Skip to main content

Establishing a theoretical foundation for measuring global health security: a scoping review



Since the 2014–2016 West Africa Ebola epidemic, the concept of measuring health security capacity has become increasingly important within the broader context of health systems-strengthening, enhancing responses to public health emergencies, and reducing global catastrophic biological risks. Efforts to regularly and sustainably track the evolution of health security capabilities and capacities over time – while also accounting for political, social, and environmental risks – could help countries progress toward eliminating sources of health insecurity. We sought to aggregate evidence-based principles that capture a country’s baseline public health and healthcare capabilities, its health security system performance before and during infectious disease crises, and its broader social, political, security, and ecological risk environments.


We conducted a scoping review of English-language scholarly and gray literature to identify evidence- and practice-based indicators and proxies for measuring health security at the country level over time. We then used a qualitative coding framework to identify recurrent themes in the literature and synthesize foundational principles for measuring global health security. Documents reviewed included English-language literature published after 2001 until the end of the research period—September 2017—to ensure relevance to the current global health security landscape; literature examining acute infectious disease threats with potential for transnational spread; and literature addressing global health security efforts at the country level.


We synthesized four foundational principles for measuring global health security: measurement requires assessment of existing capacities, as well as efforts to build core public health, healthcare, and biosecurity capabilities; assessments of national programs and efforts to mitigate a critical subset of priority threats could inform efforts to generate useful metrics for global health security; there are measurable enabling factors facilitating health security-strengthening efforts; and finally, measurement requires consideration of social, political, and ecological risk environments.


The themes identified in this review could inform efforts to systematically assess the impacts and effectiveness of activities undertaken to strengthen global health security.

Peer Review reports


“Global health security” refers to prevention, detection, and response to naturally emerging, accidental, and deliberate biological threats [1]. Since the 2014 West Africa Ebola epidemic, the concept of health security has become increasingly important within the broader context of health systems-strengthening, enhancing responses to public health emergencies, and global catastrophic biological risks [2]. In this vein, the World Health Organization’s (WHO) Ebola Interim Assessment Panel, the International Working Group on Financing Preparedness, Chatham House, Harvard University’s Global Health Institute, the National Academy of Medicine, and the World Bank Group have issued calls to improve monitoring and measurement efforts around global health security [1, 3,4,5].

The WHO’s Joint External Evaluation (JEE) tool partially addresses this need by articulating country-level capacities required to mitigate infectious disease threats; the JEE also establishes a scoring system for quantifying progress made toward meeting benchmarks specified in the International Health Regulations (IHR). However, the JEE process is voluntary and relies on an in-country assessment and in-kind contributions of personnel who conduct the evaluation. While this process remains vital, additional universal approaches to measuring baseline, country-level health security are needed. Efforts to regularly and sustainably track and reproducibly compare the evolution of health security capabilities and capacities over time – while also accounting for political, social, security, and environmental risks – could help countries progress toward eliminating sources of health insecurity.

To inform ongoing efforts to strengthen health systems and establish new mechanisms for monitoring health security -- and as a preliminary step in an ongoing project to develop a Global Health Security Index -- we performed a scoping literature review to articulate foundational principles for measuring global health security. Our objective was to identify evidence-based principles that not only capture health security capabilities before and during infectious disease crises, but also a country’s baseline public health and healthcare capacities and its broader social, environmental, and political risk environments. Themes that emerged from the literature informed our selection of indicators and sub-indicators that could help conceptualize and quantify health security capacities at the country level. In this paper, we summarize the themes we identified in the literature and also offer suggestions for improving future efforts to measure country-level health security.


We conducted a scoping review of the biomedical and social science scholarly literature, as well as the gray literature. We searched PubMed, Web of Science, and OAIster using the search terms and search limits outlined in Fig. 1. Because this review extracted data from secondary sources and did not involve human subjects research, ethical approval was not required.

Fig. 1
figure 1

Search Terms Search Terms

Documents eligible for review included only English-language literature published after 2001—to ensure relevance to the current global health security landscape—until the end of the research period (September 2017). Sources were selected if they examined acute infectious disease threats with potential for transnational spread and addressed health security-strengthening efforts at the country level. Documents were excluded if they addressed health security at subnational levels (e.g. county-, district, and/or province-level); biological threats without national or international consequences; or plant, animal, or marine infectious disease threats without known implications for human health.

After exclusion of duplicate titles (i.e., those titles that came up in more than one search), all titles were reviewed by one researcher for relevancy using the above inclusion and exclusion criteria. For those included articles, the abstracts were then reviewed to determine relevancy. All articles deemed relevant were then read in its entirety by a researcher to identify recurrent themes and proxies for measuring global health security. Using NVivo software and a qualitative coding framework developed from a priori themes derived from the JEE and previous global health security research, we coded the documents iteratively, adding new codes to the framework as we identified additional global health security themes and indicators. From the coding process, we synthesized foundational principles for measuring global health security.

Availability of data and materials

The qualitative coding framework containing all of the themes we identified, and a full list of documents reviewed are provided in Additional file 1 and Additional file 2, respectively.


