Integrated Management Systems (IMS) to Support and Sustain Quality One Health Services: International Lessons from the COVID-19 Pandemic by the IMIA Primary Care Working Group

Summary

Objectives: One Health considers human, animal and environment health as a continuum. The COVID-19 pandemic started with the leap of a virus from animals to humans. Integrated management systems (IMS) should provide a coherent management framework, to meet reporting requirements and support care delivery. We report IMS deployment during, and retention post the COVID-19 pandemic, and exemplar One Health use cases.

Methods: Six volunteer members of the International Medical Association’s (IMIA) Primary Care Working Group provided data about any IMS and One Health use to support the COVID-19 pandemic initiatives. We explored how IMS were: (1) Integrated with organisational strategy; (2) Utilised standardised processes, and (3) Met reporting requirements, including public health. Selected contributors provided Unified Modelling Language (UML) use case diagram for a One Health exemplar.

Results: There was weak evidence of synergy between IMS and health system strategy to the COVID-19 pandemic. However, there were rapid pragmatic responses to COVID-19, not citing IMS. All health systems implemented IMS to link COVID test results, vaccine uptake and outcomes, particularly mortality and to provide patients access to test results and vaccination certification. Neither proportion of gross domestic product alone, nor vaccine uptake determined outcome. One Health exemplars demonstrated that animal, human and environmental specialists could collaborate.

Conclusions: IMS use improved the pandemic response. However, IMS use was pragmatic rather than utilising an international standard, with some of their benefits lost post-pandemic. Health systems should incorporate IMS that enables One Health approaches as part of their post COVID-19 pandemic preparedness.

Keywords

Primary care - Electronic Health Records - Integrated Advanced Information Management Systems - One Health - Public Health

1 Introduction

One Health is defined by the World Health Organisation (WHO) as: “An integrated, unifying approach to balance and optimize the health of people, animals, and the environment. This is particularly important to prevent, predict, detect, and respond to global health threats such as the COVID-19 pandemic”[[1]]. The WHO, along with the European Centre for Disease Control (ECDC) and the Centre for Disease Control (CDC) in the USA also stress the importance of the work being cross sectoral. The key professions that need to be involved in One Health programmes are (1) health care including public health; (2) veterinarian; and (3) environmental scientists[[2], [3]]. One Health has been more fully defined as a transdisciplinary and trans-sectoral, and views animals especially wildlife, humans, and their shared settings or environment as linked and affected by the socioeconomic interest of humans and other external pressures such as changes in ecosystems and land use, intensification of agriculture, urbanisation, and international travel and trade [[4]].

ECDC states that after COVID-19, gastroenteritis due to campylobacter and salmonella are the next most common [[5]]. However, since that report, avian flu has emerged as another potential infection that requires a One Health approach. Whilst transmission of avian flu to humans is rare, there is a small chance of mutation to a pandemic strain. A recent editorial in the Medical Journal of Australia called for Australia to set up its own national centre for disease control, to deliver One Health; the paper stressed the need for integration [[6] [7] [8]].

Integrated management systems (IMS) should provide a coherent approach to management and be aligned with organisational strategy delivery [[9]]. They should include standardised management systems (e.g., International Standards Organisation (ISO) 9000 family) [[10], [11]], support working within legal and regulatory constraints, meet reporting requirements including those needed for public health, and support care delivery.

We carried out this study to report how IMS are being provided or maintained post COVID-19, from the perspective supporting One Health.

2 Methods

Volunteer members of the International Medical Association’s (IMIA) Primary Care Working Group completed a data collection form about the extent to which IMS exist within their health system to support One Health initiatives, with particular reference to COVID-19.

Data were specifically collected about IMS using a Donabedian approach of exploring structures, processes and outcomes [[12]], relevant to that country’s national response to the COVID-19 pandemic. The components were (1) Structural evaluation required an assessment of the extent to which, if at all, IMS was integrated with health system organisational strategy. This could be a pre-, during or post-pandemic strategy. (2) Process evaluation focussed on two areas: (2a) Use of standardised IMS processes to meet legal and regulatory constraints, ISO 9000 family being probably the best described and most used; and (2b) Meeting reporting requirements, particularly for public health. (3) Outcome evaluation was measured using the quintuple goals of health systems [[13]]. (3a) Patient experience – focussed on waiting list data or e-access information. (3b) Population health – we reported WHO life expectancy and any reports of rates of COVID mortality using ECDC or the international John Hopkins University COVID reports [[14]]. (3c) Cost control – we stated the proportion of Gross Domestic Product (GDP) spent on health care using Organisation for Economic Co-operation and Development (OECD) data [[15]], and an overview comment about vaccine uptake and testing. (3d) Maintaining the health care team – COVID service delivery comments. (3e) Equity – to report any disparities seen over the COVID-19 pandemic. We allowed 150-175 words per contributor across all sections and up to six references.

