Gerenciamento tensionado: o sistema de vigilância em saúde e a resposta à pandemia da covid-19 no Brasil / Management in tension: the Brazilian public health surveillance system and its response to the covid-19 pandemic

Resumo O artigo aborda a resposta do governo brasileiro à pandemia da covid-19, enfatizando o sistema de vigilância em saúde e de inteligência epidemiológica. Retoma a evolução da vigilância em resposta às normas do Regulamento Sanitário Internacional, no contexto da saúde global. Analisa os atos do Executivo publicados no Diário Oficial da União e se detém nos atores e grupos formados para o enfrentamento da pandemia da covid-19 de janeiro de 2020 até março de 2022. Parte da premissa de que a inteligência epidemiológica deve estar a serviço da saúde pública. Constata-se que certo tensionamento burocrático e a transferência de protagonismo entre grupos marcam o desmonte dos mecanismos de inteligência.

Abstract This article addresses the Brazilian government's response to the covid-19 pandemic, particularly the public health surveillance and epidemic intelligence system. It traces the evolution of disease surveillance as a response to the International Health Regulations in the context of global health. Executive orders published in the official gazette, Diário Oficial da União, are analyzed, as well as the actors and groups formed to tackle the pandemic between January 2020 and March 2022. The founding assumption is that epidemic intelligence must be placed at the service of public health. Bureaucratic tension and changes in protagonism among different groups can be observed as these intelligence mechanisms were dismantled.

COVID-19 in the Americas: the role of collaborating centers in understanding lessons and best practices in pandemic preparedness and response / COVID-19 en la Región de las Américas: papel de los centros colaboradores en la comprensión de las enseñanzas y mejores prácticas en la preparación y respuesta frente a pandemias / COVID-19 nas Américas: o papel dos centros colaboradores para entender as lições e melhores práticas de preparação e resposta a pandemias

ABSTRACT COVID-19 exposed major gaps in global, regional, state, and local responses to public health emergencies. In preparation for the WHA Special Session to consider the benefits of developing an international instrument on pandemic preparedness, the O'Neill Institute in partnership with Foundation for the National Institutes of Health convened 30 of the world's leading authorities on global health law, financing, biomedical science, implementation, and emergency response along with leaders from prominent international organizations. This meeting was followed by regional consultations convened in Latin America-Caribbean, Africa, and Southeast Asia. These high-level expert consultations generated in-depth discussions on weaknesses and persisting gaps in global pandemic preparedness and what a new international agreement might include to address them. Regional intergovernmental organizations like PAHO can work closely with related multilateral development banks to develop financial instruments that can smooth systemic economic disruption; and regional centers of research and manufacturing excellence can offer a strong front line for producing medicines and vaccines rapidly during a pandemic. With our research focused on the regional response to COVID-19 we are able to look at country responses individually and collectively to see how Latin America - Caribbean countries can capitalize and leverage their regional connections to strengthen their pandemic preparedness and response. By identifying existing gaps and examining the responses and approaches taken by PAHO, we can better understand the role of international and regional organizations and their collaborating centers in preparing and responding to pandemics.

RESUMEN La COVID-19 expuso grandes brechas en las respuestas locales, nacionales, regionales y mundiales a las emergencias de salud pública. En preparación para la reunión extraordinaria de la Asamblea Mundial de la Salud para considerar los beneficios de elaborar un instrumento internacional sobre la preparación frente a las pandemias, el Instituto O'Neill, en colaboración con la Fundación para los Institutos Nacionales de Salud, convocó a 30 de las principales autoridades mundiales en materia de derecho, financiamiento, ciencia biomédica, implementación y respuesta a emergencias de salud, así como a líderes de organizaciones internacionales prominentes. A esta reunión le siguieron consultas regionales convocadas en América Latina y el Caribe, África y el sudeste asiático. Estas consultas con expertos de alto nivel generaron debates en profundidad acerca de las debilidades y brechas persistentes en la preparación frente a las pandemias y qué podría incluirse en un nuevo acuerdo internacional sobre cómo abordarlas. Las organizaciones intergubernamentales regionales como la Organización Panamericana de la Salud pueden trabajar en estrecha colaboración con los bancos multilaterales de desarrollo relacionados para elaborar instrumentos financieros que puedan aliviar las perturbaciones económicas sistémicas; y los centros regionales de excelencia en investigación y producción pueden formar una sólida primera línea de acción para producir medicamentos y vacunas rápidamente durante una pandemia. Con esta investigación centrada en la respuesta regional a la COVID-19, podemos analizar las respuestas de los países de forma individual y colectiva para observar la manera en que América Latina y el Caribe pueden capitalizar y aprovechar sus conexiones regionales para fortalecer su preparación y respuesta frente a una pandemia. Al determinar cuáles son las brechas existentes y examinar las respuestas y los enfoques adoptados por la OPS, podemos comprender mejor el papel de las organizaciones regionales e internacionales y sus centros colaboradores en la preparación y respuesta frente a las pandemias.

