Background
COVID-19 remains an event of public health concern. From 2020 to 2023, more than 760 million confirmed cases and 6.8 million deaths were reported worldwide. About 76 million cases and 1.5 million deaths occurred in Latin America, 1 one of the most affected regions in the world with unprecedented negative health, social, and economic impacts.Reference Viollaz, Salazar-Saenz, Flabbi, Bustelo and Bosch 2
One of the indices that allows measuring the ability of countries to respond to this type of threat is the Global Health Security (GHS) Index, which provides an assessment of preparedness in the areas of prevention, detection and notification, rapid response, health systems, and commitment to capacity building and financing.Reference Bell, Nuzzo and Viollaz 3 Latin America has an average score of 53.4/100 (Chile 56.2; Peru 54.9; Argentina 54.4; Colombia 53.2; Brazil 51.2; Ecuador 50.8), and it is likely that the magnitude of the impact of COVID-19 in the region reflects weaknesses in preparedness, detection, and response.Reference Bell, Nuzzo and Viollaz 3
Preparedness and response plans are a guide for countries to structure actions to be taken to deal with health emergencies. The World Health Organization (WHO) in the framework of the COVID-19 pandemic described guidelines to direct preparedness and adapt the response to the contexts of each country. These guidelines consist of several main domains including country-level coordination, planning and monitoring, epidemiological surveillance, laboratories, and case diagnosis and management. 4
Global health leaders have called for investing in and prioritizing epidemic preparedness, as infectious diseases are a continuing threat. 5 COVID-19 is an opportunity to build a future by giving utility to the knowledge generated, understanding that a well-coordinated local preparedness and response action plays a fundamental role in detecting outbreaks and preventing their spread.Reference Lal, Abdalla and Chattu 6
Accordingly, it was necessary to map the available evidence on the preparedness and response measures implemented by Latin American countries and to verify whether they comply with WHO guidelines, in order to generate recommendations that will enable the countries of the region to face future health emergencies. This study sought to describe the pandemic preparedness and response measures implemented by COVID-19 in 6 Latin American countries (Argentina, Brazil, Chile, Colombia, Ecuador, and Peru) during 2020 and 2021 according to the guidelines established by WHO in the checklist of the international guide “COVID-19 Strategic Preparedness and Response Plan.”
Materials and Methods
This study is part of the final phase of the CoVIDAReference Varela, Florez and Tamayo-Cabeza 7 , Reference Ramírez Varela, Touchton, Miranda, Mejia Grueso, Laajaj, Carrasquilla, Florez, Gaviria, Hoyos, Duarte, Morales, Velasco and Restrepo 8 project which aimed to identify and describe preparedness and response measures, social, and economic incentives, infodemics, and political will in the studied countries. This manuscript will report the results related to the subsample of preparedness and response studies.
Study Design
A scoping review was developed based on the Joanna Briggs Institute reviewer’s manual,Reference Peters, Godfrey, McInerney, Aromataris and Munn 9 following the PRISMA-ScR checklist.Reference Tricco, Lillie and Zarin 10
Countries under study
The 6 countries with the highest number of confirmed cases and deaths from COVID-19 in Latin America (Argentina, Brazil, Chile, Colombia, Ecuador, and Peru) were selected for this review (see Supplementary Material 1).
Inclusion criteria
All publications that examined any preparedness and response intervention during the COVID-19 pandemic were included. All types of original research articles were considered. We included studies only conducted during the first two years of the COVID-19 pandemic (2020 to 2021), papers available as full publication in English, Spanish, and Portuguese, and pre-published, published studies, or gray literature.
Exclusion criteria
Editorials, commentaries, viewpoints, or press articles.
Sources of information
A bibliographic search was performed in the electronic databases MEDLINE, Web of Science, Epistemonikos, and LILACS of the measures adopted to face a public health crisis such as the pandemic due to COVID-19.
Gray literature was reviewed through Google Scholar using the same terms as the searches in the English, Portuguese, and Spanish databases; it was complemented with the review of the references of the studies found in a snowball search.