Additionally, contributors were requested to create a Unified Modelling Language (UML) use case diagram for a specific One Health example, from their health system. UML use case diagrams capture the interaction between the actors (people) and with the system, thereby capturing its functionality. The key actors we asked modellers to prioritise are the medical, veterinarian, and environmental actors providing health care, veterinary care and public health, and those involved in the environment and ecosystem.

3 Results

3.1 Overview

We report the results from the countries who provided data ([Tables 1] [2] [3]), then two exemplar UML use cases of One Health initiatives ([Figure 2] and [Figure 3]). We had six volunteer countries provide data from an informatics perspective ([Tables 1] [2] [3]). These were Australia ([Table 1]), Canada ([Table 1]), Chile ([Table 2]), England ([Table 2]), Norway ([Table 3]) and Peru ([Table 3]). We selected two use cases: Avian influenza (the most suggested) and flavivirus mosquito transmitted diseases (which includes yellow fever, dengue, Japanese encephalitis, and West Nile and Zika virus disease), and Hendra virus (HeV). We selected the latter to be the exemplar use case given its unusual transmission by fruit bats.

Table 1 Summary results table analysis of any formal IMS use – Australia and Canada.

Table 2 Summary results table analysis of any formal IMS use – Chile and England.

Table 3 Summary results table analysis of any formal IMS use – Norway & Peru.

3.2 Country Reports

Australian, Chilean, Norwegian and Peruvian data are national. Canadian data was from Ontario, as health services are run by province. Although England (56 million) is approximately 85% of the UK (65 million population), the devolved nations, Scotland, Wales, and Northern Ireland have their own health systems; though they did collaborate and conduct pooled analyses [[16]].

All countries or regions had some IMS and intention for this to be structurally integrated with their health system organisational strategy. Australia did not identify any formal IMS process, [Figure 1] shows the Ontario IMS version 2, which predates the pandemic. Chile adopted a pragmatic, but highly successful approach. Only Norway has comprehensively introduced such a process into practice. England used a data vault system to link together key data, this may be continued longer term [[17]]. Norway had the most integrated IMS system.

Fig. 1 This figure is obtained from Reference 19, which is available from: https://www.allianceon.org/sites/ default/files/documents/Information%20Manage­ment%20Strategy%20v2%202015-2020.docx.CIHI=Canadian Institute for Health Information; EMR=Electronic Medical Record; CIW=Canadian Index of Wellbeing; CHC=Community Health Centres.

With the exception of Norway there was little adoption of standard IMS processes, though most countries had standardisation of clinical data recording, improved data sharing and integrated working. These enabled largely effective reporting of disease, vaccination, and its effectiveness.

Patients were generally provided ready access to testing, vaccination, and vaccination certificates. Proportion of GDP invested in health care varied from 3.1% Peru, then 9.3% (Chile) through to 11.7% (Canada). There was only a small difference in life expectancy, Australia has the longest at 82.3 years, with Peru the shortest 77.23 years. Neither size of GDP spent on health care or life expectancy appeared to predict vaccine uptake or mortality, except for Peru, which had a low proportion of GDP spend on health care and a high mortality, though good vaccine coverage. Chile had the best uptake of vaccines, and one of the lowest COVID-19 mortality, with Norway and Canada also having very low mortality. There was recognition of, but national differences in the way that disparities were being addressed. However, all countries aspired to achieve the quintuple aims.

Pragmatism largely drove national or regional response to the pandemic, with these changes often stood down at the end of the pandemic period. However, the scope and functionality of disease surveillance systems were extended. There were only very limited moves towards a One Health response.

3.3 Unified Modelling Language (UML) One Health Use Cases

We present UML diagrams ([Figure 2] and [Figure 3]) which set out how human health, veterinarian, and environmental health agencies need to be involved in delivering a One Health programme. We present avian influenza and Hendra virus (HeV) infections in humans as exemplars.

Fig. 2 Use case illustrating the UK One Health response to Avian flu. The use case is presented as a UML diagram showing the interaction of the actors in human health, animal health and environmental health practitioners with this system.

Fig. 3 Use case illustrating the Australian One Health response to Hendra virus (HeV). The use case is presented as a UML diagram showing the interaction of the actors in human health, animal health and environmental health practitioners with this system.