RESUMO A COVID-19 expôs grandes lacunas nas respostas globais, regionais, estaduais e locais a emergências de saúde pública. Nos preparativos para a Sessão Especial da Assembleia Mundial da Saúde para avaliar os benefícios de desenvolver um instrumento internacional de preparação para pandemias, o Instituto O'Neill, em parceria com a Fundação para os Institutos Nacionais de Saúde, reuniu 30 das principais autoridades mundiais em direito sanitário global, financiamento, ciências biomédicas, implementação e resposta a emergências, além de líderes de organizações internacionais proeminentes. Essa reunião foi seguida por consultas regionais convocadas na América Latina/Caribe, na África e no sudeste da Ásia. Essas consultas com especialistas de alto nível geraram discussões minuciosas sobre os pontos fracos e as lacunas persistentes na preparação global para pandemias e o que poderia ser incluído em um novo acordo internacional para resolvê-los. Organizações intergovernamentais regionais, como a OPAS, podem trabalhar em estreita colaboração com os bancos multilaterais de desenvolvimento para desenvolver instrumentos financeiros capazes de atenuar a ruptura econômica sistêmica; por outro lado, centros regionais de excelência em pesquisa e fabricação podem oferecer uma linha de frente expressiva para a rápida produção de medicamentos e vacinas durante uma pandemia. Usando os dados da nossa pesquisa sobre a resposta regional à COVID-19, podemos analisar as respostas dos países de forma individual e coletiva para avaliar como os países da América Latina e do Caribe podem capitalizar e alavancar suas conexões regionais para fortalecer sua preparação e resposta à pandemia. Ao identificar lacunas existentes e analisar as respostas e abordagens adotadas pela OPAS, podemos compreender melhor o papel das organizações internacionais e regionais e de seus centros colaboradores na preparação e resposta a pandemias.

Covid-19 na América Latina: desigualdades e capacidades de resposta dos sistemas de saúde a emergências sanitárias / COVID-19 in Latin America: inequalities and response capacity of health systems to health emergencies / COVID-19 en América Latina: desigualdades y capacidad de respuesta de los sistemas de salud ante emergencias de salud

RESUMO Objetivo. Identificar correlações entre a covid-19, características demográficas e socioeconômicas e capacidade dos sistemas de saúde latino-americanos para resposta a emergências sanitárias. Método. Realizou-se um estudo ecológico, utilizando dados secundários de 20 países latino-americanos relativos a incidência, mortalidade, testagem e cobertura vacinal para covid-19 no período de 2020 a 2021, assim como informações demográficas e socioeconômicas. A preparação dos países para responder a emergências sanitárias foi explorada a partir do Relatório Anual de Autoavaliação dos Estados Partes da Organização Mundial da Saúde de 2019 sobre a implementação do Regulamento Sanitário Internacional (RSI). Realizaramse análises estatísticas por meio do teste de correlação de Spearman (rho). Resultados. Observou-se correlação positiva alta do produto interno bruto per capita e do índice de desenvolvimento humano com incidência de covid-19, testagem e cobertura vacinal; e entre proporção da população idosa e cobertura vacinal. Não foram identificadas correlações entre os indicadores da covid-19 e as capacidades prévias de implementação do RSI. Conclusões. A ausência de correlação entre indicadores relativos à covid-19 e a capacidade de implementação do RSI pode estar relacionada a limites dos indicadores utilizados ou da ferramenta de acompanhamento do RSI como instrumento indutor da preparação dos países para enfrentamento de emergências sanitárias. Os resultados sugerem a importância de condicionantes estruturais e a necessidade de estudos longitudinais, comparativos e qualitativos para compreender os fatores que influenciaram a resposta dos países à covid-19.

ABSTRACT Objective. To identify correlations between COVID-19, demographic and socioeconomic characteristics, and the capacity of Latin American health systems to respond to health emergencies. Method. An ecological study was performed using secondary data from 20 Latin American countries regarding incidence, mortality, testing and vaccination coverage for covid-19 from 2020 to 2021 as well as demographic and socioeconomic indicators. The preparedness of countries to respond to health emergencies was explored based on the 2019 State Party Self-Assessment Annual Report on the implementation of the International Health Regulations (IHR). Statistical analyses were performed using the Spearman correlation test (rho). Results. A high positive correlation was noted between gross domestic product per capita and the human development index with the incidence of COVID-19, testing, and vaccination coverage; and between the proportion of elderly population and vaccination coverage. No correlations were identified between the covid-19 indicators and previous IHR implementation capacities. Conclusions. The lack of correlation between indicators related to COVID-19 and the ability to implement the IHR may reflect limitations of the indicators used or of the IHR monitoring tool as an instrument that induces the preparedness of countries to face health emergencies. The results suggest the importance of structural conditioning factors and the need for longitudinal, comparative, and qualitative studies to understand the factors that influenced the response of countries to COVID-19.

