Thousands of turkeys killed by highly pathogenic avian influenza. ©2016 Gary Flory

Combating Pandemic Threats – Global Health Security Agenda

On 6-8 November 2018, global health leaders from around the globe met in Bali, Indonesia, for the 5th Global Health Security Agenda (GHSA) Ministerial Meeting. At the meeting, the GHSA launched a five-year plan to address health security issues called GHSA 2024 and U.S. Health and Human Services Deputy Secretary Eric Hargan reaffirmed U.S. support for the GHSA with a pledge of $150 million. This global efforts and this commitment of resources to strengthen the capacity to prevent, detect, and respond to infectious diseases are clearly needed.

The 1918 Spanish Flu sickened 500 million people and killed nearly 50 million. More recently, the 2014-2016 Ebola crisis killed more than 11,000 people and some reports suggest that the swine-flu pandemic of 2009 may have killed as many as 203,000 people. With global travel and trade increasing and population growth resulting in more interactions between humans, wildlife, and livestock, infectious disease threats are increasing rapidly. Whether naturally occurring or intentionally introduced, communities must prepare for the next infectious disease outbreak.

Fighting Back With the Global Health Security Agenda

To combat these ever-increasing threats, the Global Health Security Agenda (GHSA) was launched in February 2014 to strengthen both global capacity and each nation’s capacity to prevent, detect, and respond to infectious diseases threats. Since then, the GHSA has expanded to include over 60 countries as depicted in Table 1. The initiative brings together nations, international organizations, and nongovernmental stakeholders to make measurable strides to address public health emergencies. It supports collaboration not just among countries but also between public health, agriculture, security, and environmental sectors. The GHSA is one way to operationalize the One Health concept – the idea that the health of humans, animals, and the environment is inextricably connected.

Table1: Global Health Security Agenda Member Countries*


FranceMaliSouth Africa
Burkina FasoGuinea-BissauNorwayThailand
ColombiaJapanRepublic of the CongoUnited Arab Emirates
Côte d’IvoireJordanRepublic of KoreaUnited Kingdom
Repulic of Congo 
KenyaSaudi ArabiaUnited States
EthiopiaLiberiaSierra LeoneYemen
* as of February 2018

As described on the GHSA website, the vision of the initiative is a world safe and secure from global health threats posed by infectious diseases whether naturally occurring, deliberate, or accidental. The pathway to this vision is organized around three main objectives: to prevent, detect, and respond to disease threats. Within these three broad objectives are 11 specific targets critical to the goals of the GHSA. These targets are identified as action packages and were developed by participating countries during two commitment development meetings in 2014. Each action package includes a five-year target, an indicator to measure progress, desired outcomes, country commitments, and long-term actions.

Prevent Avoidable Catastrophes

The worst catastrophes are those that could have been prevented. This is true in business and engineering and many other fields, but is often overlooked in efforts to prevent disease outbreaks. Action packages focusing on preventing avoidable disease threats include efforts to address antimicrobial resistancezoonotic diseasesbiosafety and biosecurity, and immunization.

Of the 1,415 pathogens known to infect humans, 61% of those disease organisms are considered zoonotic. Zoonotic diseases are those that can be transmitted from animals to humans. Common examples of zoonotic disease include avian influenza, rabies, Ebola, and anthrax. To reduce the emergence and spread of infections of zoonotic diseases, the first step is to identify the diseases not only in humans but also in wildlife and livestock. With enhanced animal disease surveillance, it may be possible to identify and respond to disease outbreaks before they pose a significant risk to human populations.


Thousands of turkeys killed by highly pathogenic avian influenza. ©2016 Gary Flory

Once identified in an animal population, responders can implement a series of measures to prevent the spread of the disease within the animal population and minimize human exposure. A comprehensive animal disease response plan may include a variety of strategies including quarantine in infected animals, vaccination, movement control, enhanced surveillance, stamping out, carcass disposal, and facility disinfection.

The biosafety and biosecurity action package focuses on the storage and handling of dangerous pathogens. This is important to avoid not only the theft and intentional misuse of pathogens, but also the accidental release and spread of diseases. Implementing effective biosecurity programs requires extensive training wherever these organisms exist.