Our search initially yielded 1092 articles from PubMed, 440 articles from OAIster, and 356 articles from Web of Science (1888 total). We eliminated 396 duplicate documents, and, using the aforementioned criteria, eliminated another 1255 documents that were deemed irrelevant upon review of their titles and abstracts, producing a final set of 237 documents which were subsequently coded using NVivo 11 Pro qualitative software (see Fig. 2).

figure 2

Study Selection

Following are major thematic findings synthesized from our review of the literature, which could serve as foundational principles for measuring global health security. While these thematic findings were derived from our analysis of all 237 documents, we have cited only the documents that we deemed to be most illustrative of said themes within the body of this review. For reference, Additional fil 1 contains a full list of themes, matched with all of the corresponding documents from which they were extracted.

Measuring global health security requires analysis of existing prevention, detection, and response capacities, as well as efforts to build core public health, healthcare, and biosecurity capacities

Our review broadly affirmed the importance of assessing baseline country capacities for preventing, detecting, and responding to infectious disease threats, an approach widely adopted by existing assessment tools, including the JEE. We identified themes targeting three broad areas: performance of critical health security systems, biosafety and biosecurity, and public health preparedness. With respect to measuring system performance, the literature underscored the importance of assessing biosurveillance systems, emergency response systems, and public health laboratories [6,7,8]. Specific biosurveillance system capacities and capabilities include the presence of formal programs for monitoring influenza, foodborne pathogens, and wildlife; robust reporting mechanisms; and indicator-based, sentinel surveillance and early warning systems for outbreak detection [9, 10]. We found few descriptions of the operational capabilities required for emergency response; those identified include the ability to coordinate communication between emergency response partners, healthcare surge capacity, the presence of business continuity plans, and sustaining essential services during a crisis [11]. Many of the laboratory system performance themes we identified – including, but not limited to, the presence of national reference laboratories, the quality of diagnostic capacities for priority diseases, protocols for shipping hazardous specimens, and the presence of accreditation and biosafety policies – originated from the IHR Core Capacity Monitoring Framework (2013) [16].

Our review also highlighted the interdependence between global health security, biosecurity, and biosafety. As such, we sought to determine how best to capture the performance of national biosecurity and biosafety mechanisms [12,13,14]. Given that the definition of “biosecurity” often varies between countries, some of the themes we identified were similarly divergent [15].

Despite some differences in definition, the literature broadly affirmed that robust biosecurity and biosafety mechanisms are critical components of global health security. National laws, regulations, policies, and protocols for enforcing biosecurity and biosafety standards were broadly cited as important components of biosecurity and biosafety at the country level [16,17,18]. Additionally, the literature consistently underscored the importance of oversight and governance, particularly in the context of reducing risks in the life sciences: national select agent programs, institutional biosafety committees and other deliberative oversight bodies, codes of conduct and ethics, and educational initiatives for scientists and policymakers emerged as important features of robust oversight and governance mechanisms [18,19,20].

The literature also underscored the essential role of public health preparedness capacities in enhancing health security. Capacities for medical countermeasure development, deployment, and stockpiling – particularly of vaccines – were widely cited as important indicators of health security [21]. Other sources highlighted the importance of access to nonmedical countermeasures (e.g. personal protective equipment, masks, and respirators) in ensuring robust health sector responses to emergent threats [22]. Notably, though our review elicited some indicators for assessing healthcare delivery during infectious disease crises, few documents examined the roles of healthcare in global health security-strengthening efforts. Those that did addressed infection control in clinical settings; the merits and downsides of isolation and quarantine during severe outbreaks; surge capacities during public health crises and mass-casualty events; and coalition-building as a strategy for enhancing regional healthcare capacities [11, 22,23,24].

Our review also highlighted the importance of risk assessment, which was widely cited as an important tool for characterizing threats across the spectrum of biological risk [25,26,27]. The literature also emphasized the importance of measuring risk communication capabilities, given the social and economic costs associated with public anxiety, panic, and unrest that often accompanies health crises [28]. Finally, the themes of workforce availability and training cross-cut nearly every health security capacity identified in our review. Healthcare workforces and public health professionals in particular were singled out as critical frontline defenses against emergent threats [28, 29].

Assessments of national programs and efforts to mitigate a critical subset of priority threats could serve as useful proxies for measuring global health security

Zoonotic diseases trigger devastating economic losses in the agricultural industry and pose threats to human health, particularly for those working in poultry and swine operations. The literature indicated that infection control and occupational guidelines within these operations – including disinfection, vaccination, and use of personal protective equipment – could reduce the risk of disease transmission [30,31,32]. Programs and policies within the wild game industry (e.g. safe animal handling and regulation of trade between hunters and market owners) are also instrumental in reducing zoonotic transmission [33]. Disease surveillance among wild and domestic animal populations and collaborative approaches to threat mitigation between the human and animal health sectors were also cited as important safeguards against zoonotic disease outbreaks [33].

Widespread emergence of antimicrobial-resistant (AMR) pathogens has diminished the effectiveness of many first-line drugs. Thus, national standards, policies, and programs promoting antimicrobial stewardship (both in human and animal populations) could help mitigate AMR threats, thereby strengthening health security [31, 34]. Additionally, sentinel testing for drug resistance – including among pervasive infectious diseases such as tuberculosis – and increasing access to the diagnostic services needed to detect these pathogens are critical measures for reducing burdens of AMR pathogens [34].