RESUMEN Objetivo. Determinar las posibles correlaciones entre la COVID-19, las características demográficas y socioeconómicas, y la capacidad de los sistemas de salud latinoamericanos para responder a emergencias de salud. Método. Se realizó un estudio ecológico con datos secundarios de 20 países latinoamericanos sobre la incidencia, la mortalidad, las pruebas y la cobertura de vacunación relativas a la COVID-19 en el período 2020-2021, y con información demográfica y socioeconómica. Se exploró la preparación de los países para responder a emergencias de salud a partir del Informe Anual de Autoevaluación de los Estados Miembros de la Organización Mundial de la Salud del 2019 sobre la implementación del Reglamento Sanitario Internacional (RSI). Los análisis estadísticos se realizaron con la prueba de correlación (ro) de Spearman. Resultados. Se observó una alta correlación positiva del producto interno bruto per cápita y del índice de desarrollo humano con la incidencia, las pruebas y la cobertura de vacunación respecto a la COVID-19, así como de la proporción de personas mayores en la población con la cobertura de vacunación. No se observó ninguna correlación entre los indicadores de COVID-19 y la capacidad previa de implementación del RSI. Conclusiones. La falta de correlación entre los indicadores relativos a la COVID-19 y la capacidad de implementación del RSI puede deberse a limitaciones de los indicadores utilizados o del mecanismo de seguimiento del RSI como instrumento inductor de la preparación de los países para enfrentar emergencias de salud. Los resultados sugieren la importancia de los factores condicionantes estructurales y la necesidad de realizar estudios longitudinales, comparativos y cualitativos para determinar los factores que influyeron en la respuesta de los países a la COVID-19.

Points of entry dynamics: understanding the cross-border threats for Ebola virus disease and COVID-19 in Ghana using a logic model approach

Background. The influx of people across the national borders of Ghana has been of interest and concern in the public health and national security community in recent times due to the low capacity for the prevention and management of epidemics and other public health risks. Although the International Health Regulations (IHR) stipulate core public health capacities for designated border facilities such as international airports, seaports, and ground crossings, contextual factors that influence the attainment of effective public health measures and response capabilities remain understudied. Objective. To assess the relationship between contextual factors and COVID-19 procurement to help strengthen infrastructure resources for points of entry (PoE) public health surveillance functions, thereby eliminating gaps in the design, implementation, monitoring, and evaluation of pandemicrelated interventions in Ghana. Materials and Methods. This study employed a mixed-methods design, where quantitative variables were examined for relationships and effect size interactions using multiple linear regression techniques and the wild bootstrap technique. Country-level data was sourced from multiple publicly available sources using the social-ecological framework, logic model, and IHR capacity monitoring framework. The qualitative portion included triangulation with an expert panel to determine areas of convergence and divergence. Results. The most general findings were that laboratory capacity and KIA testing center positively predicted COVID-19 procurement, and public health response and airline boarding rule negatively predicted COVID-19 procurement. Conclusion. Contextual understanding of the COVID-19 pandemic and Ebola epidemic is vital for strengthening PoE mitigation measures and preventing disease importation.

Outbreak investigation in cargo ship in times of COVID-19 crisis, Port of Santos, Brazil / Investigação de surto em navio de carga em tempo de COVID-19, Porto de Santos, Brasil

ABSTRACT In February 2020, a Chinese cargo ship docked at the Port of Santos with reports of crew members with a feverish and respiratory condition. A team was gathered to verify the existence of suspected cases of COVID-19 inside the vessel and define its clearance. All 25 crew members were interviewed, and no suspected cases were found. The vessel was then cleared for port activities. The investigation resulted from the implementation of the contingency plan to face a public health emergency of international importance and several surveillance entities cooperated.

RESUMO Em fevereiro de 2020, um navio de carga vindo da China atracou no Porto de Santos com relato de tripulantes com quadro febril e respiratório. Uma equipe foi mobilizada para verificar a existência de casos suspeitos de COVID-19 dentro da embarcação e definir a liberação da embarcação no porto. Todos os 25 tripulantes foram entrevistados e não foram encontrados casos suspeitos. Então a embarcação foi liberada para atividades no porto. A investigação resultou da aplicação do plano de contingência diante de uma emergência de saúde pública de importância internacional e houve a colaboração de diversas entidades de vigilância.

