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Critical appraisal of the Coronavirus preparedness among countries using the global health security index

Article type: Research Introduction: This critical study was aimed to investigate the utility of the Global Health Security Index in predicting the current COVID-19 responses. Material and Methods: Number of infected patients, deaths, incidence and the death rate per 100,000 populations related to 55 countries per week for 26 weeks were extracted. The relationship of GHSI scores and country preparedness for the pandemic was compared. Results: According to the GHSI, the incidence rate in most prepared countries was higher than the incidence rate in the more prepared countries, and which was higher than the incidence rate in the least prepared countries. However, Prevention, Detection and reporting, Rapid response, Health system, compliance with international norms and Risk environment, as well as Overall, the incidence and death rate per 100,000 people have not been like this. Conclusion: Due to mismatch between the GHSI score and fact about COVID-19 incidence, it seems necessary to investigate the factors involved in this discrepancy. Article History: Received: 2022-05-28 Accepted: 2022-09-11 Published: 2022-09-21 * Corresponding author: Hamed Tabesh Department of Medical Informatics, Mashhad University of Medical Sciences, Mashhad, Iran Email: Tabeshh@mums.ac.Ir


INTRODUCTION
The novel coronavirus 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2) is an emerging disease that has become a global health concern as it spreads rapidly around the world [1]. The COVID-19 pandemic so far has affected many countries. The outbreak was first reported in Wuhan, China in late 2019 [2] and was declared a pandemic by the world health organization (WHO) [3]. As of February 13, 2021, there were nearly 108,764,866 confirmed cases of coronavirus and 2,395,030 deaths globally [4]. The COVID-19 crisis has dramatic consequences in many aspects such as economic, social, and behavioral disruptions. The pandemic has certainly led to economic decline across the globe and has affected trade, investment, and employment [5,6]. There is a rise in unemployment, pay cuts, business closures and other factors impacting the overall livelihood. Worldwide, several healthcare systems and policy makers are confronted with shortages of medical supplies and human resources necessary for fighting the disease. Limited supply of essential resources has resulted in endangering the lives of many patients [7]. The sudden outbreak of COVID-19 has therefore, disrupted the normal functioning of all aspects of life. Considering there is no specific treatment for the disease yet, all countries are focused on control and prevention strategies [8]. A few recommended intervention strategies for prevention and control focused on maintaining social distancing, hand washing, wearing masks, closing schools, universities and other public places, and staying at home [9][10][11]. In general, a country's preparedness, management and response to epidemic disease outbreaks are very important. Several indicators such as the Joint External Evaluation (JEE) [12], Epidemic Preparedness Index (EPI) [13] and Global Health Security Index (GHSI) have been developed for this purpose [14].
The GHSI is the first comprehensive assessment of a country's preparedness for epidemic outbreaks such as COVID-19. The GHSI was developed by the Nuclear Threat Initiative, Johns Hopkins Centre for Health Security, and the Economist Intelligence Unit in 2014 to improve International Health Regulations adoption and response to epidemic disease and readiness to confront it [14].
In 2019, a panel of 21 experts from 13 countries developed the comprehensive index to assess a country's ability to prevent and mitigate outbreaks. The index ranges from 0 to 100 and was used to score the global health security capabilities in 195 countries [14]. Comparison of a country's performance is based on three levels-'most prepared' (score > 66.7), 'more prepared' (33. 4-66.6) and 'least prepared' (0-33.3); six categoriesprevention, detection and reporting, rapid response, health system, compliance with international norms, and risk environment; 34 indicators and 85 subindicators [14]. A higher GHSI indicates better preparedness. The average overall GHSI score was reported as 40.2 out of a possible 100. While highincome countries report an average score of 51.9, the index shows that collectively, international preparedness for epidemics and pandemics remain very weak [14].
Since the global spread of COVID-19 in 2020, countries will be looking for measures to identify gaps, mitigate risks and direct efforts towards preventing future outbreaks [14]. The GHSI is one of the most comprehensive tools available that can be used to evaluate a country's preparedness in handling the novel COVID-19 pandemic [14]. Conducting a conformity assessment between the GHSI scores and a country's response strategy to the novel COVID-19 pandemic can be helpful in effective management, prevention, and risk mitigation of the pandemic. Therefore, the objective of this study was to evaluate the utility of the GHSI in predicting the current COVID-19 pandemic responses of countries categorized in three levels as 'most prepared', 'more prepared' and 'least prepared'.

