IHR (2005) Implementation and Health Security Capacities at National and Sub-national Levels in India in the Context of COVID-19 Outbreak

Background: The implementation of International Health regulations (2005)ensure public health measures to prevent, detect, and respond to threats and events, including infections disease events like COVID19 to the prevention and control of the international spread of the disease. At the onset of COVID19 outbreak, we analysed India’s national and subnational level preparedness capacities against COVID19. Methods: India’s health security capacities were reviewed using ve indices, i) prevent, ii) detect, iii) respond, iv) enabling function and v) operational readiness using the 2019 score of India’s State Party Annual Report. For subnational analysis, a composite measure is developed for operational readiness capacity for each state using Sustainable Development Goal index score for good health and well-being (SDG3) and indicators of COVID19 preparedness and readiness capacity. Results: India had score 60% for prevent, 90% for detect, 63.3% for respond, 80% for enabling function and 74.4% operational readiness and they were at level 3, 5, 4,5and 4 respectively. Out of 36 federal states, 5 (14%) states were level 5, 10 (28%) at level 4, 17 (47%) at level 3 and 4 (11%) states at level 2 for the operational readiness index. Conclusions: India’s capacity to prevent, detect, and respond to outbreaks were comparable with other countries in the SEAR region. It performed better on prevent, detect, respond and enabling function, which suggest that effective response to COVID19 pandemic could be enabled. The operational readiness capacities of federal states are comparable except for the few states. However, it needs to corroborate with local risk assessment due to COVID19 to fully understand the readiness capacity. Rapid development of capacities at the sub-national levels are needed to strengthen national readiness capacities.

Conclusions: India's capacity to prevent, detect, and respond to outbreaks were comparable with other countries in the SEAR region. It performed better on prevent, detect, respond and enabling function, which suggest that effective response to COVID19 pandemic could be enabled. The operational readiness capacities of federal states are comparable except for the few states. However, it needs to corroborate with local risk assessment due to COVID19 to fully understand the readiness capacity. Rapid development of capacities at the sub-national levels are needed to strengthen national readiness capacities.

Background
In December 2019, China reported to WHO cases of pneumonia of unknown cause occurring in Wuhan,Hubei. 1 The country's capacity to detect cases facilitated early recognition and veri cation of the pathogen. Viral genetic sequencing of samples indicated a novel coronavirus. 2 Early indications suggest that bats are the primary reservoir for the virus, given COVID-19's close similarity to bat coronaviruses, 3 and while identi cation of the zoonotic origin of the virus continues.
On Jan 30, WHO declared the outbreak of COVID-19 as a public health emergency of international concern under the IHR (2005).The public health measures for managing the outbreak like COVID19 rely on existing national and regional preparedness capacities to prevent, detect, verify, assess, and respond in accordance with the International Health Regulations (IHR, 2005). Since the IHR came into force in 2007, countries have made substantial efforts to strengthen their capacities to prevent, detect, and respond to public health emergencies. 4 Countries have been enhancing preparedness through the implementation and regular assessment of IHR national capacities using the components of the WHO IHR monitoring and evaluation framework to mitigate the effect of public health emergencies, including the emergence of a novel pathogen. 5 Since 31 December 2019 and as of 25 May 2020, over ve million cases of COVID-19 were reported, including 344,731 deaths from 212 countries and territories. 6,7 India reported the rst case on 28 February 2020, from Kerala in a student who returned from Wuhan, China. 8 As of 25 May 2020, India reported 144,941 cases and 4,171 fatalities. Majority cases were reported from ve states; Maharashtra, Gujarat, Delhi and Tamil Nadu, Madhya Pradesh. 9 India responded to the COVID-19 outbreak by putting measures like early detection of suspected cases and their quarantine and isolation and entry screening for passengers from China and other affected countries at major international ports on January 21 before WHO declared COVID-19 a public health emergency of international concern (PHEIC). 10 Resilient health system and Universal health coverage (UHC) aligned with the sustainable development goals (SDGs)are essential to build emergency preparedness capacity viz. ability to quickly identify and isolate a threat, target resources to it, minimising disruption to provision of essential health services during crisis. 11 We aimed to analyse the2019 SPAR scores to review the health security capacities at the national level.
We also conducted analysis of the State level data on sustainable development (SDG)health goal and COVID19 related preparedness and readiness for sub national level, which can provide information to identify gaps and strengths to strengthen IHR implementation vis a vis to respond to COVID19.

