Joint External Evaluation scores and communicable disease deaths: An ecological study on the difference between epidemics and pandemics

Abstract

The Joint External Evaluation (JEE) assesses national capacities to implement the International Health Regulations (IHR). Previous studies have found that higher JEE scores are associated with fewer communicable disease deaths. But given the impact of COVID-19 in many countries, including those believed to have developed IHR capacities, the validity of the JEE for pandemic preparedness has been questioned. We constructed univariable and multivariable linear regression models to investigate the relationship between JEE scores and i) deaths from communicable diseases before the pandemic and ii) deaths from COVID-19. We adjusted for country differences in age, health system access, national wealth, health expenditure, democratic governance, government restrictions, pre-pandemic tourist arrivals and testing capacity (estimated by test positivity rates). For COVID-19 deaths, we calculated cumulative deaths per 100,000 at 3, 6 and 12 months into the pandemic. A total of 91 countries were included, with a median JEE score of 50%. On multivariable linear regression the association between JEE scores and log COVID-19 deaths was significant and positive at 3 months (β 0.05, p = 0.02), becoming statistically non-significant, at 6 (β 0.02, p = 0.27) and 12 months (β -0.03, p = 0.19), while the association with log communicable disease deaths was significant and negative (β -0.03, p = 0.003). A higher Stringency Index was significantly associated with higher log COVID-19 deaths at 3 (β 0.04, p = 0.003) and 6 (β 0.04, p = 0.001) months, but not at 12 months (β 0.02, p = 0.08). Higher test positivity rates were associated with higher log COVID-19 deaths at all time points, at least partially attenuating the positive association between Stringency Index and log COVID-19 deaths. While universal health coverage indices (β -0.04 p<0.001) and international tourist arrivals were associated with log communicable disease deaths (β 0.02, p = 0.002), they were not associated with log COVID-19 deaths. Although the same tool is used to assess capacities for both epidemics and pandemics, the JEE may be better suited to small outbreaks of known diseases, compared to pandemics of unknown pathogens.

How prepared is the world? Identifying weaknesses in existing assessment frameworks for global health security through a One Health approach

“…However, despite considering the limitations of the COVID-19-related numbers of cases and deaths, both the GHSI and JEE indicators appear to be better suited for small outbreaks of known diseases, compared with pandemics of unknown pathogens. 66 Of the top 20 countries with the highest rates of COVID-19related mortality (deaths per million), eight countries are also listed among the top 20 countries with the highest GHSI score and six countries are listed among the top 20 countries with the highest JEE score (appendix pp 5-6). These findings mirror the analysis of the Independent Panel for Pandemic Preparedness and Response.…”