Mass gatherings present additional health security challenges by amplifying the risk of disease transmission both in host countries and countries of returning attendees. As such, the frequency of mass gatherings, as well as the size, location, duration, and season of gathering, could serve as another indicator for measuring countries’ health security vulnerabilities; for example, outbreaks of bacterial meningitis linked to annual Hajj pilgrimages resulted in global spread in 1987 and 2000 [21, 35]. Implementing mandatory vaccination policies, as done by the Saudi Ministry of Health, could help mitigate disease transmission during mass gatherings [21]. Additionally, adherence to global standards for planning for mass gatherings (such as those developed by the WHO) emerged as another important factor to consider when assessing country-level health security [35]. Lastly, the literature noted that mass gatherings could become targets of deliberate biological attacks. In advance of the 2009 Beijing Olympics, for example, China enacted enhanced emergency preparedness measures, including stockpiling pharmaceuticals. Global health security measurements should ideally capture country-level capacities for implementing such measures against deliberate attacks [36].

In addition to efforts addressing mass gatherings, the literature cited national programs targeting risks associated with biotechnology and the life sciences as similarly important components of global health security [37,38,39,40]. The life sciences are a critical tool for advancing health security, but could pose threats in the hands of a malicious actor intending to cause deliberate harm. Policies and programs addressing dual research of concern, DURC (i.e. research that could be misused in a way that endangers the public’s health) could ensure proper oversight of entities working with potentially dangerous pathogens. Keys to successful oversight include cooperation between government, academia, the private sector, and law enforcement [41, 42].

There are measurable enabling factors that facilitate global health security-strengthening efforts

Historical experiences with infectious disease outbreaks can act as an impetus for biosecurity programs, policies, and funding needed to prevent future crises. For example, the September 2001 terrorist and anthrax attacks in the United States catalyzed increased spending and support for biodefense programs [8]. However, there are notable exceptions wherein prior experiences with catastrophic outbreaks in low- and middle-income countries do not always culminate in full preparedness and response capacities across a country or region. This phenomenon has been most recently illustrated by a major outbreak of Ebola in the Democratic Republic of the Congo and an outbreak of Lassa fever in Nigeria, despite the 2014–16 West Africa Ebola outbreak highlighting critical shortcomings in the region’s health security capacities [43, 44]. Still, examining how past crises subsequently trigger changes in spending and programmatic support could elucidate how country-level health security evolves over time.

Additionally, early disease detection and prevention depends on collaboration and communication between health authorities at local, national, regional, and international levels. International norms and strategies play important roles in promoting international collaboration and communication; the IHR, for example, include a directive for signatories to help build health security capacities in resource-poor countries [35, 45]. Other efforts, such as the One Health Initiative, have highlighted intersections between human, environmental, and animal health and the need for greater coordination between these sectors [10]. Evaluating adherence to established norms and incorporation of new approaches to preventing infectious disease crises could aid in determining a country’s collaborative efforts with international partners, as well as the extent to which its animal, human, and environmental health sectors have aligned to tackle emergent threats.

In addition to norms, laws, policies, and regulations also shape health security approaches and outcomes (and vice-versa), and their presence or absence could further modulate a country’s ability to mitigate infectious disease threats. Anema notes, for instance, that many IHR signatories have met the specified core capacity requirements for establishing national legislation and policy; among these states, those which “centralized and harmonized their public health policies and practices” demonstrated greater capacities for overall IHR compliance [16]. Additionally, geopolitical and economic instability were also found to modulate state vulnerability to health security threats; Linacre, for example, notes that countries with low GDPs and primarily agrarian economies are uniquely vulnerable to the threat of agroterrorism, given its potential to slow economic growth. Poor economies, in turn, could subsequently give rise to social unrest and insurgent activity [15].

In addition to highlighting linkages between law, policy, and global health security, the literature broadly affirmed the value of participation in global multilateral institutions (e.g. the World Health Organization; the Global Fund to Fight AIDS, Tuberculosis and Malaria; GAVI, the Vaccine Alliance; and UNAIDS) and compliance with international agreements aimed at strengthening global health security (e.g. the IHR, the Biological and Toxin Weapons Convention, the Cartagena Protocol on Biosafety) [8, 17, 46, 47]. However, at least one article noted that multilateral health initiatives run the risk of establishing parallel health service delivery systems and financing schemes that could disincentivize efforts to build and strengthen in-country mechanisms for mitigating infectious disease threats [17]. Therefore, metrics for evaluating the global risk environment should ideally assess a given country’s health security capabilities against its reliance on supranational governance structures and non-governmental funding streams.

With respect to local and regional collaboration around global health security, the literature highlighted the importance of engaging civil society and private-sector stakeholders, law enforcement, the intelligence community, academia, and political leaders [41, 42, 48, 49]. The extent to which these non-public health entities could serve as another indicator of the robustness of a country’s collaborative health security efforts. Formulation of national strategic plans that coordinate multisector efforts to prevent infectious disease crises could serve as an additional indicator for country-level health security. For example, the U.S. National Strategy for Countering Biological Threats offers guidance for averting catastrophic biological events that could threaten national security [50]. Additionally, funds and resources offered through national programs – such as those offered through the U.S.’s Hospital Preparedness Program – could further incentivize multisector collaboration [51].

