National plans and overall preparedness and capacity

The overall perception of our interviewees in all five participating countries was that the level of preparedness for MERS and poliomyelitis respectively was high. Clear legal frameworks exist which indicate specific roles and responsibilities, and the key actors in each country appeared to be well informed about these. Networks with appropriate resources and diagnostic capacity for the two diseases also exist in all the countries. However, although these are well-integrated and properly functioning formal systems, informal personal networks and contacts both within the health sector and between the health and relevant non-health sectors were widely considered as being key to the effectiveness of process and practice in preparedness and response.

In countries where MERS preparedness was analysed, pandemic influenza preparedness plans exist in each of the UK, Greece, and Spain, and, as a respiratory infection, these were seen as being of at least some relevance to MERS (see https://ecdc.europa.eu/en/seasonal-influenza/preparedness/influenza-pandemic-preparedness-plans). However, while these plans are in the public domain and are therefore easily accessible, they have not been updated for several years, which points to potential gaps in preparedness. Operationally, we were informed that much knowledge and experience has been gained through various global public health events since the beginning of the century, such as Severe Acute Respiratory Syndrome (SARS, 2003), the influenza A(H1N1)pdm09 pandemic (2009), and Ebola (2014–2016); and many of the practices and lessons learned from these threats have been sufficiently generic to prepare frontline health workers and the relevant authorities for MERS. One of the major lessons learned from these events has been the necessity to develop systems for increasing health care capacity in the event of a pandemic or a major outbreak. We were informed that these systems include plans to utilise the private sector if the public sector is overwhelmed by, for example, MERS cases; and also the reorganisation of hospital ward structures such that an entire ward could be given over to patients with MERS, thereby minimising the danger of cross-infection between patients in different wards.

In relation to polio, all EU countries are obliged by the WHO’s Regional Certification Commission for Poliomyelitis Eradication (RCC) to ensure that they have poliomyelitis preparedness plans in place, including access to vaccine in case of an outbreak or plans on how to get some; and, through their obligatory annual reports to the RCC, Cyprus and Poland have both shown that they comply with this [23]. Overall poliomyelitis vaccination rates are high in both Cyprus and Poland (97 and 92%, respectively for the three doses, according to 2015 data [25]), but both countries nonetheless have relatively small but still significant numbers of refugees and populations that are hard to reach in vaccination campaigns (e.g. Roma people) and which are therefore vulnerable in case of a poliomyelitis virus outbreak. Under such circumstances it is important to have well-functioning surveillance systems in place in order to identify potential poliomyelitis cases. Acute Flaccid Paralysis (AFP) surveillance is regarded as the gold standard for detecting cases of poliomyelitis [26]; it involves finding and reporting children with AFP; transporting stool samples for analysis; isolating and identifying poliovirus in the laboratory; and mapping the virus to determine the origin of the virus strain. According to WHO guidelines, environmental surveillance can be justified in some specific situations in addition to AFP surveillance [27]. Environmental surveillance involves testing sewage or other environmental samples for the presence of poliovirus [28]. Both countries have AFP surveillance systems in place. At the time of the study, environmental surveillance systems have not been introduced, however, but the requisite technical and scientific capacity does exist, should a decision be taken in the future to bring them in.

The financial crisis and subsequent austerity measures that have affected many European countries since 2009 have had a significant adverse effect on preparedness and response capacity in some countries. We were informed of budget cuts that have adversely affected recruitment of new staff as well as opportunities for trainings and other exercises. However, we were informed that emergency funding is, or would be provided in the event of a public health emergency, either directly from governmental structures tasked with dealing with crises (i.e. civil protection or Prime Minister’s crisis centres), or, if such arrangements exist within the legal framework of a particular country, from the Ministry of Health.

Training and exercises

Training and exercises (including simulation exercises (SIMEX)) are recognised as key components of any efforts to sustain public health preparedness capacity, both through their ability to identify weaknesses in the systems and because they provide a basis for developing networks of professionals that could be called upon during a public health emergency [29]. Training and exercises can be conducted within a single country, ideally including both the health and all the relevant non-health-related sectors; or as part of a multi-country process involving neighbouring countries, including other EU Member States and/or non-EU neighbouring countries. Exercises could also provide an external impetus that demands a review of national plans, which may otherwise be seen as a low priority activity. Further, they provide an opportunity to retain staff capacities and institutional memories, including whatever lessons may have been learned from recent public health emergencies, as well as preparedness legacies from, for example, the Olympic Games (held in Greece in 2004, and the UK in 2012).