Un enfoque bioeticista y de derechos frente a la pandemia / A bioethical and rights-based approach to the pandemic

Lay bioethics is an applied ethic that allows us to face the problems generated by the tension between science and the human being.The current pandemic caused by an unknown infectious agent has highlighted the need for the application of this applied ethic, not located on the laurels of the ethereal or purely intellectual, but rather based in day-to-day reality. Decision-making from all areas of health care requires this fundamental frame of reference; the application of correct precepts in epidemiological, sanitary decisions and political measures cannot and should not be done without this frame of reference; or the result will be catastrophic.

La Bioética laica es en principio una ética aplicada que permite afrontar los problemas generados por la tensión existente entre la ciencia y el ser humano. La actual pandemia causada por un agente infeccioso no conocido ha puesto de relieve la necesidad de la aplicación de esta ética aplicada, no ubicada en los laureles de lo etéreo o puramente intelectual sino más bien asentada en la realidad del día a día. La toma de decisiones desde todos los ámbitos del quehacer sanitario requiere este marco referencial fundamental; aplicación de correctos preceptos en las decisiones epidemiológicas, sanitarias y medidas políticas no puede ni debe hacerse sin este marco referencial; otrora el resultado será catastrófico.(AU)

O Congresso Nacional e as emergências de saúde pública / The Brazilian National Congress and public health emergencies

Resumo Analisou-se a resposta do Legislativo Federal Brasileiro frente a quatro emergências de saúde pública recentes, por meio de análise documental de caráter qualiquantitativo, nos bancos de dados de informação legislativa do Congresso Nacional. Observou-se que a resposta se caracterizou por pronunciamentos (de denúncia, de pedidos de providência, de críticas e de elogios à atuação do Poder Executivo) e pela fiscalização dessa atuação por meio de requerimentos de informação, de convocação de autoridades e de audiências públicas. A produção legislativa, no entanto, foi inexpressiva, restrita à aprovação de proposições de suplementação de recursos orçamentários de iniciativa do Poder Executivo. Poucos projetos de lei de iniciativa de parlamentares trataram matérias periféricas ao problema e não prosperaram. Conclui-se que a insuficiência normativa para a atuação das autoridades sanitárias no enfrentamento de emergências de saúde pública não tem sido suprida pelo Poder Legislativo e terá de sê-lo, provavelmente, por iniciativa do Executivo.

Abstract The response of the Brazilian Legislative Branch to four recent public health emergencies is analyzed through quali-quantitative documentary held in legislative information databases of the National Congress. It was observed that this response was characterized by public statements (of denunciation, requests for action, criticism and praise to the actions of the Executive Branch) and by the overseeing of these activities through information requests, convening authorities and public hearings. The lawmaking, however, was negligible, restricted to the approval of propositions for supplemental budget resources from the Executive Branch initiative. Few bills of parliamentary initiative approached the problem and were approved. We conclude that the inefficient actuation of health authorities in coping with public health emergencies is caused by the neglect of the Legislative Branch, so the Executive Branch should probably overcome the problem.

Strengthening the communicable disease surveillance and response system, Amhara Region, Ethiopia, 2012-2014: Review of a technical cooperation project / 国際保健医療

<p><b>Objectives</b></p><p>  The International Health Regulations (2005) bound the member states of the World Health Organization (WHO) to initiate epidemiological investigations of disease outbreaks and to notify WHO within 24 hours of their detection if the event is deemed to constitute public health emergency of international concern. The Japan International Cooperation Agency started the Amhara Regional Infectious Disease Surveillance Project to strengthen the surveillance and response system in the Amhara Region of Ethiopia in 2008. The objectives of the study were to review the project activities and to share the experiences and lessons learned in 22 districts of the North and South Gondar and West Gojjam Zones from mid-2012 through 2014.</p><p><b>Methods</b></p><p>  We conducted training for district surveillance officers and focal point personnel at health centres (HCs), monitoring visits to district health offices and HCs, held review meetings on surveillance, and provided technical assistance in outbreak investigations. We evaluated the project activities in terms of the timeliness of the surveillance reports submitted by the health facilities, provision of technical assistance in outbreak investigations, and the number of training sessions held for the surveillance personnel.</p><p><b>Results</b></p><p>  The timeliness of submission of surveillance reports had improved to almost 100% at end of 2014 compared with before the review period (about 68%). From the third quarter of 2013, we conducted monitoring visits to 59 HCs every semester. We were involved in 11 outbreak investigations of measles, anthrax, pertussis, neonatal tetanus, and typhoid fever. We held a total of 25 training sessions for district surveillance officers and HC focal points.</p><p><b>Conclusion</b></p><p>  The project successfully strengthened the surveillance and response system. We recommend that the Amhara Regional Health Bureau maintain its commitment to the system in terms of human resources and funding. Training for surveillance officers and focal points should be conducted periodically.</p>

A epidemia de doença pelo vírus Ebola de 2014: o Regulamento Sanitário Internacional na perspectiva da Declaração Universal dos Direitos Humanos / The 2014 Ebola virus disease epidemic: the International Health Regulations in the perspective of the Universal Declaration of Human Rights