3.3.1 Response to Avian Influenza in the UK

The UK implemented a One Health response to the avian influenza (AI) outbreak, led by the Department for Environment, Food and Rural Affairs (DEFRA). DEFRA is the lead government department for the management of AI incidents and outbreaks in poultry and wild birds and is the policy lead for outbreaks in England. The DEFRA minister is involved in strategic decision making during an incident, working closely with the UK Chief Veterinary Officer (UK CVO) and senior officials. DEFRA may chair Cabinet Office Briefing Room (COBR) meetings and provide briefing to the Environment, Food and Rural Affairs (EFRA) select committee to ensure that strategic advice is translated into practical instructions to those carrying out the operational response ([Figure 2]) [[62]].

DEFRA leads on the management of AI incidents and outbreaks in poultry and wild birds, with Health Protection Teams (HPTs) responsible for leading the local public health response to these incidents, working in close collaboration with the Animal and Plant Health Agency (APHA) [[63]]. The health response is delivered jointly with the local authority (LA), local NHS and with support from UKHSA colleagues regionally and nationally [[64]].

AI incidents requiring follow up of exposed humans are led locally by the HPT, unless escalated to an enhanced national response as defined in the National Incident and Emergency Response Plan [[65]].

3.3.2 Hendra Virus (HeV) Outbreaks Controlled Using a One Health Approach

The 1994 outbreak of HeV in horses laid the foundation for a One Health approach in Australia [[66], [67]]. The HeV outbreak caused significant damage to the animal and public health over the subsequent years. Various stakeholders from different organisations came together for the first time to discuss the potential hosts of the virus. Fruit bats of the Pteropodidae family, (Pteropus genus) have been identified as natural hosts of the virus [[68], [69]].

Subsequently, the Queensland Animal Research Institute and the CSIRO Australian Animal Health Laboratory isolated HeV and reproduced the disease in humans and animals. The response to HeV outbreak used a One Health approach ([Figure 3]) presented as a UML use case diagram. The response highlighted the significance of effective communications between various stakeholders overcoming the bureaucratic and political challenges.

During this HeV outbreak, the communication and interaction between public and veterinary health authorities was increased [[65], [67]]. Social science, medical, veterinary, biosecurity and humanities researchers were also included in designing an integrated response in collaboration with the Australian government [[66]]. Efforts are currently underway to establish an Australian National One Health surveillance system that emphasises an integrated approach [[23]], and which prioritises proactive engagement of providers and community stakeholders. For general practice, this includes revised prescribing guidelines, screening, and timely reporting [[70]]. Australia is also developing community, multilingual awareness campaigns with translations for culturally and linguistically diverse (CALD) communities.

4 Discussion

We found that only one country, Norway, had advanced IMS, well integrated into their health system strategy. Other countries relied on one-off systems and pragmatism in supporting their COVID-19 response. Norway, who had the most established national IMS achieved the triad of comprehensive testing and other measures to reduce spread, good vaccination coverage, and a low mortality from COVID-19. Other countries did well but had to innovate and be pragmatic.

The pragmatic responses to COVID-19 were largely driven within the medical community, with very little evidence of a One Health response. The key elements of the response seen were: (1) Disease testing and measures to reduce spread, (2) Supporting rapid vaccine development, and (3) Vaccination programmes. Testing, rapid implementation of vaccination, and integrated and comprehensive health systems are needed to protect populations from diseases such as the COVID-19 pandemic.

Whilst some benefits from better data sharing and better IMS have been stepped back from, others have persisted. For example, the changes included a shift to remote consultation which has persisted [[71], [72]].

Whilst we saw little evidence of a One Health approach to the COVID-19 pandemic, countries could readily identify within their health systems use cases where this approach was used. The avian flu response in the UK and the response to the Hendra virus in Australia shows the potential for a One Health response. A One Health approach, and systems that integrate animal, human and environmental health should be part of national and regional preparation for any future pandemic. Such approaches may have enabled a more rapid identification of and control of the process that led on to the COVID-19 pandemic.

There are calls for a One Health approach for influenza surveillance, given the potential for zoonotic viruses to interact and lead to the creation of new variants, particularly of influenza A [[73]]. Whilst the epidemiology of avian influenza is well described [[74]]. it is a type of flu that has caused fatal infections [[75]]. The same applies to Hendra, where it is thought that changing of the environment in which animals, in this case bats, live can cause spill over and new disease variants [[76]]. Most importantly, it is possible that there may be One Health lessons to learn from the start of the COVID-19 pandemic [[77], [78]].