Search strategy
A search strategy was designed, composed of controlled vocabulary such as MeSH (Medical Subject Headings), DeCS (Health Sciences Descriptors), and free language. Synonyms, abbreviations, acronyms, spelling variations, and plurals were considered. MeSH terms such as “Pandemics,” “Preparedness,” “Response,” “Government Programs,” “Latin America,” “Argentina,” “Chile,” “Colombia,” “Ecuador,” “Peru,” and “Brazil” were used. The strategy was complemented with field identifiers, truncators, proximity operators, and Boolean operators. This strategy was validated with thematic and methodological experts and adapted for the different databases (see Supplementary Material 2). The search was conducted between February 1 and April 30, 2022.
Selection of sources and evidence
The list with the bibliographic references identified in the electronic searches was downloaded into the Rayyan® softwareReference Ouzzani, Hammady and Fedorowicz 11 where duplicate references were eliminated. Three reviewers independently carried out the selection by title and abstract to eliminate articles that did not meet the inclusion criteria. Subsequently, the reviewers independently downloaded and assessed the full text of potentially relevant articles and excluded studies that did not meet the eligibility criteria.
Data extraction process
Three reviewers independently extracted data (EOVD-AVM-LSRB) on a data collection instrument specially designed for the review. The matrix included year of publication, article title, country, study design and type, study setting, population, intervention, comparison, outcome, results, and observations.
WHO checklist verification
The subsample of studies identified as preparedness and response was taken, and a verification was performed using the checklist of the international guide “COVID-19 Strategic Preparedness and Response Plan,” 12 which includes 4 pillars: 1) coordination, planning, and follow-up at the country level; 2) epidemiological surveillance, immediate response teams, and case investigation; 3) laboratories and diagnosis; and 4) case management. 12 This verification was carried out to identify whether the countries had reported literature indicating that they had a response in accordance with the standards established by WHO.
Synthesis of findings
The results of the screening and final study selection process were summarized in a PRISMA-10 flowchart.Reference Page, Moher and Bossuyt 13 Initially, the subsample of preparedness and response studies was summarized by means of a characterization table with general information. The narrative synthesis of the literature extraction and verification of the countries’ literature was presented according to the checklist established by WHO in the framework of the pandemic.
Results
Selection of Studies
A total of 3446 references were identified: 924 in Pubmed, 140 in LILACS, 70 in Epistemonikos, 1230 in Web of Science, and 1082 in secondary sources and Google Scholar. After eliminating duplicates, 3441 references remained. Screening by title and abstract left 341 references of which 335 were available for full-text evaluation. Finally, 128 studies were included in the review, of which 27 were part of the preparation and response subsample, which corresponded to the scope of the study (see Figure 1).
Figure 1. Identification and selection of studies - PRISMA ScR flowchart.
Characteristics of the Subsample of Readiness and Response Studies
Table 1 summarizes the key characteristics of the subsample of studies on preparedness and response. Half of the studies (n = 14) were published in 2021. Brazil was the country with the largest number of studies reported (n = 11), and the literature found concentrated on reporting activities related to pillar 1 country-level coordination (n = 17).
Table 1. Characteristics of the subsample of readiness and response studies included in the review (N = 27)
Pillar 1. Coordination, planning, and follow-up at country level
In this pillar, all countries reported the sub-items of the checklist, with the exception of Argentina (see Table 2). In this review, 63% of the studies reported activities on pandemic coordination, planning, and follow-up.Reference Canals, Cuadrado and Canals 14 –Reference Olivier, Benkimoun and Paul 30 The main reports were related to the activation of the Emergency Operations Centers (EOC), which were used as platforms to coordinate preparedness and response to the health emergency due to COVID-19. It was found that, in general, the countries coordinated the response at the central level with the exception of Brazil where the lack of leadership by the federal government led to actions being coordinated by each administrative level.Reference Garcia, Alarcón and Bayer 22
Table 2. Number of studies identified by 2021 by country and activities from the World Health Organization preparedness and response checklist
In addition, it was found that countries implemented planning and follow-up measures such as surveillance at all potential entry points (international airports, seaports, and borders with neighboring countries), restrictions on international travel and some domestic travel, closure of schools and universities, prohibition of large mass events, and mandatory national quarantine, with the exception of Chile where a local quarantine was implemented (see Figure 2).Reference Grebe, Velez and Tiutiunnyk 16 –Reference Carrasquilla 18 , Reference Garcia, Alarcón and Bayer 22 , Reference Milet and Bravo 26
Figure 2. Pillar 1 preparedness and response measures implemented by Latin American countries in response to COVID-19.