Political leadership and commitment are instrumental in ensuring that health security remains a top priority. The U.S. federal government, for example, has launched global health programs, such as the President’s Emergency Plan for AIDS Relief, the President’s Malaria Initiative, the Global Disease Detection Program of the U.S. Centers for Disease Control and Prevention, and the Emerging Pandemic Threats Program through the United States Agency for International Development. Political support also helps ensure adequate funding for biosecurity programs, such as the U.S. Department of Defense Cooperative Threat Reduction Program Biological Threat Reduction Program and the U.S. Department of State Biosecurity Engagement Program. As such, the federal budget typically includes funds for “both biodefense and non-biodefense goals and applications,” which address a range of public health, healthcare, national security, and international security issues in addition to biosecurity, and improve preparedness and response [52, 51]. Globally, sustained financial investments also facilitate country progress toward meeting IHR benchmarks. Besides the U.S., other countries have made financial commitments to strengthening global health security, including Australia, which recently established an Indo-Pacific Centre for Health Security; Finland, which has assumed a leading role in advancing global health security efforts worldwide; Canada, through the Global Affairs Canada Weapons Threat Reduction Program and Public Health Agency Canada; and the Republic of Korea, made an early pledge of USD$100 million to support the Global Health Security Agenda [53,54,55,56].

Finally, legislative frameworks for biosecurity and biosafety may also be useful measures of country-level health security. The U.S. Federal Select Agent Program, for example, defines a set of microorganisms and toxins deemed to carry high risks of deliberate misuse and establishes strict security requirements for facilities working with designated high-priority agents; in 2017, the U.S. also implemented policies addressing oversight of pathogens with pandemic potential and enacted a brief moratorium on federally funded gain-of-function studies involving such pathogens [57, 58]. Similarly, in 2008, Israel passed the Regulation of Research into Biological Disease Agents Law, which calls for an oversight body to monitor research involving select, high-risk pathogens [59].

In addition, any legislative frameworks underpinning research should respect the rights of the individual, including ethical considerations when conducting human subject research, and also when implementing public health policies (i.e. quarantine and monitoring policies). Integration of such ethical considerations into legal frameworks will likely become increasingly important in the context of risks associated with biotechnology and the life sciences [60, 61].

Measuring global health security requires consideration of the risk environment from which infectious disease threats might emerge

The interplay between built and natural environments, climate, and human and animal activity is a critical determinant of global health security [62,63,64, 46]. Variable economic and political conditions, regulatory environments, modes of governance, laws, and policies concurrently shape state vulnerability to infectious disease threats. As such, the concept of the “risk environment” (i.e. the socioeconomic, political, regulatory, and ecological factors that could give rise to health insecurity) is a useful paradigm for measuring global health security in the context of a country’s unique baseline conditions. Additionally, geopolitical factors, such as the presence of extremist groups, ongoing conflict, and modes of governance should be considered when identifying sources of health insecurity.

Globalization was widely cited as a driving force behind transnational disease spread. Increasing travel, tourism, and trade were described as important promoters of economic growth, but ones that concomitantly elevate the risk of disease transmission among highly mobile populations connected through increasingly accessible modes of global transit [35]. Efforts to measure global health security might endeavor to capture this tension between protecting public health and ensuring unrestricted commercial activity, such as the presence of health checkpoints at ports of entry, trade embargoes, laws or policies restricting the trade of high-risk products, and safety standards for commercial goods. For example, following a 1986 outbreak of bovine spongiform encephalopathy in the United Kingdom, several countries banned imports of live ruminants and beef originating from the UK [47].

The literature also identified urbanization, changes in land use, and evolving agricultural practices as important components of the health security risk environment, given their roles in modulating disease spread between humans and animals, and creating conditions that could enable emergence of novel zoonoses [33, 65, 66]. The risks posed by increased proximity between human and animal populations manifests in other contexts as well; as noted previously, several documents described mass gatherings as potential catalysts of disease transmission, citing public health risks associated with the Hajj and the Olympic Games [21, 35]. Additionally, Brioudes and Gummow note that certain trade and agricultural practices – including swill feeding, illegal wildlife trading, and introductions of undeclared goods – could further heighten the risk of exposing emerging pathogens to susceptible human or animal populations [65].


Our review highlighted country-level considerations that could inform efforts to monitor global health security, including the presence of existing prevention, detection, and response capacities and capabilities; the presence of national programs, policies, and laws to mitigate various kinds of threats; coordination and communication between health authorities at all levels of government, as well as with other sectors (including public and private); political leadership that supports health security issues; as well as engagement in global multilateral institutions and an understanding of the risk environment.