The IMS is central to One Digital Health (ODH), a proposal to design, develop and implement a broad transdisciplinary and trans-sectoral digital platform to diagnose and manage sociotechnical challenges at the human-animal-environment interface. The ODH framework includes education, environment, human and veterinary healthcare, the healthcare industry and citizen engagement. The complexity of this horizontal interdisciplinary and intersectoral integration will increase as the micro-meso-macro vertical integration levels are applied to the technologies, data, and services being designed, developed, managed, governed, and sustained across the intersectoral enterprise-wide platform required for One Digital Health. Practically, enterprise architects and informaticians will also have to deal with a complex “analogue-digital” hybrid phase during the transition to a broader One Digital Health paradigm and platform [[79]].

The strength of this contribution was the range of countries contributing and range of health systems involved - north and south America, Europe, and Australia. Its limitation is that the volunteer authors appear to have come from systems that have largely run successful approaches to introducing vaccination and controlling severe outcomes from COVID.

5 Conclusions

The wide range of responses to the COVID-19 pandemic we describe all depended on improved IMS to draw together the necessary data. Nearly all the countries and regions who contributed to this study used a pragmatic approach to establish comprehensive IMS, rather than adoption of national standards. These IMS linked data about testing and other preventive measures, vaccination uptake and health outcomes. It is likely that the countries with the most effectively deployed IMS achieve the better outcomes. However, as our sample was limited to six nations, albeit with the best and worse COVID-19 related mortalities, our conclusions should be treated with caution. However, successful IMS need to span human, animal, and environmental services if they are to be effective in epidemics and pandemics. Health service strategies for future pandemic responses should include a One Health response, operationalised through an IMS that spans animal, human and environmental health are most likely to be successful in minimising the effect of any future pandemic.

Conflict of Interest Statement

Uy Hoang has undertaken consultation work for Janssen and Sanofi.

Simon de Lusignan has had grants, through his universities for vaccine related research from AstraZenaca, GSK, Sanofi, Seqirus, MSD, Takeda.