Methods
The methodology of index development and analysis is based on an earlier publication by Kandel N et al 12 in Lancet. We analysed India's 2019 SPAR score to review health security capacities on the basis of the following indices: (1) prevent, (2) detect, (3) respond, (4) enabling function (resources and coordination capacity), and (5) operational readiness. The scores for 18 of the 24 SPAR indicators were applied across the ve indices. Six SPAR indicators that were not directly related to these indices and infectious hazard threats, including COVID-19, were excluded. 13 The SPAR indicators selected for use and the rationale for including the indicators as part of the respective indices are shown in Panel 1. The following 18 indicators of the SPAR (12)have been used to develop an index for operational readiness**.The index helps to assess the status of national readiness capacities across each WHO region.
*According to WHO, operational readiness to respond to emergencies is a high level of readiness will allow a timely, effective and e cient response. Achieving readiness is a continuous process of establishing, strengthening and maintaining a multi-sectoral response infrastructure that can be applied at all levels, which follows an all-hazard approach, and which focuses on the highest priority risks.
Operational readiness builds on existing capacities to design and set up specialized arrangements and services for emergency response. 14 Index development and analysis: The ve levels used to rate the indices are similar to the capacity levels used to assess countries using SPAR (Panel2). 15 There is very limited functional capacity in place to prevent and control the risk/event Level2: <=40% There is limited functional capacity available on an ad-hoc basis with the support of external resources

Level3: <=60%
The functional capacity is able to perform well at the national level; however, there is limited effectiveness at the sub-national levels. This study considers this level as developmental.

Level4: <=80%
The capacity has demonstrated its functionality well at the national and sub-national levels against various events Step 1: We conducted a transformation (log and normal) of the data into a non-dimensional scale and removing outliers (rates and absolute numbers) and normalised them. The log transformation was done to gives more weight to the difference between the states with lower values and less weight to the states with higher values for indicators.
Setting up minimum and maximum and rescaling-this will help to bring all data set into one dimension and exclude the distortion effect of outliers on indicator's set. A scale of 0 to 1 is used (higher the scale lower the capacity) Step 2: We aggregated data either using geometric or arithmetic average. These aggregation methodologies are applied to indexes at each level to progress through the levels in a hierarchical bottom up approach.
Total capacity for COVID19= Isolation beds 1/n × ventilators 1/n × Quarantine beds 1/n × …… OPR capacity (total and SDG) = Total capacity 1/2 × SDG index ½ Step 3: The aggregate score is converted to level 1 to level 5, where the level 5 is better and level 1 is worst. Higher the score higher the level (Panel 4) Prevent capacity: India's prevent capacity is rated as moderate at level 3(60%), whereas the regional average for SEA region is at level 3 (58%) and the global average for prevent capacity which is at level 4 (61%). The score for capacity requirements at all times for designated airports, ports and ground crossings and emergency risk communication was 80% (level 4) whereas capacity for infection prevention and control was limited at level1.
Detect capacity: The overall score for capacity to detect encompassing system for generation of early warning signal and veri cation (100%), specimen referral and transport (80%), access to laboratory testing was robust at level 4 (80%). India fared better in capacity to detect as compared to SEAR countries (78.5%), as well as globally (75.5%).

Respond:
The score for capacity to respond was 63 percent; little above moderate.
The overall score for capacity to respond was higher as compared to SEAR(56.1%) and global levels (58.8%). India's score for emergency preparedness and response, management of health emergency response operation, effective public health response at PoEs and emergency resource mobilization was 80% (level 4) whereas the score for case management for IHR relevant events was 40% (level 2).

Enabling function:
India had high score (80% at level 4) for the enabling function; higher than the score of SEAR (65%) countries as well as overall global score (65.6 %). The score for capacities pertaining to nancing mechanism and funds for timely response, multi sectoral IHR coordination mechanisms, human resources capacity for IHR implementation was at level 4, however, score for capacity on access to essential health services was 40%(level 2).
Operational readiness capacity: Based on the composite score for operational readiness, India showed good operational readiness (74.4%, level 4) to prevent, detect and control an event, however, IPC at level 1(20%) and essential health services at level 2(40%)were found to be limiting factors.
Operational readiness capacity for sub-national level: The operational readiness of the states was assessed using a composite measure.