However, in at least one of the three countries we visited in relation to MERS, cuts in funding had been made for general preparedness and training activities, and national exercises had been cancelled. This significantly reduced the opportunities to enhance preparedness and response measures in the event of a serious public health threat to the country. In another country, the national preparedness plan called for exercises to ensure that business continuity arrangements are in place for the emergency services; and training for personnel whose work will oblige them to wear respirators. However, no details were given regarding how often or how extensive these trainings should be. It was suggested by our interviewees that executing table-top preparedness exercises may prove to be a less expensive, and therefore more feasible alternative than conducting full-scale simulation exercises. Where possible, these could be organised by national authorities, complemented as appropriate with input from international organisations.

The absence of poliomyelitis in Poland and Cyprus since 1984 and 1995, respectively [30] [31] has diminished practical, hands-on experience of dealing with the disease. It has also diminished the perceived imperative for poliomyelitis preparedness, and as such, there have been no poliomyelitis preparedness exercises conducted in either country in recent years. Since a rapid and effective initial response is essential for controlling a poliomyelitis outbreak [32], this could lead to delays and a compromised response if one was to occur. That said, some interviewees did recommend that support could be provided from, for example, ECDC for a simulation exercise or training, either at national or regional level and involving all the relevant sectors, with a particular focus on risk assessment and incident analysis, alongside a review and discussion of existing outbreak response guidelines for polio.

Risk communication

In each of the three countries we visited for MERS, media and communications experts in the respective national-level public health institutions are mandated to lead risk communication efforts for the public and for health workers during a respiratory disease epidemic or pandemic. These included the Hellenic Centre for Disease Control and Prevention in Greece, known by its Greek acronym as KEELPNO; Public Health England (PHE) in the UK; and the Coordination System for Health Alerts and Emergencies (SICAS) in Spain. One of these institutions had produced health-promoting materials that were relevant for a pandemic situation, and stored them on hidden webpages that could instantly be made public should the need arise. This is a useful model that could be applied elsewhere. Since a reportedly significant potential challenge during a pandemic concerned communicating with migrant, hard-to-reach, and non-native-speaking populations, it was pointed out that all relevant health-promoting materials should be translated into languages used by such people. Without this, they may not know how to take the necessary steps to protect themselves.

For polio, we were told that one of the most important challenges facing risk communicators who work with vaccine preventable diseases (VPDs), and specifically those who work with polio, is the fact that the public does not feel especially at risk from these diseases. With Cyprus and Poland having been polio-free for over 20 and 30 years, respectively, memories of the disease have largely faded and a majority of people are simply unaware of its potential severity. Thus there is reduced public acceptance of vaccination alongside an impression that the benefits of some vaccines may, within the current epidemiological context, only marginally outweigh their potential risks [33]. This, in combination with the fact that there could be issues with trust in some public authorities in some of the countries visited means that providing vaccine-promoting information that is trusted, believed, and acted upon requires a carefully developed strategy. Solutions suggested to us included (i) the public health authorities making systematic efforts to understand vaccine hesitancy where it exists, and responding proactively to people’s concerns using appropriate information that is already available from, for example, ECDC, WHO-Euro, and the Global Poliomyelitis Eradication Initiative; (ii) conducting trainings about vaccination for journalists, who might need to be better informed about the topic so that they do not inadvertently perpetuate myths and misperceptions about vaccination; and (iii) enhanced use of social media by the public health authorities.

An important finding from several of the countries we visited was that evaluation of the risk communication strategies operated by the public health authorities is often limited or non-existent. Thus the effectiveness of the strategies is unknown, as is the extent to which the messages could be misunderstood or misinterpreted.

From national policy to local level implementation

The relationship between the national and local levels is critical for ensuring continuity between policy and implementation, but in each of the three countries that we visited for MERS, challenges of different sorts were identified regarding the implementation of national policy at local level. These challenges arose either as a result of reportedly insufficient financial or human resources at local level, or because of particular structures or policy divisions between national, regional and local level. For example, while the decentralisation in one of the three countries was seen as a strength – as the local structures themselves developed the operational plans and as such these were ‘owned’ by the people who would implement them – we were also told that local authorities in that same country had differing financial capacity to implement activities above the nationally required minimum level, which could result in sub-optimal coordination of the national pandemic response, with different kinds and quality of activities in different regions.

Countries may also experience significant shortages of qualified personnel in some peripheral areas, with the result that the preparedness and response infrastructure in those places could potentially be sub-optimal. However, it was suggested that at the local level there may be areas with better inter-sectoral collaboration and coordination than many major urban centres, simply because people in the different sectors often know each other personally. In that sense, the limitations in one issue may be offset to some extent by the advantages in another.

