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. 2021 Dec 4;398(10316):2109-2124.
doi: 10.1016/S0140-6736(21)01897-3. Epub 2021 Nov 8.

How an outbreak became a pandemic: a chronological analysis of crucial junctures and international obligations in the early months of the COVID-19 pandemic

Sudhvir Singh  1 , Christine McNab  2 , Rose McKeon Olson  3 , Nellie Bristol  2 , Cody Nolan  3 , Elin Bergstrøm  2 , Michael Bartos  4 , Shunsuke Mabuchi  2 , Raj Panjabi  2 , Abraar Karan  3 , Salma M Abdalla  5 , Mathias Bonk  2 , Margaret Jamieson  6 , George K Werner  2 , Anders Nordström  2 , Helena Legido-Quigley  7 , Alexandra Phelan  8
Affiliations

How an outbreak became a pandemic: a chronological analysis of crucial junctures and international obligations in the early months of the COVID-19 pandemic

Sudhvir Singh et al. Lancet. .

Abstract

Understanding the spread of SARS-CoV-2, how and when evidence emerged, and the timing of local, national, regional, and global responses is essential to establish how an outbreak became a pandemic and to prepare for future health threats. With that aim, the Independent Panel for Pandemic Preparedness and Response has developed a chronology of events, actions, and recommendations, from December, 2019, when the first cases of COVID-19 were identified in China, to the end of March, 2020, by which time the outbreak had spread extensively worldwide and had been characterised as a pandemic. Datapoints are based on two literature reviews, WHO documents and correspondence, submissions to the Panel, and an expert verification process. The retrospective analysis of the chronology shows a dedicated initial response by WHO and some national governments, but also aspects of the response that could have been quicker, including outbreak notifications under the International Health Regulations (IHR), presumption and confirmation of human-to-human transmission of SARS-CoV-2, declaration of a Public Health Emergency of International Concern, and, most importantly, the public health response of many national governments. The chronology also shows that some countries, largely those with previous experience with similar outbreaks, reacted quickly, even ahead of WHO alerts, and were more successful in initially containing the virus. Mapping actions against IHR obligations, the chronology shows where efficiency and accountability could be improved at local, national, and international levels to more quickly alert and contain health threats in the future. In particular, these improvements include necessary reforms to international law and governance for pandemic preparedness and response, including the IHR and a potential framework convention on pandemic preparedness and response.

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Conflict of interest statement

Declaration of interests AP has worked as a consultant with WHO on unrelated projects; was a member of a WHO Technical Advisory Group related to the IHR and COVID-19; is principal investigator in a project funded by the Carnegie Corporation to examine legal elements of a potential pandemic treaty (grant number G-21-58414); and is principal investigator of a project funded by the US Centers for Disease Control to examine national responses to COVID-19 (grant number NU2HGH2021000469: Component 3). HL-Q has worked as a consultant with WHO on unrelated projects and is a member of the WHO Europe High Level Expert Consultation Group on COVID-19 strategies. MBa has worked as a consultant with WHO on projects concerning gaps in pandemic preparedness, a global hub for pandemic and epidemic intelligence, and investment in WHO. RMO has previously worked as a Consultant for WHO with the Violence Against Women Team on unrelated topics. MBo has worked as a consultant with WHO on unrelated projects. CM has worked as a consultant with WHO on unrelated projects and worked full time at the WHO Headquarters from 2000 to 2008. SMA has worked as a consultant with WHO on unrelated projects and is the Lead Project Director of a grant from The Rockefeller Foundation to examine the intersection of data, determinants of health, and decision making. NB has worked as a consultant to WHO through the Global Preparedness Monitoring Board, on a project related to polio assets and COVID-19, and on unrelated topics; and is consulting with the Nuclear Threat Initiative and Johns Hopkins University as they develop the Global Health Security Index (2021). SM has worked with the World Bank to help accelerate their COVID-19 rapid response, and as a Senior Advisor with the Bill and Melinda Gates Foundation. AN has worked as a staff member at WHO, including as Acting Director General and as a Country Representative; and worked as the Ambassador for Global Health for the Government of Sweden before being appointed to lead the Independent Panel secretariat. AK has done unpaid work for the Biden-Harris campaign on COVID-19 related school reopenings, and worked as an unpaid medical fellow on the Massachusetts Department of Public Health COVID-19 response. RP is the US Global Malaria Coordinator at the US Agency for International Development, but his views in this paper are based on his work with the Independent Panel, in which he served until Jan 31, 2021. GKW has served on the UN's High-Level Commission on Health Employment and Economic Growth. The views expressed herein do not necessarily reflect the views of the US Government or its departments and agencies. All other authors declare no competing interests.

Figures

Figure
Figure
Conceptual framework for analysis of obligations and informing objectives for future threats IHR=International Health Regulations. PHEIC=Public Health Emergency of International Concern.
See this image and copyright information in PMC

References

    1. Dong E, Du H, Gardner L. An interactive web-based dashboard to track COVID-19 in real time. Lancet Inf Dis. 2020;20:533–534. - PMC - PubMed
    1. Nuclear Threat Initiative. Johns Hopkins Bloomberg School of Public Health Center for Health Security Global Health Security Index. 2019. https://www.ghsindex.org/wp-content/uploads/2019/10/2019-Global-Health-S...
    1. Independent Panel on Pandemic Preparedness and Response Final report of the Independent Panel on Pandemic Preparedness and Response. 2021. https://theindependentpanel.org/wp-content/uploads/2021/05/COVID-19-Make... - PMC - PubMed
    1. WHO . 3rd edn. World Health Organization; Geneva: 2008. International health regulations (2005)
    1. Nuzzo J, Mullen L, Snyder M, Cicero A, Inglesby TV. Johns Hopkins Center for Health Security; Baltimore, MD: 2019. Preparedness for a high-impact respiratory pathogen pandemic.

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