^* Joint first authors

^# Joint senior authors

• References

• 1 One Health Geneva, Switzerland: World Health Organisation (WHO); 2017 [Accessed Sept 21^st 2017. Available from: https://www.who.int/news-room/questions-and-answers/item/one-health].
• 2 One Health: Centers for Disease Control and Prevention; 2023 [Accessed April 13^th 2023. Available from: https://www.cdc.gov/onehealth/index.html].
• 3 Suk J, Ciotti M. Towards One Health preparedness. Stockholm, Sweden: European Centre for Disease Prevention and Control; 2018 May 2018. [Available from: https://www.ecdc.europa.eu/sites/default/files/documents/One-Health-preparedness-24-May-2018.pdf].
• 4 Schneider M, Munoz-Zanzi C, Min K, Aldighieri S. “One Health” From Concept to Application in the Global World. Oxford Research Encyclopedia of Global Public Health [Internet]. 2019 [Accessed April 29^th 2023. Available from: https://oxfordre.com/publichealth/view/10.1093/acrefore/9780190632366.001.0001/acrefore-9780190632366-e-29].
• 5 The European Union One Health 2020 Zoonoses Report. Stockholm, Sweden: European Centre for Disease Prevention and Control (ECDC); 2021. doi: 10.2903/j.efsa.2019.5926.
• 6 Avian influenza Stockholm, Sweden: European Centre for Disease Prevention and Control (ECDC); [Available from: https://www.ecdc.europa.eu/en/avian-influenza].
• 7 Information on Bird Flu Atlanta, Georgia, USA: Centers for Disease Control and Prevention (CDC); 2023 [updated 10th April 2023. Available from: https://www.cdc.gov/flu/avianflu/index.htm.
• 8 Steele S, Toribio J, Mor S. A vision of a One Health system for Australia: on the need to rethink our health system. Med J Aust 2022;217(9):459-63. doi: 10.5694/mja2.51733.
• 9 Nagel-Piciorus C, Nagel-Piciorus L, Sârbu R. Milestones in Implementation of an Integrated Management System in the Health Sector. Case Study Radiologische Netzwerk Rheinland. The AMFITEATRU ECONOMIC journal 2016;18(42):432-45.
• 10 ISO 9001 and related standards, Quality management Geneva, Switzerland: International Organization for Standardization (ISO); [Available from: https://www.iso.org/iso-9001-quality-management.html].
• 11 ISO/DIS 5477 Health informatics — Interoperability of public health emergency preparedness and response information systems – Business rules, terminology and data vocabulary Geneva, Switzerland: International Organization for Standardization (ISO); [Available from: https://www.iso.org/standard/81303.html].
• 12 Donabedian A. The quality of care. How can it be assessed? JAMA 1988;260(12):1743-8.
• 13 Nundy S, Cooper L, Mate K. The Quintuple Aim for Health Care Improvement: A New Imperative to Advance Health Equity. JAMA 2022;327(6):521-2. doi: 10.1001/jama.260.12.1743.
• 14 Dong E, Du H, Gardner L. An interactive web-based dashboard to track COVID-19 in real time. Lancet Infect Dis 2020;20(5):533-4. doi: 10.1016/S1473-3099(20)30120-1.
• 15 Health Expenditure: Organisation for Economic Co-operation and Development (OECD); [Available from: https://www.oecd.org/els/health-systems/health-expenditure.htm].
• 16 Vasileiou E, Shi T, Kerr S, Robertson C, Joy M, Tsang R, et al. Investigating the uptake, effectiveness and safety of COVID-19 vaccines: protocol for an observational study using linked UK national data. BMJ Open 2022;12(2):e050062. doi: 10.1136/bmjopen-2021-050062.
• 17 Shrotri M, Krutikov M, Palmer T, Giddings R, Azmi B, Subbarao S, et al. Vaccine effectiveness of the first dose of ChAdOx1 nCoV-19 and BNT162b2 against SARS-CoV-2 infection in residents of long-term care facilities in England (VIVALDI): a prospective cohort study. Lancet Infect Dis 2021;21(11):1529-38. doi: 10.1016/S1473-3099(21)00289-9.
• 18 Yam E. COVID-19 will further exacerbate global antimicrobial resistance. J Travel Med 2020;27(6). doi: 10.1093/jtm/taaa098.
• 19 Information Management Strategy v2. Association of Ontario Health Centres (AOHC). [Available from: https://www.allianceon.org/sites/default/files/documents/Information%20Management%20Strategy%20v2%202015-2020.docx].
• 20 Goel V, McGrail K. Modernize the Healthcare System: Stewardship of a Strong Health Data Foundation. Healthc Pap 2022;20(3):61-8. doi: 10.12927/hcpap.2022.26842.
• 21 Population health data: Australian Government, Department of Health and Aged Care; [Available from: https://www.health.gov.au/topics/preventive-health/population-health-data].