There was considerable overlap between the themes identified in the literature and priorities outlined in the Global Health Security Agenda (GHSA), IHR, and JEE tool. Generally, the literature affirmed that many of the goals and indicators specified in both are valuable benchmarks for assessing baseline, country-level health security capacities. The prevent-detect-respond paradigm articulated in the GHSA serves as a useful organizing principle for conceptualizing global health security, and the JEE tool puts forth a valuable methodology for measuring both health security capacities and country progress toward IHR targets. The JEE also rightly prioritizes inter-sectoral discussion between agencies of national governments and is intended as a tool to begin the development of a national action plan for health security containing specific milestones to be filled and financed over a specific set of timeframes. Given that the JEE consists of subjectively assigned scores based largely on qualitative observation, the comparisons between countries and over years of the JEE process over time remains in question. Therefore, in addition to the JEE, efforts to measure global health security over time might benefit from focusing on outcome-based metrics that capture a country’s demonstrated prevention, detection, and response capabilities during an infectious disease outbreak. With respect to syndromic surveillance, for example, the JEE considers the size and coverage of a given surveillance system, its electronic reporting capacities, and its methods of data validation; by contrast, Glassman suggests that a country measuring the effectiveness of its syndromic surveillance systems should consider metrics such as rates of disease underreporting or numbers of misidentified cases [67]. Other such metrics for measuring functionality and effectiveness of surveillance systems could include whether a country has an established mechanism for regular sharing of surveillance data between human, animal, and environmental health authorities. While both approaches have merits and limitations, focusing on metrics that assess demonstrated capabilities against desired outcomes could also help countries chart actionable paths toward increased IHR compliance and greater health security.

We found little overlap between the global health security literature – which focuses primarily on acute infectious disease threats – and scholarly work on health system resilience, which encompasses a broader universe of core public health and healthcare assets and functions, such as health workforces, financing, universal health coverage, public risk communication, and integration between the sectors involved in mitigating infectious disease threats. Though our review yielded few tangible metrics for measuring healthcare sector performance, it did underscore the critical roles that healthcare capabilities play in strengthening country-level health security. As demonstrated during the 2014 Ebola outbreak, a healthcare sector’s ability to scale up operations in response to an accelerating threat, diagnose and isolate sick patients, and prevent the spread of infection in clinical settings – all while minimizing disruptions to routine healthcare delivery – are crucial determinants of an outbreak’s broader community impacts. However, current frameworks for assessing global health security – including the JEE – feature few indicators addressing core healthcare capacities and capabilities and their integration into emergency response activities. Given that a country’s infectious disease response capabilities depend on the broader functionality of its health systems, these core public health and healthcare capacities should figure more prominently in efforts to conceptualize and measure global health security. For example, researchers have already sought to identify global and public health core competencies for nursing education; a similar explication of core public health and healthcare functions essential to strengthening health security could enhance efforts to improve infectious disease threat mitigation [68].

Notably, our review also highlighted the importance of the risk environment. Historically, the risk environment framework has been used in the context of drug-related harm reduction activities, HIV prevention, and assessments of global nuclear security [69, 70]. However, many measurement efforts do not account for the full spectrum of social, political, and environmental risks that could give rise to, exacerbate, or mitigate infectious disease crises. Extrapolating the risk environment framework to encompass health security challenges at the population- and system-level underscores the interdependence between built, social, and natural environments, and better captures the potential for disease emergence at the human-animal-ecosystem interface. Furthermore, integrating economic, regulatory, and political considerations into measurements of global health security aligns with observed increases in global travel, migration, and commerce, as well as ongoing changes in land use, climate, and geopolitical stability.

In addition to the conceptual challenges associated with measuring global health security, several practical barriers continue posing technical challenges. Even with a strong theoretical foundation, measurement efforts might still be hindered by limited data availability. Many of the metrics employed in the JEE and other tools – both qualitative and quantitative – are not regularly or systematically collected in a standardized manner. Though alternative metrics could support more conceptually sound methods of measurement, poor data availability would still preclude their adoption and meaningful use. International organizations that routinely collect needed metrics should accelerate efforts to identify high-priority data needs, collect said data, and make them readily accessible to the public; the private sector might play an important role in making greater data availability a reality. Finally, although measuring global health security is a critical step in progressing toward greater IHR compliance, measurement alone cannot improve country-level health security capacities. As such, measurement efforts should be linked to incentives (i.e. funding and programmatic support) that promote capacity-building across all sectors involved in infectious disease mitigation.

Our investigation had a few limitations; namely, that the themes identified are a function of available published scholarship. The majority of the articles reviewed were produced by researchers representing predominantly high-income countries. As such, the literature skewed heavily toward themes (e.g. dual-use research of concern) that may not be top health security priorities for policymakers in lower-income countries with differing health security threat landscapes (e.g. greater risks from naturally emerging zoonoses) as compared to industrialized nations. Additionally, though we attempted to systematically review the gray literature, our search engines did not produce many of the foundational documents published by the WHO, ministries of health, and non-governmental groups in the health security space. Future efforts to measure global health security might benefit from additional, complementary modes of data collection, such as consultations with subject matter experts. This might also be useful in further refining those capacities and capabilities that are necessary in countries with poor healthcare and public health infrastructure. Finally, we acknowledge that there is ongoing debate over the definition of global health security itself, and that our inclusion and exclusion criteria – while reflective of the definition used by the WHO – might not have allowed us to identify literature proposing alternative definitions.


In light of ongoing international initiatives aiming to enhance global capacities and capabilities for infectious disease preparedness and response, the evidence-based themes identified in this review could inform efforts to systematically assess the impacts and effectiveness of activities undertaken to strengthen global health security.