Resumo Introdução No contexto da epidemia de doença pelo vírus Ebola (DVE) de 2014 na África Ocidental, este artigo tem como objetivo discutir as estratégias internacionais de controle de doenças transmissíveis com base no Regulamento Sanitário Internacional (RSI) da Organização Mundial da Saúde (OMS), na perspectiva da Declaração Universal dos Direitos Humanos (DUDH) da Organização das Nações Unidas (ONU). Método Trata-se de um estudo exploratório, de natureza qualitativa, realizado a partir de pesquisa bibliográfica sobre DVE, tomando como fonte de dados documentos oficiais disponíveis nos sites oficiais da ONU, OMS e Organização Pan-Americana da Saúde (OPAS), bem como artigos científicos relacionados ao tema, além da leitura do RSI e da DUDH. Resultado Os resultados mostraram que, durante a epidemia, as ações e as medidas de controle para o combate à doença desrespeitaram o RSI na perspectiva dos ideais de direito à saúde e de direitos humanos. Conclusão É necessário que agências e organizações que dispõem de poder decisório internacional se predisponham a acompanhar e auxiliar os países vulneráveis na África Ocidental para a garantia dos direitos humanos e evitar que novas epidemias possam acontecer.

Abstract Introduction In the context of the 2014 West African Ebola virus outbreak, this article aims to discuss the international strategies for the control of communicable diseases, based on the International Health Regulations (IHR) adopted by the World Health Assembly in May 2005, in the perspective of the United Nations Universal Declaration of Human Rights (UDHR). Method This is an exploratory, qualitative study conducted from a bibliographic research on the Ebola Virus Disease (EVD). Data were collected from documents available at the official websites of the UN, WHO and PAHO, as well as from scientific papers related to the topic and reading of the IHR and UDHR. Result The results show that certain action and control measures applied during the epidemic for combating the disease were not in accordance with the International Health Regulations, considering the ideals of right to health and human rights. Conclusion It is necessary that agencies and organizations with international decision-making power join forces to assist vulnerable countries in West Africa in order to ensure human rights and prevent new epidemics.

International Health Regulations (2005) facilitate communication for in-flight contacts of a Middle East respiratory syndrome case, Hong Kong Special Administrative Region, 2014

The International Health Regulations (IHR) (2005) require World Health Organization Member States to notify events fulfilling two of four criteria: (1) serious public health impact; (2) unusual or unexpected event; (3) significant risk of international spread; or (4) significant risk of international travel or trade restrictions. In-flight transmission of infections like severe acute respiratory syndrome is well documented. With the enormous amount of air travel today, the risk of increasing in-flight transmission and subsequent international spread of infections are increasing. Prompt notification and information sharing under the IHR mechanism is critical for effective contact tracing and prompt control measures. We report on a case of in-flight exposure to an infection with significant public health risks that was successfully resolved using IHR (2005) guidelines.

Strengthening public health laboratory capacity in Thailand for International Health Regulations (IHR) (2005).

Introduction: Thailand conducted a national laboratory assessment of core capacities related to the International Health Regulations (IHR) (2005), and thereby established a baseline to measure future progress. The assessment was limited to public laboratories found within the Thai Bureau of Quality and Safety of Food, National Institute of Health and regional medical science centres. Methods: The World Health Organization (WHO) laboratory assessment tool was adapted to Thailand through a participatory approach. This adapted version employed a specific scoring matrix and comprised 16 modules with a quantitative output. Two teams jointly performed the on-site assessments in December 2010 over a two-week period, in 17 public health laboratories in Thailand. The assessment focused on the capacity to identify and accurately detect pathogens mentioned in Annex 2 of the IHR (2005) in a timely manner, as well as other public health priority pathogens for Thailand. Results: Performance of quality management, budget and finance, data management and communications was considered strong (>90%); premises quality, specimen collection, biosafety, public health functions, supplies management and equipment availability were judged as very good (>70% but ≤90%); while microbiological capacity, staffing, training and supervision, and information technology needed improvement (>60% but ≤70%). Conclusions: This assessment is a major step in Thailand towards development of an optimized and standardized national laboratory network for the detection and reporting of infectious disease that would be compliant with IHR (2005). The participatory strategy employed to adapt an international tool to the Thai context can also serve as a model for use by other countries in the Region. The participatory approach probably ensured better quality and ownership of the results, while providing critical information to help decision-makers determine where best to invest finite resources.