Study Population and Data Source
For this cross-sectional study we included participating countries from the 2019 GHSI list [14] that rank and score countries at three levels of preparedness, i.e., 'most prepared, 'more prepared', and 'least prepared'. The first four countries based on their rank in each of the three levels, for all six categories, i.e., prevention, detection and reporting, rapid response, health system, compliance with international norms, and risk environment were included. We systematically selected countries in this manner to ensure representation from all three levels of preparedness. If data was unavailable for a given country, the next country in the rank order was included. As a result, a sample of 54 unique countries was identified for analysis (Table 1). This sample size was deemed appropriate for country wide comparisons (~25% of total 195 countries). We extracted data for positive cases and deaths due to COVID-19 for a period of 26 weeks after the 100 th case was reported for each of the included country from https://www.worldometers.info/coronavirus/.

Statistical Analysis
Our variables of interest were the weekly standardized number of COVID-19 cases and deaths. We calculated the incidence and mortality rates per 100,000 populations for each country using the formula: Mij =Frequency of case in (j) week/Country (i) population*100,000.
The incidence and mortality average per 100,000 populations for 26 weeks was calculated as follows: Where, K is the number of countries = 13 Based on the data prepared in the first phase, graphs of mortality and incidence rates per 100,000 populations of each country were drawn in different dimensions and different levels of GHSI. Based on this, 4 * 6 * 3 diagrams were drawn in the form of 18 figures.