Pillar 3. Epidemiological surveillance, immediate response teams, and case investigation
Epidemiological surveillance activities were reported by 22% of the studies and only half of the countries reported the checklist topics (see Table 2).Reference Carrasquilla 18 , Reference Gonzales-Castillo, Varona-Castillo and Domínguez-Morante 21 , Reference Manrique Hernandez, Moreno Montoya and Hurtado Ortiz 31 –Reference Donida, da Costa and Scherer 34 The main activities identified in this pillar were early case detection, contact tracing, and isolation orders for international travelers and suspected cases.
In Brazil, a mobile application was developed that facilitated contact tracing.Reference Donida, da Costa and Scherer 34 Through this system, the numbers of persons with suspected infection, persons with confirmed disease, and deaths were obtained.Reference Donida, da Costa and Scherer 34
In Colombia, the “Testing, Tracing, and Sustainable Selective Isolation Strategy” (PRASS) was implemented at the national level, and a call center was installed for contact tracing throughout the country,Reference Carrasquilla 18 while in Peru, to manage the pandemic, the regional and local governments used immediate response teams that participated in the support of clinical evaluation, testing, and sampling of COVID-19.Reference Rees, Peralta Quispe and Scotter 33
Pillar 5. Laboratories and diagnostics
Only 22% of the studies reported findings related to SARS-CoV-2 diagnostic response capacity; no activities related to virus sequencing, or the implementation of tests prioritized in scenarios of diagnostic insufficiency, were reported (see Table 2).Reference Canals, Cuadrado and Canals 14 –Reference Grebe, Velez and Tiutiunnyk 16 , Reference Carrasquilla 18 , Reference Kameda, Barbeitas and Caetano 35 , Reference Torres, Sippy and Sacoto 36
The countries studied sought to increase diagnostic capacity by creating new laboratories and training human talent in molecular techniques. In these countries, SARS-CoV-2 diagnosis was carried out by public, private, and university laboratories.Reference Canals, Cuadrado and Canals 14 –Reference Grebe, Velez and Tiutiunnyk 16 , Reference Carrasquilla 18 , Reference Kameda, Barbeitas and Caetano 35 , Reference Torres, Sippy and Sacoto 36 Colombia was the first country in Latin America to apply the Berlin Protocol with the leadership of the National Institute of Health (INS),Reference Carrasquilla 18 and Chile was the country with the highest testing capacity per person.Reference Grebe, Velez and Tiutiunnyk 16 Ecuador had a centralized PCR testing system in which samples from each province were sent to a limited number of regionally located laboratories for processing.Reference Torres, Sippy and Sacoto 36
Differences in diagnostic capacity were found to exist between countries at the subnational level, with greater deployment of testing in urban areas.Reference Canals, Cuadrado and Canals 14 , Reference Kameda, Barbeitas and Caetano 35 , Reference Torres, Sippy and Sacoto 36 In addition, diagnosis was limited by the dependence on imported supplies and reagents in the richer countries and the scarce human and physical resources needed for its implementation.Reference Kameda, Barbeitas and Caetano 35
Pillar 7. Case management
In this pillar, not all countries reported evidence, and only 22% of the studies described activities related to case management (Table 2).Reference Carrasquilla 18 , Reference Milet and Bravo 26 , Reference Garcia-Huidobro, Rivera and Chang 37 –Reference Leite, Finkler and Martini 40
The countries under study focused on increasing the capacity for clinical care with the creation of new Intensive Care Unit (ICU) beds, the acquisition of mechanical ventilators, and implementation of telemedicine. It was found that outpatient care was reduced, and elective surgery was suspended. Also described was the increase in the hiring of health human talent, as well as their training for the clinical management of COVID-19.