Analysis on International Health Regulations (2005) public health emergency core capacity for health departments in China / 中国卫生政策研究

Objective:To describe the current situation of IHR ( 2005 ) public health emergency core capacity at the provincial, city, district or county level for health departments in China, discover gaps in the implementation of IHR(2005) public health emergency core capacity, and thereby provide reference for the construction of IHR(2005) public health emergency core capacity. Methods: A survey was conducted from 211 questionnaires of IHR (2005) public health emergency core capacity, which included 7 provinces, 64 cities, and 140 counties ( districts) in the health departments. Results:The indicator of IHR (2005) public health emergency core capacity is suitable for the conditions in China;there is a lack of institution building in China concerning IHR (2005) public health emergency core capacity;there is a decreasing trend at the provincial, city and county ( district) level. Conclusion:Recommen-dations were proposed to strengthen China’s institution building of IHR (2005) public health emergency core capaci-ty, focus on strengthening construction of county (district) level IHR (2005) public health emergency core capacity, strengthen the weak links of the IHR (2005) public health emergency core capacity index, strengthen China’s appli-cability research concerning IHR (2005) public health emergency core capacity.

Implementación del Reglamento Sanitario Internacional en Cuba: evaluación de capacidades básicas del sector salud en provincias seleccionadas / Implementation of the International Health Regulations in Cuba: evaluation of basic capacities of the health sector in selected provinces

Objetivo. Obtener información de línea base sobre el estado de las capacidades básicas delsector salud a nivel local, municipal y provincial, a fin de facilitar la identificación de prioridadesy orientar las políticas públicas dirigidas a garantizar los requisitos y capacidades establecidosen el Anexo 1A del Reglamento Sanitario Internacional de 2005 (RSI-2005).Métodos. Se realizó un estudio descriptivo de corte transversal mediante la aplicación de uninstrumento de evaluación de capacidades básicas referidas a la autonomía legal e institucional,el proceso de vigilancia e investigación y la respuesta frente a emergencias sanitarias en36 entidades involucradas en el control sanitario internacional de los niveles local, municipaly provincial en las provincias de La Habana, Cienfuegos y Santiago de Cuba.Resultados. Los policlínicos y centros provinciales de higiene y epidemiología de las tres provinciascontaban con más del 75% de las capacidades básicas requeridas. Doce de 36 unidadesdisponían del 50% del marco legal e institucional implementado. La vigilancia e investigaciónde rutina presentaron una disponibilidad variable, mientras que las entidades de La Habanacontaron con más del 40% de capacidades básicas en el campo de la respuesta ante eventos.Conclusiones. Las provincias evaluadas cuentan con capacidades básicas instaladas quepermitirán la implementación del RSI-2005 según el plazo previsto por la Organización Mundialde la Salud. Es necesario establecer y desarrollar planes de acción eficaces para consolidara la vigilancia como una actividad esencial de seguridad nacional e internacional en términosde salud pública.

Objective. Obtain baseline information on the status of the basic capacities ofthe health sector at the local, municipal, and provincial levels in order to facilitateidentification of priorities and guide public policies that aim to comply with therequirements and capacities established in Annex 1A of the International HealthRegulations 2005 (IHR-2005).Methods. A descriptive cross-sectional study was conducted by application ofan instrument of evaluation of basic capacities referring to legal and institutionalautonomy, the surveillance and research process, and the response to healthemergencies in 36 entities involved in international sanitary control at the local,municipal, and provincial levels in the provinces of Havana, Cienfuegos, andSantiago de Cuba.Results. The polyclinics and provincial centers of health and epidemiology in thethree provinces had more than 75% of the basic capacities required. Twelve out of36 units had implemented 50% of the legal and institutional framework. There wasvariable availability of routine surveillance and research, whereas the entities inHavana had more than 40% of the basic capacities in the area of events response.Conclusions. The provinces evaluated have integrated the basic capacities thatwill allow implementation of IHR-2005 within the period established by the WorldHealth Organization. It is necessary to develop and establish effective action plans toconsolidate surveillance as an essential activity of national and international securityin terms of public health.

Evaluation of Brazil's public health surveillance system within the context of the International Health Regulations (2005) / Evaluación del sistema de vigilancia de salud pública del Brasil dentro del contexto del Reglamento Sanitario Internacional (2005)

OBJECTIVE: To evaluate Brazil's public health surveillance system (HSS), identifying its core capacities, shortcomings, and limitations in dealing with public health emergencies, within the context of the International Health Regulations (IHR 2005). METHODS: In 2008-2009 an evaluative cross-sectional study was conducted using semistructured questionnaires administered to key informants (municipal, state, and national government officials) to assess Brazilian HSS structure (legal framework and resources) and surveillance and response procedures vis-à-vis compliance with the IHR (2005) requirements for management of public health emergencies of national and international concern. Evaluation criteria included the capacity to detect, assess, notify, investigate, intervene, and communicate. Responses were analyzed separately by level of government (municipal health departments, state health departments, and national Ministry of Health). RESULTS: Overall, at all three levels of government, Brazil's HSS has a well-established legal framework (including the essential technical regulations) and the infrastructure, supplies, materials, and mechanisms required for liaison and coordination. However, there are still some weaknesses at the state level, especially in land border areas and small towns. Professionals in the field need to be more familiar with the IHR 2005 Annex 2 decision tool (designed to increase sensitivity and consistency in the notification process). At the state and municipal level, the capacity to detect, assess, and notify is better than the capacity to investigate, intervene, and communicate. Surveillance activities are conducted 24 hours a day, 7 days a week in 40.7% of states and 35.5% of municipalities. There are shortcomings in organizational activities and methods, and in the process of hiring and training personnel. CONCLUSIONS: In general, the core capacities of Brazil's HSS are well established and fulfill most of the requisites listed in the IHR 2005 with respect to both structure and surveillance and response procedures, particularly at the national and state levels.