Availability of data and materials

Not applicable. No original data were collected over the course of this study; all documents and articles examined are publicly available secondary sources (see Additional file 1 and Additional file 2.



Antimicrobial resistance


Global Health Security Agenda


International Health Regulations


Joint External Evaluation


World Health Organization


  1. World Health Organization. Report of the Ebola interim assessment panel. Geneva, Switzerland: World Health Organization; 2015.

    Google Scholar 

  2. Schoch-Spana M, Cicero A, Adalja A, et al. Global catastrophic biological risks: toward a working definition. Health Security. 2017;15(4).

    Article  PubMed  PubMed Central  Google Scholar 

  3. Harvard Global Health Institute, National Academy of Medicine. Monitoring Global Health Security and Pandemic Preparedness. Boston, Massachusetts. 2017.

  4. The National Academies of Sciences, Engineering, and Medicine. The Neglected Dimension of Global Security: A Framework to Counter Infectious Disease Crises. Washington, DC. 2016.

  5. Chatham House. Global Health crises: monitoring and reporting Progress towards preparedness; 2017. Available from: 2018.

  6. Andrus J, Aguilera X, Olivia O, Aldighieri S. Global health security and the international health regulations. BMC Public Health. 2010;10(1).

    Article  PubMed  PubMed Central  Google Scholar 

  7. Hamblion E, Salter M, Jones J. Achieving compliance with the international health regulations by overseas territories of the United Kingdom of Great Britain and Northern Ireland. Bull World Health Organ. 2014;92:836–43.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Honigsbaum M. Between securitisation and neglect: managing Ebola at the borders of global health. Med Hist. 2017;61(2):270–94.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Aledort JE, Lurie N, Wasserman J, Bozzette SA. Non-pharmaceutical public health interventions for pandemic influenza: an evaluation of the evidence base. BMC Public Health. 2007;7(208).

  10. Taboy C, Chapman W, Albetkova A, Kennedy S, Rayfield M. Integrated disease investigations and surveillance planning: a systems approach to strengthening national surveillance and detection of events of public health importance in support of the international health regulations. BMC Public Health. 2010;10(1):1–6.

    Article  Google Scholar 

  11. Courtney B, Toner E, Waldhorn R, Franco C, Rambhia K, Norwood A, et al. Healthcare coalitions: the new foundation for national healthcare preparedness and response for catastrophic health emergencies. Biosecur Bioterror. 2009;7(2):153–63.

    Article  PubMed  Google Scholar 

  12. Boisvert R, Kay D, Turvey C. Macroeconomic costs to large scale disruptions of food production: the case of foot- and-mouth disease in the United States. Econ Model. 2012;29:1921–30.

    Article  Google Scholar 

  13. Bork K, Halkjae-Knudsen V, Hansen J, Heegard E. Biosecurity in Scandinavia. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 2007;5(1):62–72.

    Article  Google Scholar 

  14. Colf L. Preparing for nontraditional biothreats. Health Security. 2016;14(1):7–12.

    Article  PubMed  Google Scholar 

  15. Linacre N, Koo B, Rosegrant M, Msangi S, Falck-Zepeda GJ, et al. Security analysis for Agroterrorism: applying the threat, vulnerability, consequence framework to developing countries. Washington, DC: International Food Policy Research Institute; 2005.

    Google Scholar 

  16. Anema A, Druyts E, Hollmeyer H, Hardiman M, KWilson K. Descriptive review and evaluation of the functioning of the international health regulations (IHR) annex 2. Glob Health. 2012;8(1).

    Article  PubMed  PubMed Central  Google Scholar 

  17. MacIntyre C. Biopreparedness in the age of genetially engineered pathogens and open access science: an urgent need for a paradigm shift. Mil Med. 2015;180:943–9.

    Article  PubMed  Google Scholar 

  18. Uhlenhaut C, Burger R, Schaade L. Protecting society. EMBO Rep. 2013;14(1):25–30.

    Article  CAS  PubMed  Google Scholar 

  19. Gottron F, Shea D. Oversight of high-containment biological laboratories: issues for congress. Washington, DC; 2009.

  20. World Health Organization. Responsible life sciences research for Global Health security: a guidance document. Geneva, Switzerland; 2010.

  21. Abd El Ghany M, Hazem S, Hill-Cawthorne G. Hajj vaccinations - facts, challenges, and hope. Int J Infect Dis. 2016;47:29–37.

    Article  PubMed  Google Scholar 

  22. Aledort J, Lurie N, Wasserman J, Bozzette S. Non-pharmaceutical public health interventions for pandemic influenza: an evaluation of the evidence base. BMC Public Health. 2007;7.

  23. Jacobs L. Rights and quarantine during the SARS global health crisis: differentiated legal consciousness in Hong Kong, Shanghai, and Toronto. Law & Society Review. 2007;41(3):511–52.

    Article  Google Scholar 

  24. Levi J, Inglesby T, Segal L, Vinter S. Pandemic flu preparedness: lessons from the frontlines. Washington, DC: Trust for America's Health; 2009.

    Google Scholar 

  25. Hennessey M, Lee B, Goldsmith T, Halvorson D, Hueston W, McElroy K, et al. Supporting business continuity during a highly pathogenic avian influenza outbreak: a collaboration of industry, academia, and government. Avian Dis. 2010;54:387–9.