In Peru and Brazil, there were significant regional disparities in infrastructure and professional resources that affected health outcomes during the pandemic.Reference Cáceres Cabana, Malone and Zeballos 25 , Reference Milet and Bravo 26 , Reference Silva, Carvalho Dutra and Andrade 38 In addition, a lack of critical beds was reported in the poorest regions, as well as a lack of essential supplies such as oxygen.Reference Milet and Bravo 26 , Reference Silva, Carvalho Dutra and Andrade 38
Discussion
To our knowledge, this is the only review that addresses the importance of documenting how prepared were countries in the region to face a pandemic such as COVID-19 according to WHO standards. The main findings for each pillar in this review include: 1) In Latin America, the literature showed reports of heterogeneous responses to the pandemic; most countries coordinated their response at the central level with the establishment of management teams and activation of emergency operations centers for response coordination; 2) The capacity to perform epidemiological surveillance activities such as early case detection, contact tracing, and real-time monitoring of data was quickly exceeded; 3) There was low capacity in laboratory infrastructure, specialized human talent, and deployment of molecular tests for SARS-CoV-2 detection; 4) There were deficiencies in infrastructure, and equipment and medical supplies were revealed, as well as large regional disparities in the distribution of health services; 5) A gap was identified in the literature on virus-sequencing activities, prioritization of tests in diagnostic failure scenarios, and epidemiological surveillance literature in Argentina, Chile, and Ecuador.
In Latin America, the response to the pandemic was heterogeneous, partly explained by different national and subnational policies on COVID-19 control with varying degrees of implementation and application of different restriction measures.Reference Garcia, Alarcón and Bayer 22 Latin American countries were aligned with the coordination activities listed in Pillar 1 by WHO, with the activation of EOCs and central coordination at the national level with the exception of Brazil. This is similar to the findings of Mustafa et al. who reported 98% alignment of the preparedness and response plans of 106 countries with the WHO global guidance for Pillar 1 coordination.Reference Mustafa, Zhang and Zibwowa 41 Also, WHO reported that 180 countries have a COVID-19 response coordination mechanism such as an EOC that facilitates information sharing for decision-making. 4 National leadership is crucial in the response and serves as a platform for decision-making with multisectoral participation.Reference Frenk, Godal and Gómez-Dantés 42
The countries of the region had already faced other public health emergencies such as dengue, chikungunya, H1N1, and Zika. This experience provided them with important lessons on how to deal with epidemics and allowed them to strengthen their surveillance systems. However, these lessons learned were not enough to deal with COVID-19; the pandemic surpassed the capacities of these countries, which have had a tradition of dealing with emerging events.Reference Ruiz-Gómez and Fernández-Niño 43 Although this review shows the efforts made to comply with the activities listed in epidemiological surveillance, these were limited by the low deployment of tests that prevented effective contact tracing and isolation of cases. Countries such as Singapore with recent epidemic experiences already had structures and systems in place since the 2003 SARS experience, and the “test, trace and isolate” strategy was possibly the main factor in flattening the epidemic curve at the beginning of the pandemic.Reference Prado, de, Rossi and Chaves 44 However, this is the case for few countries. WHO described that case and cluster investigations, contact tracing, and contact quarantine were inadequate in most countries of the world. The situation was even more pronounced where diagnostic capacity was limited. 4
Addressing the diagnosis of SARS-CoV-2 was a challenge for the countries of the region. The cost and complexity of molecular tests that require infrastructure, equipment, specialized supplies, and trained human talent, as well as global competition for supplies and reagents, limited diagnostic capacity.Reference Gimeno Cardona, García de la Pedrosa, Leiva León, Cercenado Mansilla and Cantón Moreno 45 In this review, there was a lack of reporting of information on activities such as virus sequencing and prioritization of tests in diagnostic failure scenarios. African countries had a similar situation; most had low diagnostic capacity compared to their population size (31.7 million PCR tests for COVID-19 with a population of over one billion people) and an over-reliance on imported supplies and reagents.Reference Tessema, Kinfu and Dachew 46
Prior to the pandemic, health systems in Latin American countries were already deficient in infrastructure and human talent, and there were large health inequalities at the national and subnational levels.Reference Barreto, Miranda and Figueroa 47 Adapting services to increase the capacity for care made it possible to increase the supply for people with COVID-19 but had an impact on the provision of other services, especially in peri-urban, rural, and indigenous areas. 48 In China, Primary Health Care (PHC) was an essential component of the response, contributing to data collection and epidemiological studies that led to successfully containing the spread of the pandemic.Reference Prado, de, Rossi and Chaves 44 It is necessary to adopt responses with the One Health approach, and global health security must recognize the importance of also strengthening environmental and animal health systems, since it has been demonstrated that where there is capacity in the 3 systems, progress is made in the control of possible outbreaks and epidemics.Reference Elnaiem, Mohamed-Ahmed and Zumla 49
However, the literature from Argentina, Chile, and Ecuador did not report activities of the epidemiological surveillance pillar. The lack of literature on these activities may be explained by the nature of the evidence on epidemiological surveillance which, being of a local order, is not reported in indexed literature but generally in gray literature. Likewise, this gap in the literature could be attributed to the low investment in science, technology, and innovation in Latin American countries (between 0.6-0.7% of Gross Domestic Product), 50 which in turn hinders the publication of scientific evidence.