Discussion
We used the 2019 SPAR to assess the country's capacity to prevent, detect and respond to public health events including COVID19. The response to SPAR for various capacities is collated at national level in consultation with stakeholders and the report is submitted to WHO through the NFP-IHR mechanism. The study has limitations as it does not take into account the IHR capacity data at sub national level as there is no mechanism to collection and report the sub-national information based on the IHR reporting. India is a federal state with variations in level of capacity at each level. Therefore, to re ect the sub-national capacity we used the SDG and COVID19 related data, which may not be sensitive and speci c as that of SPAR score. However, they re ect the health systems capacity and resilience.
The study takes into account the strength of IHR capacities at national level and does not take into account several factors that affect the emergence and spread of an infectious disease outbreak within countries and between regions, including IHR adherence to infection prevention and control measures, population movement, climate-related pressures, and the density of populations. When an outbreak is caused by an airborne pathogen, population movement and density or crowding are known to directly affect spread of infection.Analysis of other risk variables associated with tackling an infectious disease outbreak and managing health emergencies would bene t understanding of existing capacities, including vulnerabilities due to socioeconomic conditions, co-morbid conditions, and lack of health infrastructure, which we did not take into account. Respond capacity: Our ndings show that India's respond capacity is moderate as compared to robust respond capacity displayed by Thailand in the South East Asia region; however, it is comparable to average capacity of SEAR countries. According to a study published by Kandel et al, more than fty percent countries reported either low or moderate capacity. 12 These ndings suggest that there is a need to enhance the respond capacity of the countries globally including India which can be achieved through strengthening emergency preparedness, emergency resource mobilization and effective prevention and control strategies for infectious disease outbreaks.
Communicating the risk effectively to the public has been the core strategy of preventive and control measures to combat COVID-19. Risk communication strategies adopted include setting up a 24×7 National Helpline, community engagement through Gram Sabhas, regular media brie ngs, and public awareness campaigns on safe practices such as hand hygiene, respiratory etiquette and physical distancing has been scaled up through various channels of communication. 28 Aarogya Setu, a mobile application launched by GoI proactively informs the users of the app regarding risks, best practices and relevant advisories pertaining to the containment of COVID-19." 29 Similarly, Republic of Korea's has also used smart phone apps to ag infection hotspot and send alerts on cases and access to testing. 30 Infection prevention and control (IPC) measures are essential to ensure healthcare workers are protected from infection with 2019-nCoV and ampli cation events in healthcare facilities. This nding is similar to other countries. 31,32 An IPC programme at national and facility level with a dedicated and trained team, or at least an IPC focal point, should be in place and supported by the national authorities and facility senior management. 33 Other major challenges for India include limited functional capacity for case management capacity for IHR related hazards. The case management is vital capacity to control the COVID19 pandemic.
Enabling function: India has better enabling function in place as compared to the global and regional average, which is evident from the multi sectoral approach adopted by the government and availability of nancing mechanisms, adequate human resources and emergency logistics for timely response to public health emergencies. However, enabling function was found to be low in many low resource countries underlining the importance of increase investments for scaling health security and IHR implementation. 12  Kerala is one of the states which is performed well among the States. The state is known for its health systems capacity and many of the health outcome and impact measures are one of the better in the world. With its experience of handling the Nipah outbreak in 2018, Kerala realised the merits of containing virus transmission by quickly tracing all the contacts and repeated it to perfection this time as well.
Kerala with its good health-care infrastructure, strong political and administrative leadership, local community engagement has been lauded for the "unparalleled" containment and testing strategies referred to as the "Kerala model". It is a success born out of decades-old social revolution and development. Similar ndings have been reported from another study which highlights negative relationship between the two variables (medical infrastructure using per-capita health expenditure at the state level) a rming that the more a state spends on the health sector, the lower will be the severity of any disease. 42 The COVID19 pandemic has highlighted the need for countries to understand that the virus can overwhelm even the most robust health systems, resulting in the need to entirely recon gure health sectors in response. As the world responds to the pandemic, there will be many lessons to strengthen preparedness in future; however, looking at the Kerala model and other countries in the world which are responding the pandemic well they have some commonality in capacities. They are strong leadership and governance, community engagement and mobilisation of community workers, accountability of public and the government, rapid mobilisation of resources and existing health systems experience of handling outbreaks and events. Investment in these areas is equally important while strengthening health systems for health security capacities for emergency preparedness and response. 43