In the case of poliomyelitis preparedness, both the countries that we visited appeared to have structures in place to ensure a coordinated and effective flow between national policy and local level implementation. As with many small countries, the Cypriot system includes some minor local level administrative functions, but since the country is so small, a large proportion of the national level administrative, legislative and organizational work is effectively also local. Operationally, this results in a system that does not give much room for decision making power at the local level, but it also means that policies and directives tend to be easily followed and implemented.

Poland, as a much larger country, operates on a largely decentralized basis. District level authorities have authority to enforce public health regulations, including quarantine if necessary; but the Ministry of Health in Warsaw provides guidelines for the lower administrative levels in order to ensure uniformity in planning and implementation. We were not informed of any significant weaknesses in this system.

Interoperability between the health and non-health sectors

One of the most important non-health-related sectors of relevance for MERS is, we were told, air travel. If MERS spread widely in a country, then Civil Protection agencies would be engaged, as would Border Control. In addition, working with journalists would be key to ensuring an effective response (as suggested under Risk Communication above). Collectively, these sectors represent a wide array of different actors, and ensuring interoperability between them and the health sector could represent a challenge. For example, interoperability with Border Control was reportedly poor in one of the countries we visited, with personnel said to be ill-trained regarding what to do if presented with someone presenting with respiratory distress.

By contrast, those sectors that have a clear financial incentive for controlling infectious diseases – including agriculture/animal health, tourism, and air travel – were seen as more likely to have in place public health preparedness and response plans that were interoperable with those of the health sector. Within the agricultural sector, for example, while there are very few camels in Europe, recent evidence points to the possibility that pigs are susceptible to the MERS virus [34]. The historically strong collaboration between the animal and human health sectors that exists in many countries provides a good basis for addressing the potential risks arising from this finding. Such collaboration can be seen within the context of the ‘One Health’ approach, which “recognizes that the health of humans, animals and ecosystems are interconnected, [and which] involves applying a coordinated, collaborative, multidisciplinary and cross-sectoral approach to address potential or existing risks that originate at the animal-human-ecosystems interface” [35].

Safety is of course also a primary concern for airlines, as their very survival depends on ensuring safe travel. Consequently, systematic thinking about safety has been fully integrated into all aspects of this sector. At one airport we visited, we were told of a generic pandemic preparedness plan, which includes updated lists of key contacts for all the key institutions involved (including the national public health agency, the ambulance service, and major hospitals), and which lists clear standard operating procedures for different eventualities. If an aircraft arrived with a passenger on board who appeared to be carrying a serious infectious disease, for example, air traffic controllers would be obliged to obtain as much information as possible from the pilot in advance of their arrival, and this would be forwarded to the airport authorities who would then contact the national public health agency. Once landed, the aircraft must follow clear rules about where it is to be parked, and how the disembarking passengers are to be processed.

With regard to polio, we were told that the relevant sectors in both countries included Border Control and the Interior Ministry for the border regions, and, more widely, those responsible for managing migration and refugees. The formal procedures for inter-sectoral collaboration are reportedly not always as clearly delineated as they are for the sector-specific work, in part due to what was described as the ‘vertical modes of communication’ in the respective sectors. Overall, the success of inter-sectoral collaboration in poliomyelitis preparedness and response relies more on personal contacts between the key actors than on formal protocols, at least in part because there have been no cases for many years, and therefore familiarity with these protocols is limited. A local level example in one country was described to us as having very well organized inter-sectoral collaboration on poliomyelitis preparedness, involving the health authorities, the border guards, and the Ministry of the Interior, but this was because the key actors in this region know each another personally, and they meet through their work on a regular basis. However, effective and sustainable inter-sectoral collaboration on this basis is vulnerable to individual personnel moving from one official position to another, or otherwise being unavailable in a crisis situation.

Cross-border collaboration

We found few significant disease-specific issues in relation to cross-border collaboration. Rather, the nature and extent of cross-border collaboration in addressing health threats appears to be determined primarily by the larger political context, as well as by the formal and informal relationships that may have developed between individuals and institutions on both sides of the border or borders in question.

For example, our findings suggest that a key determining factor relating to cross-border collaboration is whether or not the neighbour in question is a fellow member of the EU. As a general rule, collaboration and information exchange is greatly facilitated if it takes place between two EU Member States as opposed to between an EU Member State and a non-EU Member State. For example, the Early Warning and Response System (EWRS) was cited by interviewees in several countries as an invaluable instrument for keeping abreast of infectious disease developments in fellow-EU countries. Operated by ECDC, EWRS is an internet-based system for sharing information about health alerts between EU Member States. It includes an option for sending a copy of any message to WHO if the information might be of wider concern, for example in the context of the International Health Regulations. EWRS does not operate outside the EU.