RESULTS
The countries selected for examining in this study, shown in Table 1, were at different dimensions and different levels of GHSI. Firstly, countries were divided into three levels based on the list provided in the document [14]: 'Most Prepared', 'More Prepared', and 'Least Prepared'. Next, the first four countries were considered, then the incidence and mortality rate of 26 weeks after seeing the 100th patient was extracted from www.worldmeters.info/coronavirus. In the absence of data for a country on the site, other countries in the next rank were replaced. The extracted data (mortality and incidence rates) for each country were listed in Table 1. Based on the data in Table 1, as well as the population of each country (which is extracted from the same site and can be seen in Table 2), the incidence of Coronavirus per 100,000 population of selected countries at different levels and different dimensions of GHSI were drawn in Fig 1 to 7. The incidence of Coronavirus per 100,000 populations in selected countries at different levels, different dimensions of GHSI, and as a whole was plotted in Fig 1 and 2.
The important thing about Figures is that the horizontal axis is represents related to the weeks and the vertical axis is related to the incidence rate per hundred thousand populations.
Part A, section 1 in Fig 1 shows that among the four countries which were ranked the "most prepared" by the GHSI to prevent epidemic crises, the United States had the highest incidence of Coronavirus disease per 100,000 populations in the 26 weeks after seeing the 100th case patient in each country. In the following, Thailand and the Netherlands were not much different and had a lower incidence. Part B shows that among the four countries that according to GHSI are "more prepared" to prevent epidemic crises, within 26 weeks after seeing the 100th case patient in each country, Germany, Ireland, and Belgium had almost the same experience in Coronavirus incidence rates per 100,000 populations. Part C shows that Qatar has experienced the highest incidence than other "least prepared" countries.
In Part A, section 2 in Fig 1,  weeks after seeing the 100th case patient, the incidence rate in the United States was higher than other countries at the most prepared level, and the incidence rate in other countries was almost the same, regardless of the ninth week peak in Canada. In Part B, among four countries were "more prepared" for detection and reporting, according to the GHSI, Singapore and Kyrgyzstan had peaked at weeks 9 and 16. However, Philippines and Zimbabwe have not seen a significant increase. Part C shows that among the four countries that according to GHSI were the "least prepared" in terms of detection and reporting, within 26 weeks after seeing the 100th case sick person, Qatar has the highest rate of Coronavirus per 100,000 populations. While they were not much different among other countries, also they have experienced a lower incidence.
Part A, section 3 in Fig 1 shows that among the four countries with the highest GHSI in terms of rapid response, the United States had the highest incidence of Coronavirus per 100,000 populations, in the 26 weeks following the 100th case patient. While there were not any different differences among other countries. Also they have experienced a lower incidence. Part B in Fig 1 shows that among the four countries that have been "more prepared" according to the GHSI, France has had a higher incidence than other countries in the 26 weeks since the 100th case patient was observed in the country. In Part C, among the four countries that according to GHSI had the "least preparedness" in terms of rapid response, during the 26 weeks after seeing the 100th case patient, Cabo Verde Kaburdeh and Saudi Arabia, had an oscillating trend. Croatia and LesothoLesto have experienced fewer outbreaks, with the explanation that Croatia has peaked in week 25.
Part A, section 4 in Fig 1 shows that among the four countries that have been "most prepared" in terms of Health System according to GHSI, the United States had the highest incidence in 26 weeks, Canada had the peak in week 9, while Netherlands and Thailand have experienced the lowest incidence. Part B shows that among the four countries that were "more prepared" according to the GHSI in terms of Health System, four countries had the same incidence within 26 weeks after seeing the 100th case patient. Part C shows that South Africa had the highest incidence among the four countries that had a low little GHSI preparedness in terms of Health System within 26 weeks of seeing the 100th case patient.
Part A, section 5 in Fig 1 shows that among the four countries that were the "most prepared" according to GHSI in terms of Compliance with International Norms, the United States had the highest incidence and little a small difference was observed in other countries. Part B shows that among the four countries that were "more prepared" in terms of compliance with international norms according to the GHSI, Kyrgyzstan and Sweden had peaked in the same range, while Ethiopia and Uganda had not had a significant increase. In Part C, Qatar has a significant increase compared to other countries among the four countries that according to GHSI were "least prepared" in terms of Compliance with International Norms.
Part B, section 6 in Fig 1 shows that among the four countries that have been" most prepared" according to GHSI in terms of risk environment, Oman had the highest incidence, while they were not much different among other countries. Also, in Part C, Madagascar has a sudden peak among the four countries that were less prepared according to the GHSI in terms of risk environment, and while other countries have not experienced a significant increase. Part A in Fig 2 shows that among the four countries that were the "most prepared" according to the GHSI, United States had the highest incidence, and then other countries experienced the similar same incidence. In Part B, among the four countries that have been "more prepared" for prevention, Spain had a significantly high incidence of Coronavirus. In Part C, South Africa had a high incidence among the four countries that are were "less prepared" in general according to GHSI.  The death rate due to Coronavirus per 100,000 population of selected countries at different levels, different dimensions of GHSI, and also in general within 26 weeks after observing the 100th patient case was shown in Fig 3 and 4.
Part A, section 1 in Fig 3 shows that among the four countries which were the "most prepared" for GHSI outbreaks to prevent epidemic crises, the mortality rate was almost the same within 26 weeks of seeing the 100 th case patient. In Part C, among the four countries that according to the GHSI were "least prepared" to prevent epidemic crises, we have seen mortality with fluctuating rates in Namibia Nomina and Qatar, while the mortality rate in Ghana Qana and Niger was insignificant.
Part B, section 2 in Fig 2 shows that among the four countries that according to GHSI were "more prepared" in terms of Detection and Reporting, at 26 weeks after observing the 100th patient case, Kyrgyzstan had a sudden peak in death rate at 15th weeks, while other countries have not experienced much as many deaths. Also, in Part C, among the four countries that according to the GHSI were "least prepared" to prevent epidemic crises, Bolivia had the highest mortality rate. However, the other three countries had the lowest mortality rate.
Part B, section 3 in Fig 3 shows that among the four countries that were "more prepared" for the Rapid Response according to the GHSI, for during 26 weeks after seeing the 100th confirmed case patient, France had a sudden increase in mortality at week 6, while other three countries have not experienced much as many deaths. Also, in the Part C, among the four countries that according to GHSI are "less prepared" to prevent the occurrence of epidemic crises, all four countries had experienced fluctuated mortality trends.
Part B, section 4 in Fig 2 shows that among the four countries that were "more prepared" according to the GHSI in terms of Health System, France had a sudden increase in mortality at 6 weeks, during for 26 weeks after seeing the 100th confirmed case patient. However, the other three countries have had almost a similar the same experience.
In Part B, section 5 in Fig 3, we have seen two peaks in weeks 5 and 15 for Switzerland and Kyrguz among the four countries that have been "more prepared" in terms of Compliance with International nNorms according to GHSI. Section C shows that among the four countries that were "least prepared" according to GHSI in terms of Compliance with International Norms, within 26 weeks after seeing the 100th patient case, Andorra had two peaks of mortality rates in the second and the 15th weeks.
Part A, section 6 in Fig 3 shows that among the four countries that were "Most prepared" according to the GHSI in terms of Risk environment, Australia had the lowest mortality rate, in 26 weeks after the 100th patient case. Luxembourg and Switzerland have experienced more deaths in weeks 4 and 5. In Part B, among the four countries that were "more prepared" according to the GHSI in terms of Risk Environment, in the 26 weeks since after the 100th patient case was observed, Mauritius has had fewer deaths as compared to, while the other three countries that have higher and fluctuating mortality rates. Part C shows that among the four countries that, according to the GHSI, were "least prepared" in terms of Risk environment, Sudan has a higher mortality rate than the other three countries within 26 weeks of seeing the 100th sick person case.
Part A in Fig 4 shows that among the four countries, UK had the "most preparedness" in general, within 26 weeks of seeing the 100th confirmed case patient, all four countries had almost the same mortality. In Part B, Spain had the highest mortality rate among the four countries that have been "more prepared" according to the GHSI, within 26 weeks of seeing the 100th case person. Part C shows that among the four countries with the lowest overall GHSI preparedness, Estonia had a peak mortality rate at week 5, within 26 weeks of after seeing the 100th patient confirmed case, and other countries have experienced a similar the same mortality rate. To evaluate the performance of GHSI leveling in the Coronavirus crisis, the average death rate per 100,000 populations was calculated for selected countries at different levels in each dimension. Tables  2 and 3 shows the average incidence, mortality, and extent of change per 100,000 populations in countries at a certain level in different GHSI dimensions over 26 weeks. Based on the average observed for the countries in each level, the observed ranking was also reported.
There was no correlation between the incidence rate per 100,000 populations in selected countries and different levels of GHSI in terms of different dimensions. According to the GHSI, it was expected that the incidence rate in the Most-prepared countries would be higher than the incidence rate in the More-prepared countries, and higher than the incidence rate in the Least-prepared countries.
According to the results in the prevention dimension, in Most-prepared countries, a lower incidence has been observed in infection rate per 100,000 people than in More-prepared and Least-prepared countries.
In terms of Detection and Reporting, in Moreprepared countries, less incidence was observed in 100,000 people than in Most-prepared countries. In terms of Rapid Response and Health System, Moreprepared countries had lower incidence than Mostprepared countries and Least-prepared countries had lower incidence than Most-prepared countries.
In terms of Compliance with International nNorms, More-prepared countries have less occurrence than Most-prepared countries. In terms of Risk environment, Least-prepared countries have less occurrence than More-prepared, and More-prepared have less occurrence than Most-prepared. In terms of Overall, More-prepared and Least-prepared countries have experienced less incidence than Mostprepared countries.