• 22 Aggarwal M, Katz A, Oandasan I. Current State of Quantitative Data Available for Examining the Work of Family Physicians in Canada. Healthc Policy 2021;17(1):48-57. doi: 10.12927/hcpol.2021.26578.
• 23 Options for a national One Health antimicrobial resistance and antimicrobial usage surveillance system: Allen and Clarke Consulting; 2021 [Accessed Sept 21^st 2021. Available from: https://www.health.gov.au/sites/default/files/documents/2022/02/foi_3490_-_document_1_-_interim_report_-_antimicrobial_resistance_surveillance_system_0.pdf].
• 24 Widdifield J, Eder L, Chen S, Kwong J, Hitchon C, Lacaille D, et al. COVID-19 Vaccination Uptake Among Individuals With Immune-mediated Inflammatory Diseases in Ontario, Canada, Between December 2020 and October 2021: A Population-based Analysis. J Rheumatol 2022;49(5):531-6. doi: 10.3899/jrheum.211148.
• 25 Grima A, Murison K, Simmons A, Tuite A, Fisman D. Relative Virulence of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Among Vaccinated and Unvaccinated Individuals Hospitalized With SARS-CoV-2. Clin Infect Dis 2023;76(3):e409-e15. doi: 10.1093/cid/ciac412.
• 26 Razak F, Shin S, Naylor C, Slutsky A. Canada’s response to the initial 2 years of the COVID-19 pandemic: a comparison with peer countries. CMAJ 2022;194(25):E870-e7. doi: 10.1503/cmaj.220316.
• 27 Dyer O. Covid-19: Canada outperformed comparable nations in pandemic response, study reports. BMJ 2022;377:o1615. doi: 10.1136/bmj.o1615.
• 28 Shariff S, Richard L, Hwang S, Kwong J, Forchuk C, Dosani N, et al. COVID-19 vaccine coverage and factors associated with vaccine uptake among 23 247 adults with a recent history of homelessness in Ontario, Canada: a population-based cohort study. Lancet Public Health 2022;7(4):e366-e77. doi: 10.1016/S2468-2667(22)00037-8.
• 29 Parrella A, Dalton C, Pearce R, Litt J, Stocks N. ASPREN surveillance system for influenza-like illness - A comparison with FluTracking and the National Notifiable Diseases Surveillance System. Aust Fam Physician 2009;38(11):932-6.
• 30 Pearce C, McLeod A, Patrick J, Ferrigi J, Bainbridge M, Rinehart N, et al. Coding and classifying GP data: the POLAR project. BMJ Health Care Inform 2019;26(1). doi: 10.1136/bmjhci-2019-100009.
• 31 Pearson S, Pratt N, de Oliveira Costa J, Zoega H, Laba T, Etherton-Beer C, et al. Generating Real-World Evidence on the Quality Use, Benefits and Safety of Medicines in Australia: History, Challenges and a Roadmap for the Future. Int J Environ Res Public Health 2021;18(24). doi: 10.3390/ijerph182413345.
• 32 Ahern S, Evans S, Hopper I, Zalcberg J. Towards a strategy for clinical quality registries in Australia. Aust Health Rev 2019;43(3):284-7. doi: 10.1071/AH17201.
• 33 Almeida P, Oliveira S, Giovanella L. Network integration and care coordination: the case of Chile’s health system. Cien Saude Colet 2018;23(7):2213-28. doi: 10.1590/1413-81232018237.09622018.
• 34 de Lusignan S, Leston M, Ikpoh M, Howsam G. Data saves lives: bottom-up, professionally-led endorsement would increase the chance of success. Br J Gen Pract 2022;72(724):512-3. doi: 10.3399/bjgp22X720965.
• 35 Hawkes N. NHS faces huge challenge to become digitally driven by 2028, a decade later than originally promised. BMJ 2018;361:k1957. doi: 10.1136/bmj.k1957.
• 36 Dabanch J, González C, Cerda J, Acevedo J, Calvo M, Díaz E, et al. Chile’s National Advisory Committee on Immunization (CAVEI): Evidence-based recommendations for public policy decision-making on vaccines and immunization. Vaccine 2019;37(32):4646-50. doi: 10.1016/j.vaccine.2019.06.069.
• 37 Aguilera X, Mundt A, Araos R, Weitzel T. The story behind Chile’s rapid rollout of COVID-19 vaccination. Travel Med Infect Dis 2021;42:102092. doi: 10.1016/j.tmaid.2021.102092.
• 38 Castillo C, Villalobos Dintrans P, Maddaleno M. The successful COVID-19 vaccine rollout in Chile: Factors and challenges. Vaccine X 2021;9:100114. doi: 10.1016/j.jvacx.2021.100114.
• 39 Jara A, Undurraga E, González C, Paredes F, Fontecilla T, Jara G, et al. Effectiveness of an Inactivated SARS-CoV-2 Vaccine in Chile. N Engl J Med 2021;385(10):875-84. doi: 10.1056/NEJMoa2107715.
• 40 Moberly T. Ten things you need to know about the Health and Care Bill. BMJ 2022;376:o361. doi: 10.1136/bmj.o361.
• 41 Joy M, McGagh D, Jones N, Liyanage H, Sherlock J, Parimalanathan V, et al. Reorganisation of primary care for older adults during COVID-19: a cross-sectional database study in the UK. Br J Gen Pract 2020;70(697):e540-e7. doi: 10.3399/bjgp20X710933.