OBJETIVO: Evaluar el sistema de vigilancia de salud pública del Brasil, identificando sus capacidades básicas, deficiencias y limitaciones para manejar emergencias de salud pública, dentro del contexto del Reglamento Sanitario Internacional (RSI 2005). MÉTODOS: En el período 2008-2009 se llevó a cabo un estudio transversal de evaluación utilizando cuestionarios semiestructurados administrados a informantes clave (funcionarios del gobierno municipal, estatal y nacional) a fin de evaluar la estructura del sistema de vigilancia de salud pública del Brasil (marco jurídico y recursos), y la vigilancia y los procedimientos de respuesta, con relación al cumplimiento de los requisitos del RSI 2005 para el manejo de emergencias de salud pública de importancia nacional e internacional. Los criterios de evaluación incluyeron la capacidad de detectar, evaluar, notificar, investigar, intervenir y comunicar. Las respuestas se analizaron por separado según el nivel gubernamental (departamentos de salud municipales y estatales y ministerio de salud nacional). RESULTADOS: En general, en los tres niveles del gobierno, el sistema de vigilancia de salud pública del Brasil tiene un marco jurídico bien establecido (incluidas las reglamentaciones técnicas esenciales) y la infraestructura, los suministros los materiales y los mecanismos requeridos para el enlace y la coordinación. Sin embargo, todavía hay algunos puntos débiles a nivel estatal, especialmente en las zonas fronterizas y los pueblos pequeños. Los profesionales de campo deben conocer más la herramienta de decisión del anexo 2 del RSI 2005 (diseñada para aumentar la sensibilidad y la consistencia del proceso de notificación). En el nivel estatal y municipal, la capacidad para detectar, evaluar y notificar es mejor que la capacidad para investigar, intervenir y comunicar. Las actividades de vigilancia se llevan a cabo 24 horas al día, 7 días a la semana, en 40,7% de los estados y 35,5% de los municipios. Existen deficiencias en las actividades de organización y los métodos, y en el proceso de contratación y capacitación del personal. CONCLUSIONES: En general, las capacidades básicas del sistema de vigilancia de salud pública del Brasil están bien establecidas y cumplen la mayoría de los requisitos enumerados en el RSI 2005, tanto con respecto a la estructura como a la vigilancia y los procedimientos de respuesta, en particular en los niveles nacional y estatal.

Health security as a public health concept: a critical analysis / La seguridad sanitaria como un concepto de salud pública: un análisis crítico / A segurança sanitária como um conceito de saúde pública como um conceito de saúde pública: uma análise crítica

Existe una creciente aceptación del término de seguridad sanitaria. Sin embargo, hay variadas definiciones de seguridad sanitaria como un término operativo en salud publica, muchas veces incompatibles e incompletas, insuficientes para reconciliar este concepto con la atención primaria comunitaria en salud. Más significativo aún es la existencia de marcadas diferencias en la comprensión y uso de este concepto en diferentes escenarios. Los legisladores en los países industrializados usan el término en relación a la protección de la población de riesgos externos como el terrorismo y las pandemias; mientras que los trabajadores de la salud y los legisladores de los países en desarrollo y dentro del sistema de las Naciones Unidas comprenden el término en un contexto más amplio de salud pública. Este concepto es utilizado inconsistentemente dentro de las mismas agencias de las Naciones Unidas; como por ejemplo el uso restrictivo que del término "seguridad sanitaria global" hace la Organización Mundial de la Salud…

There is growing acceptance of the concept of health security. However, there are various and incompatibledefinitions, incomplete elaboration of the concept of health security in public health operational terms, andinsufficient reconciliationof the health security concept with community-based primary health care. Moreimportant, there are major differences in understanding and use of the concept in different settings. Policymakersin industrialized countries emphasize protection of their populations especially against external threats,for example terrorism and pandemics; while health workers and policymakers in developing countries andwithin the UN system understand the term in a broader public health context. Indeed, the concept is usedinconsistently within the UN agencies themselves, for example the World Health Organization’s restrictiveuse of the term ‘global health security’. Divergent understandings of ‘health security’ by WHO’s memberstates, coupled with fears of hidden national security agendas, are leading to a breakdown of mechanismsfor global cooperation such as the International Health Regulations. Some developing countries are beginningto doubt that internationally shared health surveillance data is used in their best interests. Resolutionof these incompatible understandingsis a global priority…