In one country that we visited with a non-EU Member State neighbour, two distinct perspectives of cross-border relations emerged in the interviews: the national level perspective, and the local level perspective. At national level, the flow of health information between the two capital cities was reportedly very limited, in spite of friendly relations between the countries, with most information about the other country reaching our hosts via WHO and ECDC. This was due to quite different organisational cultures between the two countries, which complicated communications. Consequently, the International Health Regulations provided the only real means for our hosts to learn about events in the other country.

At local level, by contrast, there was a very good exchange of information between the respective border control authorities, based on a longstanding bilateral legal agreement. Each border post between the two countries had personnel whose jobs specifically included communicating with their counterparts across the border. Further, border guard commanders in both countries were obliged to immediately notify their counterparts across the border in the event of any sudden and unexpected illness or disease that was identified in the area under their jurisdiction. However, much of this information stayed and was acted upon at the local level, and – because it was operational as opposed to strategic – it was not sent to national level.

In spite of the stated advantages of working with fellow EU Member States, one challenge was mentioned that arises from the EU’s Schengen Agreement. At least up until the current refugee crisis, there has been free movement between all signatory countries, with no form of border control. This means that once people have entered into the Schengen Area – even if they have originated from a high-risk country for a particular infectious disease – there is no realistic way of systematically following up on their health status or ensuring that they receive health care as necessary. As MERS cases at early stages and poliomyelitis infections are usually asymptomatic, enhanced epidemiological surveillance and early detection therefore remain the best preventive measures. For poliomyelitis, WHO recommendations for travellers to and from countries where the virus is circulating to be vaccinated should be followed [36].

Participation in European and other international disease surveillance networks and associated research projects was recognised as playing an important role in maintaining high levels of cross-border preparedness. Similarly, simulation exercises involving several countries were described to us as being invaluable opportunities for identifying weaknesses in preparedness systems, and for creating the basis for strong, cross-border professional networks that could prove critical in tackling cross-border health threats. The EpiSouth project was cited as an example of this [37], which included both EU and non-EU Member States from the entire Mediterranean region. Such exercises are expensive, however, and EU support for more such multi-country simulation exercises, possibly also including non-EU countries, was suggested as a potentially good investment.

Study strengths and weaknesses

Some reflections on our methodological approach are due here. Perhaps the major advantage of our overall strategy – the use of foreign, or otherwise external social scientists to conduct open-ended interviews with in-country experts – was that it provided the opportunity for the latter to reflect on their work in a way that can offer a fresh perspective on what may often seem self-evident to them as ‘insiders’ [51].

Further, the multi-sectoral perspective that we took provided us with a much wider lens through which to view the different countries’ preparedness activities and capacities than would have been gained had we focused only on the health sector. From the participating countries’ points of view, our meetings with stakeholders from non-health-related sectors brought people out of their sectoral ‘silos’, and, in this sense, the research process itself contributed to awareness raising about public health preparedness, and to facilitating contacts between the different stakeholders and sectors.

In spite of these clear advantages, there were also practical challenges inherent in our methodology, not least of which were the time and effort required by the national counterparts to organise the interviews and the schedules for our visits. Language issues also presented challenges: all the interviews in Spain were conducted by native Spanish speakers, but not all interviewees in Poland, Cyprus or Greece were comfortable or able to communicate effectively in English, which meant that on a few occasions we had to bring in professional translators. This had cost implications, and, although the translators were invariably excellent, some nuances may have been lost. In addition, the research team was not able to understand all the documentation sent to us by the ECDC NFPs in these countries, which meant we had to use translation software. Again, although this facilitated our understanding the main points, some of the finer details may have been lost.

Finally, this was an exploratory study that covered a broad range of topics, based on a limited number of key informants per country. A number of areas were identified that would benefit from more detailed investigation in future. For example, we did not review the participating countries’ health systems structures or organisations in relation to their preparedness and response capacity, even if these are clearly important for ensuring good overall coordination at regional and national level. In addition, we did not manage to gather rich material on business continuity, risk assessment, or on the interoperability of plans between different sectors in the event of a public health emergency. We believe that our overall methodological approach could be used as the basis for designing a more comprehensive study, including on these specific topics, aimed at further improving our understanding of preparedness planning and implementation processes.