• 42 de Lusignan S, Dorward J, Correa A, Jones N, Akinyemi O, Amirthalingam G, et al. Risk factors for SARS-CoV-2 among patients in the Oxford Royal College of General Practitioners Research and Surveillance Centre primary care network: a cross-sectional study. Lancet Infect Dis 2020:S1473-3099(20)30371-6. doi: 10.1016/S1473-3099(20)30371-6.
• 43 Elson W, Zambon M, de Lusignan S. Integrated respiratory surveillance after the COVID-19 pandemic. Lancet 2022;400(10367):1924-5. doi: 10.1016/S0140-6736(22)02325-X.
• 44 Leston M, Elson W, Watson C, Lakhani A, Aspden C, Bankhead C, et al. Representativeness, vaccination uptake and COVID clinical outcomes 2020-21 in the UK’s Oxford-RCGP Research and Surveillance Network: cohort profile. JMIR Preprints 2022:39141. doi: 10.2196/39141.
• 45 Ryvarden E. The Norwegian health sector should be unified around one IT system. Tidsskr Nor Laegeforen 2018;138(13). doi: 10.4045/tidsskr.18.0656.
• 46 Research WHOAfHPaS. Primary health care systems (PRIMASYS): case study from Peru: abridged version. Licence: CC BY-NC-SA 3.0 IGO. Geneva, Switzerland: World Health Organization (WHO); 2017; [Available from: https://apps.who.int/iris/handle/10665/341084].
• 47 Dyb K, Warth L. The Norwegian National Summary Care Record: a qualitative analysis of doctors’ use of and trust in shared patient information. BMC Health Serv Res 2018;18(1):252. doi: 10.1186/s12913-018-3069-y.
• 48 Cobos Muñoz D, Sant Fruchtman C, Miki J, Vargas-Herrera J, Woode S, Dake F, et al. The Need to Address Fragmentation and Silos in Mortality Information Systems: The Case of Ghana and Peru. Int J Public Health 2022;67:1604721. doi: 10.3389/ijph.2022.1604721.
• 49 Gravningen K, Nymark P, Wyller T, Kacelnik O. A new automated national register-based surveillance system for outbreaks in long-term care facilities in Norway detected three times more severe acute respiratory coronavirus virus 2 (SARS-CoV-2) clusters than traditional methods. Infect Control Hosp Epidemiol 2022:1-7. doi: 10.1017/ice.2022.297.
• 50 Ministerial Resolution No. 905-2020 / MINSA, Ministry of Health, (2020), Health Directive No. 122-MINSA / 2020 / CDC “Health Directive for the Epidemiological Surveillance of Coronavirus Disease (COVID-19) in Peru”. Ministerio de Salud; 2020. [Available from: https://www.gob.pe/institucion/minsa/normas-legales/1322786-905-2020-minsa].
• 51 Zanaboni P, Kummervold P, Sørensen T, Johansen M. Patient Use and Experience With Online Access to Electronic Health Records in Norway: Results From an Online Survey. J Med Internet Res 2020;22(2):e16144. doi: 10.2196/16144.
• 52 Alarcón-Yaquetto D, de Ferrari A, Málaga G. The road to patient-centred care in Peru: The difficulties and opportunities to achieve participatory health care. Z Evid Fortbild Qual Gesundhwes 2022;171:113-6. doi: 10.1016/j.zefq.2022.04.027.
• 53 Roque K, Ruiz R, Otoya-Fernandez I, Galarreta J, Vidaurre T, de Mello R, et al. The impact of telemedicine on cancer care: real-world experience from a Peruvian institute during the COVID-19 pandemic. Future Oncol 2022;18(31):3501-8. doi: 10.2217/fon-2022-0239.
• 54 Millones A, Lecca L, Acosta D, Campos H, Del Águila-Roja, E, Farroñay S, et al. The impact of the COVID-19 pandemic on patients’ experiences obtaining a tuberculosis diagnosis in Peru: a mixed-methods study. BMC Infect Dis 2022;22(1):829. doi: 10.1186/s12879-022-07832-2.
• 55 Liu Y, Zhao S, Yang L, Aliaga-Linares L, He D. All-cause mortality during the COVID-19 pandemic in Peru. IJID Reg 2022;5:177-9. doi: 10.1016/j.ijregi.2022.10.005.
• 56 Quevedo-Ramirez A, Al-Kassab-Córdova A, Mendez-Guerra C, Cornejo-Venegas G, Alva-Chavez K. Altitude and excess mortality during COVID-19 pandemic in Peru. Respir Physiol Neurobiol 2020;281:103512. doi: 10.1016/j.resp.2020.103512.
• 57 Sempé L, Lloyd-Sherlock P, Martínez R, Ebrahim S, McKee M, Acosta E. Estimation of all-cause excess mortality by age-specific mortality patterns for countries with incomplete vital statistics: a population-based study of the case of Peru during the first wave of the COVID-19 pandemic. Lancet Reg Health Am 2021;2:None. doi: 10.1016/j.lana.2021.100039.
• 58 Panorama de la Salud: Latinoamérica y el Caribe 2020 “Health Overview: Latin America and the Caribbean 2020”: Organisation for Economic Cooperation and Development (OECD) and The World Bank; [Available from: https://doi.org/10.1787/740f9640-es].
