46 due to limited stockpiles and lack of finances to maintain them.23 OPR actions for an imminent threat would focus on scaling up manufacturing plans and to ensure that a stockpile is in place.
Prepositioning essential supplies is essential for OPR, with an adequate supply of medical equipment to the frontline identified as vital for reducing health emergency risks.77 Additionally, measures to quickly acquire and distribute medical supplies using government-set prices, prioritise frontline health professionals and vulnerable populations for the disbursement of medical countermeasures and promote local manufacturing were identified.20 Other countries described OPR actions to introduce therapeutics, diagnostics and vaccines.37
One study identified research topics such as system OPR, knowledge, attitudes and practices of the health workforce, epidemiology of the disease at the national level, best practices at the points of entries and isolation centres and infection-control measures as important to inform OPR actions.78 Research should also support decision-making, cost-effectiveness, intervention effectiveness and the impact of these on pandemic trajectories.50 79 Competing demands can limit the volume of research conducted which was considered a missed opportunity.32 Early convening of expert groups to advise government was identified as useful for managing health service responses and OPR, and their work should as far as possible be informed by evidence (eg, scenario planning).33 Health systems researchers occupying the highest levels of oversight across the sectors were said to enhance the use of evidence and data for decision-making.36 Another paper noted that lessons learnt by regions found that funding for research and investigations during OPR and response should also be in place.39
Emergency coordination
We identified several critical and overarching governance-related elements that facilitated OPR within regions and countries. Lessons from OPR or responses to previous diseases have demonstrated the importance of a coordinating body at regional or national levels19 35 36 41 42 46 48 75 78 80 81 led by high-level officials.19 48 80 These structures should provide leadership and coordination,42 46 62 82 guidance and action plans,36 and communication of critical information.48 80 Strong and skilled leadership was a notable enabler29 32 36 54 83 and was marked by active OPR involvement of the responsible health departments, and effective coordination with multiple stakeholders as the planning or response evolved.29 32 54 82 84 Flexibility and adaptation, particularly during OPR, were important.32
Many included articles emphasised the timely activation of coordination mechanisms and risk assessments to inform plans.18 19 31 34 38 47 54 69 75 83 85 86 This involved the establishment and operationalisation of intersectoral and/or interdisciplinary teams (eg, task teams,19 33 75 80 special councils41 42 46 and command centres30 41) to provide technical expertise,25 42 78 87 prepare and coordinate the implementation of policy decisions32 80 87 and guide lower health system-level or governmental-level structures or actors.28 32 88 An Incident Management System was adopted in several countries with a dedicated lead,32 35 36 83 89 and this was further recommended in the grey literature.72 90 91 When operationalising these aspects for an efficient and effective response, the early establishment of clear roles and responsibilities, with a clear lead was considered vital and instrumental for later response success.28 32 The highest levels of government should be involved, with an all-of-society and/or all-of-government approach.32 35 69 70 79 87–89
To successfully implement coordination and response to an emergency, workforce management is key for a successful response. Actions taken include recruitment of staff from the private sector, healthcare students or retired or non-practising trained workers,31 40 42 48 78 89 92 community health workers and community-based organisations19 31 40 48 73 or volunteers.19 48 89 Grey literature emphasised, actions in support of cross-border response teams or surge teams with rapid staff registration and accreditation systems, staff redeployment and reallocation,18 72 93 and appropriate training.18 90 94 95 Also critical was ensuring the availability of emergency medical services for immediate response and the early deployment of multidisciplinary Rapid Response Teams in high-risk groups.23 31 53 83 87 89 Some papers emphasised prioritising actions which enable rapid deployment of these teams.53 83
Other important factors included threat-specific contingency planning at national and subnational levels for identifying preparedness gaps and actions to work around them, thus supporting rapid detection, response and containment.18 19 35 83 89 Contingency plans helped to prioritise targeted actions83 as well as identify and prioritise at-risk geographic areas and vulnerable communities.40 57 Having recently updated or tested contingency plans in place was stated as essential to enhance OPR and effective response,25 39 96 and these should support operations and logistics, help understand organisational structures and functions, and optimise resources.44 68 93 They should further ensure critical infrastructure for health system functioning and ensure clinical and health service-level plans are detailed and able to assist in preparing for increased patient volumes or need for critical care services.19 68 Contingency plans should incorporate past experiences and learnings from other outbreaks, changing contexts52 and the results of simulation exercises conducted on the preparedness and response systems.18 19 23 Countries with similar public health emergency experiences have been found to be better prepared than those without previous experience,63 raising the importance of practice, via simulation exercises and training, for a new imminent threat.19 23
Furthermore, country risk and vulnerability assessments should be available and guide risk assessment activities.19 31 35 38 39 47 52 53 57 84 They were recommended to be focused on geographical areas with particularly high assessed risks39 52 89 and related to prevention and control strategies.19 47 84 The assessments should be conducted to ensure that the contingency plans contain appropriate OPR actions and consider local contexts47 68 89 and can also be used to guide the prioritisation of actions.47 89 Risk assessments for future waves or outbreaks should also be conducted, and updated worst-case scenarios incorporated into contingency plans.39 63
OPR needs bespoke financial planning.22 28 70 It was recommended that contingency funds be available for OPR,83 ring-fenced and situated within a dedicated emergency programme.19 50 70 There should be existing emergency financial management systems which allow for rapid, transparent and efficient use of funding.40 42 Contingency funds were emphasised as particularly important as resources should not be diverted from necessary routine programmes.25 50 Having contingency funds in place would ensure a few key capacities: first, earmarked resources for the hazard are ensured22 and lead to rapid activation of key surveillance and early response activities.25 50 Second, changes which may need to occur to financing healthcare services are already outlined, such as creating financial protection mechanisms for discontinued outpatient services or outlining how citizens or health insurance systems pay for screening and diagnostic testing.42 Finally, contingency funds should cover workforce surge, including staff, supplies, training and workforce management.73