    Article  PubMed  Google Scholar 

  26. Lev O, Samimian-Darash L. Biosecurity policy in the US: a critical assessment. Front Public Health. 2014;2(110):1–3.

    Google Scholar 

  27. Link H. Playing god and the intrinsic value of life: moral problems for synthetic biology. Sci Eng Ethics. 2013;19:435–48.

    Article  PubMed  Google Scholar 

  28. Briggs C. Communicating biosecurity. Med Anthropol. 2011;30(1):6–29.

    Article  PubMed  Google Scholar 

  29. Ijaz K, Kasowski E, Arthur R, Angulo F, Dowell S. International health regulations - what gets measured gets done. Emerg Infect Dis. 2012;18(7).

    Article  PubMed  PubMed Central  Google Scholar 

  30. Fasina F, Joannis T, Abolnik C, McCrindle C, Bisschop S. Community measures: a key to highly pathogenic avian influenza control in developing nations. Intern J Appl Res Vet Med. 2006;4(3):249–54.

    Google Scholar 

  31. Agunos A, Pierson FW, Lungu B, Dunn PA, Tablante N. Review of nonfoodborne zoonotic and potentially zoonotic poultry diseases. Avian Dis. 2016;60:553–75.

    Article  PubMed  Google Scholar 

  32. Artois M, Bicout D, Gavier-Widen D, et al. Outbreaks of highly pathogenic avian influenza in Europe: the risks associated with wild birds. Rev Sci Tech. 2009;28(1):69=92.

    Article  PubMed  Google Scholar 

  33. Heymann D, Dixon M. Infections at the animal/human interface: shifting the paradigm from emergency response to prevention at source. Curr Top Microbiol Immunol. 2013;366:207–15.

    PubMed  Google Scholar 

  34. Dar O, Hasan R, Schlundt J, et al. Antimicrobials: access and sustainable eff ectiveness: exploring the evidence base for national and regional policy interventions to combat resistance. Lancet. 2016;387:285–95.

    Article  PubMed  Google Scholar 

  35. Ahmed A, Barbeschi M, Memish Z. The quest for public health security at hajj: the WHO guidelines on communicable disease alert and response during mass gatherings. Travel Med Infect Dis. 2009;7:226–30.

    Article  PubMed  Google Scholar 

  36. Huang Y. Managing biosecurity threats in China. Biosecurity and Bioterrorism: Biodefense Strategy. Practice, and Science. 2007;9(1):31–40.

    Google Scholar 

  37. World Health Organization. Responsible life sciences research for global health security: a guidance document. Geneva, Switzerland: World Health Organization; 2010.

    Google Scholar 

  38. National Research Council of the National Academies. In: Academies TN, editor. Sequence-based classification of select agents. Washington, DC; 2010.

  39. Atlas R, Campbell P, Cozzarelli NR, Curfman G, Enquist L, Fink G, et al. Statement on the consideration of biodefence and biosecurity. Nature. 2003;421:771.

    Article  PubMed  CAS  Google Scholar 

  40. Burns K, Casadevall A, Cohen M, Ehrlich S, Enquist L, Fitch J, et al. Adaptations of avian flu virus are a cause for concern. Science. 2012;335:660–1.

    Article  Google Scholar 

  41. Hester S, Cacho O. The contribution of passive surveillance to invasive species management. Biol Invasions. 2017;19(737–48):737–48.

    Article  Google Scholar 

  42. Zuckerman M. Biosecurity: a 21st century challenge. New York City, NY: Carnegie Corporation of New York; 2005.

    Google Scholar 

  43. Gatherer D. Ebola returns to its Congo Basin heartland. J Gen Virol. 2018;99:861–3.

    Article  CAS  PubMed  Google Scholar 

  44. Du Toit A. Lassa fever outbreak in Nigeria. Nat Rev Microbiol. 2018;16:260.

    PubMed  Google Scholar 

  45. Baker M, Forsyth A. The new international health regulations: a revolutionary change in global health security. N Z Med J. 2007;120:1267.

    Google Scholar 

  46. Murray K, Skerratt L, Speare R, et al. Cooling off health security hot spots: getting on top of it down under. Environ Int. 2012;48:56–64.

    Article  PubMed  Google Scholar 

  47. Maye D, Dibden J, Higgins V, Potter C. Governing biosecurity in a neoliberal world: comparative perspectives from Australia and the United Kingdom. Environ Plan. 2012;44:150–68.

    Article  Google Scholar 

  48. Ho L, Tsai Y, Lee W, Liao S, Wu L, Wu Y. Taiwan's travel and border health measures in response to Zika. Health Security. 2017;15(2):185–91.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Sun X, Keim M, Dong C, Mahany M, Guo X. A dynamic process of health risk assessment for business continuity management during the world exposition Shanghai, China, 2010. J Bus Contin Emer Plan. 2014;7(4):347–64.

    PubMed  Google Scholar 

  50. Koblentz G. From biodefence to biosecurity: the Obama administration’s strategy for countering biological threats. Int Aff. 2012;88(1):131–48.

