Table I.
Risk Framework––Scoring Criteria
| Risk Factor | Risk Score | Comment | |||
|---|---|---|---|---|---|
| 1 | Gross domestic product (GDP) | Low‐income countries = 3 | Middle (lower and upper) income countries = 2 | High‐income countries = 1 | The World Bank classifies countries' GDP on the income level as high, middle (upper and lower), and low income. |
| 2 | Health expenditure, total (% of GDP) | Lower third (1.0–7.0%) = 3 | Middle third (7.1–14.0%) = 2 | Upper third (14.1–20.0%) = 1 | Country's health expenditure spread was divided into upper, middle, and lower third. |
| 3 | History of war/civil unrest within the last decade | > Five years = 3 | ≤Five years = 2 | No conflicts = 1 | Wars/civil unrest could destroy a nation's health system within two years. The longer the war, the more destructive impact it has on basic amenities and the health system. This reduces prompt response to disease outbreak. |
| 4 | Use of traditional healer and high‐risk traditional practicesa | High = 3 | Moderate = 2 | Low = 1 | Traditional healers are associated with high‐risk traditional practices such as the use and reuse of unsterilized needles/sharp objects/knives for blood‐letting procedures and unsafe burial practice. The higher the rate of use, the higher the risk of disease spread. |
| 5 | Consumption of bush meat | Routine = 3 | Occasional = 2 | Never = 1 | Consumption of bush meat has been associated with EVD outbreak in the past. The more frequently its consumption, the more the likelihood of exposure to infection. |
| 6 | Unsafe animal handling practices | Low = 3 | Occasional = 2 | Routine = 1 | Unsafe animal handling practices such as not using hand gloves and not performing hand‐washing after contacts with animals. |
| 7 | Physician density (per 1,000 population) | <0.1 = 2 | ≥ 0.1 = 1 | Sufficient number of physician as well as proportionate distribution across the country enhances adequate access to basic medical care. Insufficient physicians in the workforce is associated with increased travel distance and time for patient, thereby increasing the risk of disease spread. Other associated risks include increased contact with more patients due to increased workload for the physician. The World Bank recommended a minimum of 0.1 physician/1,000 population. | |
| 8 | Nurses and midwife density (per 1,000 population) | <0.2 = 3 | 0.2–0.4 = 2 | >0.4 = 1 | Nurses and midwives form a significant proportion of the health workforce. They play a major role in the hospital setting as well as other settings such as homecare and community. The World Bank recommends a minimum of 0.2–0.4 nurses and midwives/1,000 population. |
| 9 | Density of skilled health workers (nurses, midwives, and physicians) 22.8/10,000 | <22.8/10,000 = 2 | ≥22.8/10,000 | The World Health Organization recommends a minimum of 22.8 skilled health‐care workers per 10,000 population to provide basic health coverage. Countries that fail to achieve this target are at higher risk of disease spread than others. | |
| 10 | Hospital beds density (per 1,000 population) | Lower density (0.1–2/1,000) = 3 | Middle density (>2–4/1,000) = 2 | Upper density (>4/1,000) = 1 | Hospital beds are an indicator for available resources to deliver in‐patient services both in a normal hospital setting and during outbreaks when patient loads are likely to be increased. Insufficient hospital beds are likely to increase home/community stay, thereby increasing the risk of infectious disease spread. |
| 11 | Availability of diagnostic capacity of infectious agent(s) in available laboratory (including laboratory density and laboratory staff density) | Absent = 2 | Present = 1 | Availability of diagnostic capacity facilitates prompt detection/diagnosis of disease and confirmation of outbreak. This therefore enhances prompt public health intervention. The lack of such facility is associated with high risk of disease spread with major consequences. | |
| 12 | Timeliness of laboratory result | <80% of result available within minimum turnaround time for test = 2 | ≥80% of result available within minimum turnaround time for test = 1 | The presence of diagnostic capacity does not translate to performance. IDSR recommends that a minimum of 80% of test result should be available within the minimum turnaround time of the test. | |
| 13 | Disease surveillance response (DSR) indicators | <80% of target = 2 | ≥80% of target = 1 | Risk scores were assigned to DSR using the core capacity areas recommended in the technical guidelines for integrated disease surveillance and response. 80% is the recommended target. | |
| 14 | Nature of land border/border security | >3 or landlocked = 3 | 1 or 3 sided = 2 | Entirely surrounded by water = 1 | Topographic features of land borders correlate with the degree of pedestrian mobility and the time required to travel across the border. This also correlates with the likelihood of interborder disease spread. |
| 15 | Quarantine system/screening at the borders | Rarely = 3 | Occasional = 2 | Efficient /functional = 1 | Proper screening at the borders (air, land, and sea) can help to identify and prevent the spread of infection into a country. Identified cases can be promptly quarantined. |
| 16 | Roadways/transportation network | Poor = 2 | Good = 1 | Poor roadways/transportation networks affect patients’ evacuation to treatment center, specimen transportation to the laboratory, and contact tracing. | |
| 17 | Overcrowded living | High = 2 | Low = 1 | Overcrowded living is associated with infection of several people simultaneously as well as rapid spread. | |
| 18 | Use of unregulated traditional medicine | High = 2 | Low = 1 | Traditional medicine and cultural and spiritual belief in some countries serve as the main source of primary care. Countries with high use are associated with high risk (a score of 2) and those with low use have a low risk (a score of 1). | |
| Total | Highest = 46 | Lowest = 18 | |||
a
High‐risk traditional practices such as unsafe burial practices and scarification marks.