• 59 Diaz E, Dimka J, Mamelund S. Disparities in the offer of COVID-19 vaccination to migrants and non-migrants in Norway: a cross sectional survey study. BMC Public Health 2022;22(1):1288. doi: 10.1186/s12889-022-13687-8.
• 60 Herrera-Añazco P, Benites-Zapata V, Hernández V. Association between the Non-use of Health Services and Maltreatment Based on Ethnicity in Peru. J Health Care Poor Underserved 2022;33(1):234-52. doi: 10.1353/hpu.2022.0018.
• 61 Ferreira L, Utazi C, Huicho L, Nilsen K, Hartwig F, Tatem A, et al. Geographic inequalities in health intervention coverage - mapping the composite coverage index in Peru using geospatial modelling. BMC Public Health 2022;22(1):2104. doi: 10.1186/s12889-022-14371-7.
• 62 Contingency Plan for Exotic Notifiable Diseases of Animals in England. London, UK: Department for Environment, Food and Rural Affairs (DEFRA); 2022. [Available from: https://www.gov.uk/government/publications/contingency-plan-for-exotic-notifiable-diseases-of-animals-in-england].
• 63 Notifiable Avian Disease Control Strategy for Great Britain. London, UK: Department for Environment, Food and Rural Affairs (DEFRA); 2019. [Available from: https://www.gov.uk/government/publications/notifiable-avian-disease-control-strategy].
• 64 Managing the human health risk of avian influenza in poultry and wild birds. Guidance for health protection teams Version 6.0. London, UK: UK Health Security Agency (UKHSA); 2023. [Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1132518/avian-influenza-guidance-and-algorithms-for-managing-incidents-in-birds.pdf].
• 65 NHS England incident response plan: NHS England; 2017 [Accessed Nov 10th 2022. Available from: https://www.england.nhs.uk/publication/nhs-england-incident-response-plan-national].
• 66 Hayman D, Gurley E, Pulliam J, Field H. The application of one health approaches to henipavirus research. Curr Top Microbiol Immunol 2013;365:155-70. doi: 10.1007/82_2012_276.
• 67 Black P, Douglas I, Field H. This could be the start of something big-20 years since the identification of bats as the natural host of Hendra virus. One Health 2015;1:14-6. doi: 10.1016/j.onehlt.2015.07.001.
• 68 Hendra virus disease Geneva, Switzerland: World Health Organisation (WHO); [Available from: https://www.who.int/health-topics/hendra-virus-disease#tab=tab_1].
• 69 Coghill A, Black P, Shipp M. The role of One Health in understanding and controlling zoonotic diseases in Australia. Microbiol Aust 2012 [Available from: https://www.publish.csiro.au/ma/pdf/ma12148].
• 70 Godinho M, Ashraf M, Narasimhan P, Liaw S. Community health alliances as social enterprises that digitally engage citizens and integrate services: A case study in Southwestern Sydney (protocol). Digital Health 2020;6:2055207620930118. doi: 10.1177/2055207620930118.
• 71 Lim J, Broughan J, Crowley D, O’Kelly B, Fawsitt R, Burke M, et al. COVID-19’s impact on primary care and related mitigation strategies: A scoping review. Eur J Gen Pract 2021;27(1):166-75. doi: 10.1080/13814788.2021.1946681.
• 72 Khalil-Khan A, Khan M. The Impact of COVID-19 on Primary Care: A Scoping Review. Cureus 2023;15(1):e33241. doi: 10.7759/cureus.33241.
• 73 Saha S, Davis W. The need for a One Health approach for influenza surveillance. Lancet Glob Health 2022;10(8):e1078-e9. doi: 10.1016/S2214-109X(22)00240-6.
• 74 Alexander D. An overview of the epidemiology of avian influenza. Vaccine 2007;25(30):5637-44. doi: 10.1016/j.vaccine.2006.10.051.
• 75 Jadhao S, Nguyen D, Uyeki T, Shaw M, Maines T, Rowe T, et al. Genetic analysis of avian influenza A viruses isolated from domestic waterfowl in live-bird markets of Hanoi, Vietnam, preceding fatal H5N1 human infections in 2004. Arch Virol 2009;154(8):1249-61. doi: 10.1007/s00705-009-0429-2.
• 76 Eby P, Peel A, Hoegh A, Madden W, Giles J, Hudson P, et al. Pathogen spillover driven by rapid changes in bat ecology. Nature 2023;613(7943):340-4. doi: 10.1038/s41586-022-05506-2.
• 77 Worobey M, Levy J, Malpica Serrano L, Crits-Christoph A, Pekar J, Goldstein S, et al. The Huanan Seafood Wholesale Market in Wuhan was the early epicenter of the COVID-19 pandemic. Science 2022;377(6609):951-9. doi: 10.1126/science.abp8715.
• 78 Maxmen A. Wuhan market was epicentre of pandemic’s start, studies suggest. Nature 2022;603(7899):15-6. doi: 10.1038/d41586-022-00584-8.
• 79 Benis A, Tamburis O, Chronaki C, Moen A. One Digital Health: A Unified Framework for Future Health Ecosystems. J Med Internet Res 2021;23(2):e22189. doi: 10.2196/22189.

Publication History

Article published online:
06 July 2023