Existe uma crescente aceitação do termo segurança sanitária. Entretanto, há variadas definições de segurançasanitária como um termo operacional em saúde pública, muitas vezes compatíveis e incompletas, insuficientes para reconciliar este conceito com o atendimento primário comunitário em saúde. Mais significativo ainda é a existência de grandes diferenças na compreensão e uso deste conceito em diferentes cenários.Os legisladores nos países industrializados usam o termo com relação à proteção da população de riscos externos como o terrorismo e as pandemias; enquanto que os trabalhadores da saúde e os egisladores dos países em desenvolvimento e dentro do sistema das Nações Unidas compreendem o termo em um contextomais amplo de saúde pública. Este conceito é utilizado de forma inconsistente dentro das mesmas agências das Nações Unidas; como por exemplo, o uso restritivo do termo “segurança sanitária global” que a Organização Mundial da Saúde faz. A divergente compreensão do termo “segurança sanitária” pelos Estados membros da Organização Mundial da Saúde, junto com os temores derivados de agendas próprias e secretas de segurança nacional, está derivando em um colapso dos mecanismos de cooperação global estipulados, por exemplo, no Regulamento Sanitário Internacional. Alguns países em desenvolvimento estão começando a perguntar-se se a informação da vigilância em saúde compartilhada a nível internacional esta sendo utilizada em seu beneficio. Resolver estas incompatibilidades de compreensão conceitual é uma prioridade global…

International Health Regulations A Major Paradigm Shift from 1969 to 2005.

The International Health Regulations (IHR 1969), replaced by IHR 2005 had been adopted by the World Health Assembly on 23 May 2005 and came into force on 15 June 2007. IHR 2005 are a legally binding agreement among World Health Organisation (WHO) member states and other states that have agreed to be bound by them. New revision was necessitated by concerns about increasing global health threats and the need to respond with more effective surveillance and control practices. The limitations of IHR 1969, which led to their revision, related to their narrow scope, their dependence on official country notifications, and their lack of a formal internationally coordinated mechanism to contain international disease spread. The IHR 2005, which is firmly based on practical experiences, has broaden the scope of IHR 1969 to cover existing, new and re-emerging diseases, including emergencies caused by non-infectious disease agents.

Lessons learned from international responses to severe acute respiratory syndrome (SARS)

In early February 2003, a previously unknown disease causing severe pneumonia was recognised. This disease which is now known as severe acute respiratory syndrome (SARS) is believed to have had its origins in the Guangdong Province of China, and was the cause of a multi-country epidemic resulting in significant morbidity and mortality. The World Health Organization (WHO) has been coordinating the international response to provide the epidemiological, laboratory, clinical and logistic requirements needed to contain this disease.A rapid spread of SARS around the world occurred at its onset, facilitated greatly by air travel. Between November 2002 and July 2003, a total of 8,094 cases and 774 cases were reported from 26 countries worldwide.WHO responded quickly to this multi-country outbreak and on 12 March released a "global alert" about SARS. This was followed by the first WHO travel advisory on 15 March. The Global Outbreak Alert and Response Network was activated, and international experts were brought together to implement enhanced global surveillance systems for SARS.The international community has learned a lot of lessons from the SARS outbreak. Particularly, rapid and transparent information sharing between countries is critical to prevent international spread of the disease. However, information exchange was less than optimal in the early phase of the outbreak.

Lessons Learned from International Responses to Severe Acute Respiratory Syndrome (SARS)

In early February 2003, a previously unknown disease causing severe pneumonia was recognised. This disease which is now known as severe acute respiratory syndrome (SARS) is believed to have had its origins in the Guangdong Province of China, and was the cause of a multi-country epidemic resulting in significant morbidity and mortality. The World Health Organization (WHO) has been coordinating the international response to provide the epidemiological, laboratory, clinical and logistic requirements needed to contain this disease. A rapid spread of SARS around the world occurred at its onset, facilitated greatly by air travel. Between November 2002 and July 2003, a total of 8,094 cases and 774 cases were reported from 26 countries worldwide. WHO responded quickly to this multi-country outbreak and on 12 March released a “global alert” about SARS. This was followed by the first WHO travel advisory on 15 March. The Global Outbreak Alert and Response Network was activated, and international experts were brought together to implement enhanced global surveillance systems for SARS. The international community has learned a lot of lessons from the SARS outbreak. Particularly, rapid and transparent information sharing between countries is critical to prevent international spread of the disease. However, information exchange was less than optimal in the early phase of the outbreak.