In addition to robust biosecurity programs and zoonotic disease response strategies, there are preventative action packages designed to address microbial resistance and to prevent death and illness through the implementation of a robust vaccination program.

Decontamination procedures following a zoonotic animal disease. ©2016 Gary Flory

Detecting Threats Early

The second broad objective of the GHSA is to detect disease threats early. This objective includes four action packages: national laboratory systemsreal-time surveillancereporting, and workforce development. Together these action packages save lives by improving the ability to quickly identify disease outbreaks, share disease detection information with public health officials, and train staff to detect and investigate disease outbreaks.

Responding to Disease Threats

The third and final objective is to enhance response to confirmed disease threats. During any disaster, the difference between success and failure often lies in the effectiveness of the communication. Emergency operations centers with well-trained staff are able to efficiently monitor and respond to disasters by deploying resources where they can do the most good. The last two action packages – linking public health with law and multisectoral rapid response and medical countermeasures and personnel deployment – support the deployment of trained, cross-sector responders from the emergency operations center.

Mobile field hospital in Malaysia for responding to infectious disease threats. ©2013 Gary Flory

Measuring Capabilities

At the heart of the GHSA is the country assessment conducted by a standardized joint external evaluation (JEE) process. The JEE process measures a country’s current capabilities and progress toward building capacity to prevent, detect, and respond to infectious disease threats. The assessment also highlights gaps in capabilities to inform the development of implementation plans.

The JEE is a two-stage process that includes a self-evaluation conducted by in-country representatives from many sectors including ministries of health, agriculture, wildlife, environment, and defense. Together these stakeholders collect the necessary information to evaluate the country’s capabilities to prevent, detect, and respond to infectious diseases.

An external evaluation follows the self-evaluation phase. This evaluation is conducted by a JEE team made up of experts from member countries, the World Health Organization, the World Organization for Animal Health, the Food and Agricultural Organization, and a variety of other international organizations. Together the JEE team and experts from the host country assign scores to the country’s capabilities in the 19 areas covered in the JEE tool. In addition to the scoring each area, the team identifies strengths, best practices, areas of improvement, challenges, and priority actions. The information collected in the process is published in a Joint External Evaluation Mission Report containing approximately 60 priority actions identified in the external evaluation process.

Filling the Gaps

With the gaps and priority actions identified through the JEE process, countries are able to develop a five-year action plan to address gaps in capabilities. These plans, or roadmaps, include annual milestones and provide a way to prioritize and match action items to available resources. They also provide potential funders a way to identify projects that match the mission of their organizations.

Since it was launched in 2014, membership in the Global Health Security Agenda has risen steadily from 40 participating countries to over 60. Each year, more joint external evaluations are conducted, roadmaps are developed, and priority action items are addressed to increase the global capacity to prevent, detect, and respond to infectious diseases threats.

There is no doubt that funding for the Global Health Security Agenda will be cyclical and that significant funding cuts by donor partners will negatively impact the ability to implement priority projects and improve global response capacity. Regardless of funding, a global, focused, and strategic approach will be more effective than the independent efforts of individual countries to prevent, detect, and respond to infectious diseases threats.

This article was modified from one first published in CBNW (Chemical, Biological & Nuclear Warfare) journal, May 2018.

Gary Flory

Gary Flory is the agricultural program manager for the Virginia Department of Environmental Quality and an independent global consultant, trainer, and speaker in the areas of emerging infectious diseases, counter-agroterrorism, One-Health, and animal carcass disposal. He has conducted training, given presentations, and deployed on animal disease outbreaks to a number of countries including the Dominican Republic, Vietnam, Tunisia, Korea, Cambodia, Laos, Malaysia, and Azerbaijan. He supports a variety of organizations including the United States Department of Agriculture, the Food and Agriculture Organization of the United Nations (FAO), and the World Organization for Animal Health (OIE). He currently serves on FAO’s African Swine Fever Global Pool of Expertise. In addition to numerous other articles, reports, and guidance documents, he was a lead author of FAO’s recently released, “Carcass management guidelines – Effective disposal of animal carcasses and contaminated materials on small to medium-sized farms” and USDA’s “Catastrophic Livestock Composting Protocol and Mortality Composting Protocol for Avian Influenza Infected Flocks.” He can be contacted at



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