The COVID-19 pandemic exposed shortcomings in national responses and weaknesses in assessment frameworks, with high- and low-income countries showing that plans must be comprehensive, cross-sectoral, and supported by global coordination.Reference Sachs, Karim and Aknin 51 Although complying with the activities listed in WHO international guidance is important, it is also true that these assessment frameworks have been undermined by their failure to consider the role and complexities of social, economic, political, regulatory, and ecological factors that enable effective preparedness and response.Reference Traore, Shanks and Haider 52 This review evidenced the efforts of Latin American countries to meet WHO standards in each of the pillars of the response; however, these were overwhelmed by the magnitude of the pandemic that surpassed the capacities of health systems and prevented the containment of its spread.
Latin American countries need to strengthen and improve existing surveillance systems with robust information systems that allow reliable monitoring of data in real time. They should also develop capacities in metagenomics and molecular diagnostic methods, with greater deployment of laboratory infrastructure and specialized human talent that will allow early detection of new infectious agents to guide public health response strategies. Regional disparities in the distribution of health services, especially highly complex services, should be reduced, seeking equitable access, especially for vulnerable groups.
Limitations
Since the nature of scoping reviews is to map literature, no quality assessment was performed in this review. Although rigorous search strategies were implemented in 4 bibliographic databases, this review may have missed studies that could have been identified through other databases. Most of the included studies were based on data from the early stages of the pandemic.
Conclusions
This is the first review that addresses the importance of documenting how prepared the countries of the region were to face a pandemic such as COVID-19 considering WHO standards and guidelines. Sixty-three percent of the literature reports concentrated on the activities of the coordination pillar at the country level. In Latin America, the literature showed reports of heterogeneous responses to the pandemic; 4 of the 6 countries coordinated their response at the central level with the establishment of management teams and the activation of emergency operations centers for the coordination of the response.
However, this review identified a gap in the literature on laboratory and diagnostic pillar activities such as virus sequencing and prioritization of tests in diagnostic failure scenarios. There was also a lack of literature reporting on epidemiological surveillance pillar activities in Argentina, Chile, and Ecuador.
Supplementary material
To view supplementary material for this article, please visit http://doi.org/10.1017/dmp.2024.142.
Author contribution
LSRB contributed to the conceptualization, methodology, data collection and analysis, and writing: original draft, review, and editing. EOVD contributed to the conceptualization, methodology, data collection and analysis, and writing: original draft, review, and editing. AVM contributed to the methodology and data collection. LSZ contributed to the writing: original draft, review, and editing. GINC contributed to the methodology and writing: original draft, review, and editing. ARV contributed to conceptualization, methodology, data collection and analysis, fund acquisition and writing: original draft, review, and editing.
Funding statement
This research was funded by a scholarship granted to ARV as a Junior Fellow at OSUN Academy, Queen Elizabeth II Academy for Leadership in International Affairs, Chatham House, UK; and a collaboration agreement between Universidad de los Andes, Colombia.