DISCUSSION
According to the results of the mortality survey, in terms of prevention, the Least-prepared countries had a lower mortality rate than the More-prepared and Most-prepared. In terms of the Detection and Reporting dimension, in More-prepared countries, the mortality rate was lower than in the Leastprepared and Most-prepared countries. In terms of rapid response, the Least-prepared countries had a lower mortality rate than the More-prepared countries and the More-prepared countries had lower mortality than the Most-prepared countries. In terms of Health System, the Least-prepared countries had a lower mortality rate than the More-prepared and the Most-prepared countries. In terms of Compliance with International nNorms, Moreprepared countries had fewer deaths than the Most-prepared and Least-prepared ones. In terms of Risk environment, the Least-prepared countries had lower deaths than the Most-prepared and the Moreprepared countries. In general, the Least-prepared and the More-prepared countries had a lower mortality rate than the Most-prepared countries.
With regard to content validity, we found that the WHO situation reports on the COVID-19 pandemic up to 31 July 2020 indicated that a number of countries with high GHSI scores have had large numbers of cases and deaths from COVID-19,36 while some others with modest GHSI scores appear to have successfully contained or suppressed pandemic spread.

CONCLUSION
The number of infections with coronavirus is increasing. The spread of the coronavirus remains a cause for concern in all of across the worlds. The sudden outbreak of this disease has created unpredictable conditions all over the world. It has crippled most industries and the economy has also affected all aspects of people's lives. Preparing against epidemic diseases, managing and responding to them at all times has been essential and remains challenging. An index called GHSI has been developed and has expressed the degree of preparedness of different countries in confront of epidemic diseases with a score. This index had considered a high score for the readiness of developed countries, which may be impossible in reality. Therefore, in the present critical study, we examine the relationship between the GHSI score and what is happening in the case of the coronavirus pandemic. Our results suggest that the GHSI is a somewhat valid measure of health security, but remains incomplete. The results of this study can be used to identify the most successful countries in controlling covidCOVID-19 according to their capabilities. The indexes provided by reputable institutions and universities may not necessarily correspond to reality, and the performance of countries may differ from the indicators. With the knowledge gained of earned from the current study, it is possible to change the procedure in order to apply more control measures and apply different interventions in order to prevent the further spread of the virus. The number of new cases of the disease in different countries each week can vary depending on the population, facilities, disease management, and many other factors. The results of this study can be effective in the management of CovidCOVID-19 and can be useful for modifying current indexes or developing new indexes in the future.