    Article  PubMed  Google Scholar 

  51. Toner E, Waldhorn R, Franco C, Courtney B, Rambhia K, Norwood A, et al. Hospitals rising to the challenge: the first five years of the U.S. hospital preparedness program and priorities going forward. Washington, DC; 2009.

  52. Katz R, Sorrell E, Kornbler S, Fischer J. Global Health security agenda and the international health regulations: moving forward. Biosecurity and Bioterrorism. Biodefense Strategy, Practice, and Science. 2014;12(5):231–8.

    Google Scholar 

  53. Kamradt-Scott A. Securing indo-Pacific health security: Australia’s approach to regional health security. Aust J Int Aff. 2018;72(6):500–19.

    Article  Google Scholar 

  54. Bell E, Tappero J, Ijaz K, et al. Joint external evaluation—development and scale-up of global Multisectoral health capacity evaluation process. Emerg Infect Dis. 2017;23:S33–9.

    Article  PubMed Central  Google Scholar 

  55. Nixon S, Lee K, Bhutta Z, et al. Canada's global health role: supporting equity and global citizenship as a middle power. Lancet. 2018;391(10131):1736–48.

    Article  PubMed  Google Scholar 

  56. Nuzzo J, Inglesby TUS. Global Health security investments improve capacities for infectious disease emergencies. Health Security. 2018;16:S1.

    Article  Google Scholar 

  57. U.S. Department of health and human services. Use, and Transfer of Select Agents and Toxins; Biennial Review; Final Rule. Washington, DC: Possession; 2012.

    Google Scholar 

  58. U.S. Office of the Assistant Secretary for Preparedness & Response. Gain-of-Function Research. 2019; Accessed March 25, 2019.

  59. Rager-Zisman B. Ethical and regulatory challenges posed by synthetic biology. Perspect Biol Med. 2012;55(4):590–607.

    Article  PubMed  Google Scholar 

  60. Minarcine S. Health security intelligence: assessing the nascent public health capability. Monterey, CA: Department of National Security Affairs, Naval Postgraduate School; 2012.

    Google Scholar 

  61. Selgelid M. Gain-of-function research: ethical analysis. Sci Eng Ethics. 2016;22:923–64.

    Article  PubMed  PubMed Central  Google Scholar 

  62. Canyon D, Burkle F, Speare R. Managing community resilience to climate extremes, rapid unsustainable urbanization, emergencies of scarcity, and biodiversity crises by use of a disaster risk reduction bank. Disaster Medicine and Public Health Preparedness. 2015;9(6):619–24.

    Article  PubMed  Google Scholar 

  63. Chrétien J. Adapting to health impacts of climate change in the Department of Defense. Health Security. 2016;14(2):86–92.

    Article  PubMed  Google Scholar 

  64. World Health Organization. In: Hales S, Kovats S, Lloyd S, Campbell-Lendrum D, editors. Quantitative risk assessment of the effects of climate change on selected causes of death, 2030s and 2050s. Geneva, Switzerland; 2014.

  65. Brioudes A, Gummow B. Field application of a combined pig and poultry market chain and risk pathway analysis within the Pacific Islands region as a tool for targeted disease surveillance and biosecurity. Prev Vet Med. 2016;129:13–22.

    Article  PubMed  Google Scholar 

  66. Graham J, Leibler J, Price L, Otte J, Pfeiffer D, Tiensin T, et al. The animal-human interface and infectious disease in industrial food animal production: rethinking biosecurity and biocontainment. Public Health Rep. 2008;123:282–99.

    Article  PubMed  PubMed Central  Google Scholar 

  67. Glassman A, Lofgren K. Getting serious on Global Health security. Global Health Policy Blog Washington, DC. 2016.

  68. Clark M, Raffray M, Hendricks K, Gagnon A. Global and public health core competencies for nursing education: a systematic review of essential competencies. Nurse Educ Today. 2016;40:173–80.

    Article  PubMed  Google Scholar 

  69. Rhodes T. The ‘risk environment’: a framework for understanding and reducing drug-related harm. The. Int J Drug Policy. 2002;13(2):85–94.

    Article  Google Scholar 

  70. NTI. NTI nuclear security index: building a framework for assurance, accountability, and action. Washington, D.C. 2018.

Download references


Not applicable.


The authors have no sources of funding to declare.

Author information

Authors and Affiliations



SR, DM, and JN developed the study design. SR and DM conducted the literature review, analyzed the findings, and drafted the manuscript. JN, EC, MN, and BP reviewed the manuscript and made additional contributions to the content.

Corresponding author

Correspondence to Sanjana J. Ravi.

Ethics declarations

Ethics approval and consent to participate

Not applicable. This study did not involve human subjects research and was therefore not required to undergo a review by an ethics committee.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Additional files

Additional file 1:

Coding Framework Coding Framework. The formal coding framework used to identify metrics in the literature for measuring global health security. The definition of each code is provided, along with the number of sources in which the code was used, and the number of times the code was used across all sources. (DOCX 29 kb)

Additional file 2:

GHS Literature Review. Comprehensive List of Literature Reviewed (alphabetical) The full list of gray & scholarly publications identified in our review. (DOCX 35 kb)

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ravi, S.J., Meyer, D., Cameron, E. et al. Establishing a theoretical foundation for measuring global health security: a scoping review. BMC Public Health 19, 954 (2019).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: