Urban Pandemic Preparedness Peer-Reviewed Literature

  • Abubakar I, Gautret P, Brunette GW, et al. (2012). Global perspectives for prevention of infectious diseases associated with mass gatherings. The Lancet, 12(1), 66-74.
    • Although definitions of mass gatherings (MG) vary greatly, they consist of large numbers of people attending an event at a specific site for a finite time. Cities are home to many MGs, including concerts, parades, rallies, and sporting events. This study assess risks of communicable diseases that are associated with MGs, outlines approaches to risk assessment and mitigation, and draw attention to some key challenges encountered by organizers and participants.
  • Agarwal, S, Bhanot, A, Goindi, G. (2005). Understanding and Addressing Childhood Immunization Coverage in Urban Slums. Indian Pediatrics, 42(7), 653-63.
    • Urban poor, many residing in slums, comprise about a quarter of India’s urban population. Immunization coverage among urban poor children is a dismal 43%. This paper attempts to understand the current scenario and challenges in improving immunization coverage in urban slums in India.  It also discusses possible mechanisms for effectively reaching the often left-out urban poor.
  • Aylwin CJ, König TC, Brennan NW, et al. (2006). Reduction in critical mortality in urban mass casualty incidents: analysis of triage, surge, and resource use after the London bombings on July 7, 2005. The Lancet, 368(9554), 2219–25.
    • The terrorist bombings in London on July 7, 2005, produced the largest mass casualty event in the UK since World War II. The aim of this study was to analyse the prehospital and in-hospital response to the incident and identify system processes that optimize resource use and reduce critical mortality. Critical mortality was reduced by rapid advanced major incident management and seems unrelated to over-triage. Hospital surge capacity can be maintained by repeated effective triage and implementing a hospital-wide damage control philosophy, keeping investigations to a minimum, and transferring patients rapidly to definitive care.
  • Bayram JD, Sauer LM, Catlett C, et al. (2013). Critical Resources for Hospital Surge Capacity: An Expert Consensus Panel. PLoS Currents, 5, ecurrents.dis.67c1afe8d78ac2ab0ea52319eb119688. 
    • The authors convened an expert panel representing health providers, administrators, emergency planners, and specialists, and asked them to review four disaster scenarios and prioritize 132 hospital resources. Of the 132 hospital resources, 25 were considered critical for all four scenarios by more than 50% of the participants.  The absence of any these resources may compromise patient care. Intravenous crystalloid solution was the only resource ranked by all participants as critical across all scenarios.
  • Bell DM, Weisfuse IB, Hernandez-Avila M, et al. (2009). Pandemic Influenza as 21st Century Urban Public Health Crisis. Emerging Infectious Diseases, 15(12), 1963–69.
    • The percentage of the world’s population living in urban areas is rapidly increasing. Crowded urban areas in developing and industrialized countries are uniquely vulnerable to public health crises and face daunting challenges in surveillance, response, and public communication. The revised International Health Regulations require all countries to have core surveillance and response capacity by 2012. Innovative approaches are needed because traditional local-level strategies may not be easily scalable upward to meet the needs of huge, densely populated cities, especially in developing countries. The responses of Mexico City and New York City to the initial appearance of influenza A pandemic (H1N1) 2009 virus during spring 2009 illustrate some of the new challenges and creative response strategies that will increasingly be needed in cities worldwide.
  • Boyce MR., Katz R., Standley CJ. (2019). Risk Factors for Infectious Diseases in Urban Environments of Sub-Saharan Africa: A Systematic Review and Critical Appraisal of Evidence. Tropical Medicine and Infectious Diseases, 4(4), 123. DOI: 10.3390/tropicalmed4040123.
    • Urbanization is having a profound effect on global health and could significantly impact the epidemiology of infectious diseases. A better understanding of infectious disease risk factors specific to urban settings is needed to plan for and mitigate against future urban outbreaks. This paper is a systematic literature review of the Web of Science and PubMed databases to assess the risk factors for infectious diseases in the urban environments of sub-Saharan Africa. The papers reviewed covered 31 countries in sub-Saharan Africa with East Africa being the most represented sub-region. Malaria and HIV were the most frequent disease focuses of the studies.
  • Covello VT, Peters RG, Wojtecki JG, et al. (2001). Risk Communication, the West Nile Virus Epidemic, and Bioterrorism: Responding to the Communication Challenges Posed by the Intentional or Unintentional Release of a Pathogen in an Urban Setting. Journal of Urban Health, 78(2), 382–92.
    • The intentional or unintentional introduction of a pathogen in an urban setting presents severe communication challenges. Risk communication—a science-based approach for communicating effectively in high-concern situations—provides a set of principles and tools for meeting those challenges. This article presents a brief overview of the risk communication theoretical perspective and basic risk communication. The risk communication perspective is applied to the West Nile virus epidemic in New York City in 1999 and 2000 and to a possible bioterrorism event. The purpose is to provide practical information on how perceptions of the risks associated with a disease outbreak might be perceived and how communications would be best managed.
  • Dalziel BD, Pourbohloul B, Ellner SP. (2013). Human mobility patterns predict divergent epidemic dynamics among cities. Proc R Soc Bio, 280, 20130763.
    • This article investigates whether systematic differences in human mobility patterns are sufficient to cause inter-city variation in epidemic dynamics for infectious diseases spread by casual contact between hosts. Using census data from 48 Canadian cities, the authors conclude that systematic variation in mobility patterns is sufficient to cause significant differences among cities in infectious disease dynamics — even among cities of the same size. This suggests that differences among cities in host contact patterns are sufficient to drive differences in infectious disease dynamics.
  • Dalziel BD, Kissler S, Gog JR, et al. (2018). Urbanization and humidity shape the intensity of influenza epidemics in U.S. cities. Science, 362(6410), 75–79.
    • Influenza epidemics vary in intensity from year to year, driven by climatic conditions and by viral antigenic evolution. This study demonstrates predictable differences in influenza incidence, driven by fluctuations in humidity and modulated by population size, suggesting that influenza control measures could work differently in large metropolitan areas compared to small towns.
  • Eastman AL, Rinnert KJ, Nemeth IR, et al. (2007). Alternate site surge capacity in times of public health disaster maintains trauma center and emergency department integrity: Hurricane Katrina. Journal of Trauma, 63(2), 253–57.
    • Hospital surge capacity has been advocated to accommodate large increases in demand for healthcare; however, existing urban trauma centers and emergency departments (TC/EDs) face barriers to providing timely care even at baseline patient volumes. This study sought to describe how alternate-site medical surge capacity absorbed large patient volumes while minimizing the impact on routine TC/ED operations immediately after Hurricane Katrina. The authors concluded that alternate-site medical surge capacity provided for the safe and effective delivery of care to a large influx of patients seeking urgent and emergent care. This protected the integrity of existing public hospital TC/ED infrastructure and ongoing operations.
  • Foote M, Daver R, Quinn C. (2015). Using “Mystery Patient” Drills to Assess Hospital Ebola Preparedness in New York City, 2014-2015. Health Security, 15(5), 500–08
    • In response to the Ebola virus disease (EVD) outbreak in West Africa, rapid measures were taken to ensure readiness at frontline New York City (NYC) healthcare facilities, including mandating monthly EVD mystery patient drills to test screening protocols. This study analyzed after-action reports to describe the use of mystery patient drills to test rapid identification and isolation of potential EVD cases in NYC emergency departments. Themes for improvement included ensuring timely screening, staff competency with personal protective equipment (PPE), and clarifying notification procedures and staff roles. Mystery patient drills gave hospitals the means to test screening and isolation protocols and identify key gaps, such as competency-based training in PPE, to improve their capacity to respond to highly communicable diseases. Findings from this study will inform the development of a standardized mystery patient drill program.
  • Hadi T, Fleshler K. (2016). Integrating Social Media Monitoring Into Public Health Emergency Response Operations. Disaster Medicine and Public Health Preparedness, 10(5), 775–80
    • The authors describe how social media monitoring was used during public health emergency responses in New York City, including Ebola and Legionnaire’s responses and for planned events. They offer concepts and implementations that can be applied to those who want to build a social media monitoring team.
  • Hoffman LM. (2013). The return of the city‐state: urban governance and the New York City H1N1 pandemic. Sociology of Health & Illness, 35, 255–67.
    • This article examines New York City’s response to the 2009 H1N1 pandemic in the context of the post‐9/11 US security regime. While the federal level ‘all‐hazards’ approach made for greater depth of support, it also generated unrealistic assumptions at odds with an effective local response. The combination of structurally induced opportunity and actor-specific strengths made for effective local governance by the New York City Department of Health and Mental Hygiene. By underlining the importance of locality as a first line of defense and linking defense function to policy initiative in regard to health governance, this study illustrates the relevance of institutional city structure. 
  • Katz R, Mookherji S, Kaminski M, et al. (2012). Urban Governance of Disease. Administrative Sciences, 2, 135–47.
    • Rapid population growth, urbanization, and the growing challenges faced by the urban poor require redefining the paradigm for public health interventions in the 21st century, creating new approaches that take urban determinants of health into consideration. The widening disparity between the urban poor and the urban rich further exacerbates health inequities. Existing tools for global governance of urban health risks fall short, particularly in the lack of formal mechanisms to strengthen collaboration and communication among national and municipal agencies and between their local and international non-governmental partners. There is also a clear disconnect between governance strategies crafted at the international level and implementation on the ground. The challenge is to find common ground for global goods and municipal needs, and to craft innovative and dynamic policy solutions that can benefit some of the poorest citizens of the global urban network.
  • Khan K, McNabb SJ, Memish ZA, et al. (2012). Infectious disease surveillance and modelling across geographic frontiers and scientific specialties. The Lancet, 12(3), 222-30
    • Infectious disease surveillance for mass gatherings (MGs) can be directed locally and globally, but epidemic intelligence from these two levels is not well integrated. Historically, modeling activities related to MGs have focused on crowd behaviors and their relation to the safety of attendees. Integrating these efforts with recent developments in internet-based disease surveillance, migration modeling, mobile phone technology surveillance, metapopulation epidemic modeling, and crowd behavior modeling is important for progress. Integrating these efforts could help identify infectious disease threats of international concern at the earliest stages possible; provide insights into which diseases are most likely to spread into the MG; help with anticipatory surveillance at the MG; enable mathematical modelling to predict the spread of infectious diseases ; simulate the effect of public health interventions aimed at different levels; serve as a foundation for scientific research and innovation in MG health; and strengthen engagement between the scientific community and stakeholders at local, national, and global levels.
  • Kissler SM, Gog JR, Viboud C, et al. (2018). Geographic transmission hubs of the 2009 influenza pandemic in the United States. Epidemics, 
    • Current knowledge suggests densely-populated, well-connected areas play an important in the spread and epidemiology of infectious diseases. However, for pandemic influenza, epidemiological data have not been detalied enough geographic resolution to test this assumption. This study makes use of fine-scale influenza-like illness incidence data derived from  medical claims records gathered across the United States to identify the key geographic sites of the autumn wave of the 2009 A/H1N1 influenza pandemic. Results show that, counterintuitively, large and well-connected cities did not play the largest role in the spread, indicating that factors beyond population density and travel volume are necessary to explain the  sites of the pandemic.
  • Koh HK, Shei AC, Bataringaya J, et al. (2006). Building Community-Based Surge Capacity Through A Public Health And Academic Collaboration: The Role Of Community Health Centers. Public Health Reports, 121(2), 211–16.
    • This article describes a collaboration among community health centers, government agencies, and academia in the Boston metropolitan area to develop community-based surge capacity. The project is described in detail and lessons learned about how community health centers can expand health care capacity to supplement, support, and extend efforts are discussed.
  • Kyriacou DN, Dobrez D, Parada JP, et al. (2012). Cost-Effectiveness Comparison of Response Strategies to a Large-Scale Anthrax Attack on the Chicago Metropolitan Area: Impact of Timing and Surge Capacity. Biosecurity and Bioterrorism : Biodefense Strategy, Practice, and Science, 10(3), 264–79.
    • This study examines the cost-effectiveness of a response to an anthrax attack in a major metropolitan area based on pre- and post-attack prophylaxis and/or vaccination. Results indicate that post-attack response involving antibiotic prophylaxis and vaccination of all exposed people represents the most cost-effective response strategy for a large-scale anthrax attack. 
  • Lim S, Closson T, Howard G, et al. (2004). Collateral damage: the unforeseen effects of emergency outbreak policies. The Lancet Infectious Diseases, 4(1), 697-703.
    • The 2003 SARS outbreak took Toronto, Ontario, and Canada, by surprise. It has been estimated that the outbreak cost the Toronto-area economy over $1 billion. To the credit of those involved, extraordinary measures were quickly devised and disseminated, and the outbreak was contained. However, a lack of planning and the decentralized nature of the health-care system meant that these control measures were quite disruptive. Several of the control strategies were difficult to implement and resulted in considerable confusion, fear, and costs. This article discusses these challenges and offers suggestions for improving outbreak planning.
  • Madad SS, Masci J, Cagliuso NV Sr., et al. (2016). Preparedness for Zika Virus Disease — New York City, 2016. MMWR Morb Mortal Wkly Rep, 65, 1161–65.
    • NYC Health + Hospitals created a Zika Preparedness and Response Action Plan by building upon the framework established in 2014 to screen patients for possible exposure to Ebola virus disease. The Zika plan includes universal screening for travel-associated Zika virus exposure, signage and maps depicting areas with active Zika virus transmission, laboratory services, and timely linking of infected patients to appropriate care. A robust emergency preparedness and response program can help health care systems limit the effects of Zika virus and ensure appropriate screening, diagnosis, and care. Potentially effective strategies include modification of established and tested protocols, offering ongoing health care provider education, and close collaboration with state and local health departments for Zika guidance and support.
  • Madad SS, Tate A, Rand M, et al. (2018). Zika Virus Preparedness and Response Efforts Through the Collaboration Between a Health Care Delivery System and a Local Public Health Department. Disaster Medicine and Public Health Preparedness, 1-3.
    • This article reports on the Zika response in New York City. By leveraging an existing relationship, NYC Health+Hospitals worked closely with New York City Department of Health and Mental Hygiene to ensure that Zika-related processes and procedures within NYC Health+Hospitals facilities aligned with the most current Zika virus guidance. The coordination, collaboration, and communication between the health care delivery system and the local public health department examined in this article demonstrate the importance of working together to combat a complex public health emergency and how this relationship can serve as a guide for other jurisdictions to optimize collaboration between external partners during major outbreaks, emerging threats, and disasters that affect public health. 
    • The response to the Ebola outbreak in Port Harcourt commenced with the investigation of a suspected case of Ebola – a medical doctor who had treated a primary contact of the index case in Lagos, Nigeria. This paper discusses the strategies and activities implemented by two units involved in contact tracing in response to the outbreak.
  • McCloskey B, Endericks T, Catchpole M, et al. (2014). London 2012 Olympic and Paralympic Games: public health surveillance and epidemiology. The Lancet, 383(9934), 2083-89.
    • Mass gatherings (MGs) are regarded as potential risks for transmission of infectious diseases and might compromise the health system of areas in which they are hosted. This paper details the planning and the surveillance systems that were used to monitor public health risks during the London Olympic and Paralympic Games of 2012, and draw attention to the public health issues—infectious diseases and chemical, radiation, and environmental hazards—that arose.
  • Munster VJ, Bausch DG, de Wit E, et al. (2018). Outbreaks in a Rapidly Changing Central Africa — Lessons from Ebola. NEJM, DOI:10.1056/NEJMp1807691.
    • The authors of this perspective piece discuss how various demographic, social, and economic factors – including urbanization – contributed to the unprecedented size of the 2014 Ebola outbreak. They conclude that the rapidly many developing Central African countries have not adequately invested in health care infrastructure. Thus, strong international commitments will be necessary to prevent devastating infectious disease outbreaks in the future. 
  • National Academies of Sciences, Engineering, and Medicine. (2018). Urbanization and slums: Infectious diseases in the built environment: Proceedings of a workshop. Washington, DC: The National Academies Press.
    • As the world becomes increasingly urbanized and interconnected, infectious diseases—both existing and emerging—will pose a serious and rapidly escalating threat to urban populations if left unaddressed. The proceedings of this workshop aim to describe the role of the built environment in the emergence and reemergence of infectious diseases that affect human health.
  • Fawole O, Dalhat M, Park M, et al. (2017). Contact tracing following outbreak of Ebola virus disease in urban settings in Nigeria. The Pan African Medical Journal, 27(S1), 8. 
    • An outbreak of Ebola virus disease occurred in Nigeria between July and September 2014. Contact tracing commenced in Lagos, and extended to Port Harcourt and Enugu as the outbreak continued to spread. This case study aims to help trainees to review concepts, apply skills, and address challenges for contact tracing based on the experience of the Nigerian Field Epidemiology Training Network during the 2014 Ebola virus disease outbreak.
  • Pfeifer JW,  Roman O. (2016). Tiered Response Pyramid: A System-Wide Approach to Build Response Capability and Surge Capacity. Homeland Security, 12(5), 1–19.
    • Today’s expanding disaster landscape demands crisis managers to configure their organizations to handle a wider range of extreme events. This requires more varied capabilities, capacity and delivery of services. The article proposes that crisis managers must move away from organization-centered planning to a system-wide approach for preparedness. We lay out the limitations of using the current tiered response triangle for planning and argue for implementing a system-wide approach by using a Tiered Response Pyramid to increase response capabilities and surge capacity for large scale disasters. The tiered response pyramid offers crisis managers a way to visualize multiple response options that leverage each other’s resources and create a more resilient response system for complex events.
  • Quinn CS. (2008). Crisis and Emergency Risk Communication in a Pandemic: A Model for Building Capacity and Resilience of Minority Communities. Health Promotion Practice, 9 (4), 18S–25S.
    • The author discusses challenges public health agencies face when communicating risk to certain populations during a pandemic. Recommendations are made for a risk communication strategy based on community engagement, disaster risk education, and crisis and emergency risk communication to help prepare minority communities and government agencies to prepare, respond, and work together in a pandemic.
  • Qureshi K, Gershon RRM, Sherman MF, et al. (2005). Health care workers’ ability and willingness to report to duty during catastrophic disasters. Journal of Urban Health: Bulletin of the New York Academy of Medicine,  82(3), 378–88.
    • This study describes a survey conducted to determine responsiveness and willingness of healthcare workers to work during disasters. Greater than 6,400 New York City healthcare workers participated in the survey. Results show that workers were least willing during a SARS outbreak (48%), radiological event (57%), smallpox epidemic (61%), and chemical event (68%). Barriers included childcare, elder care, and pet care, but the authors noted that many barriers were also open to interventions.
  • Hatchett RJ, Mecher CE, Lipsitch M. (2007). Public health interventions and epidemic intensity during the 1918 influenza pandemic. Proceedings of the National Academy of Sciences of the United States of America, 104(18), 7582-87.
    • >Hatchett and colleagues examined 19 categories of public health responses in 17 cities during the first 16 weeks of the 1918 influenza pandemic to determine their effectiveness. They found that early interventions were most effective in lowering peak death rates and that early closures of schools, churches, and theaters were associated with lower peak excess death rates.
  • Rinchiuso-Hasselmann A, Starr DT, McKay RL, et al. (2010). Public compliance with mass prophylaxis guidance. Biosecurity & Bioterrorism, 8(3), 255-63.
    • These authors discuss the results from a series of focus groups conducted by the New York City Department of Health and Mental Hygiene to determine what improvements could be made to public communication and education plans to ensure that public adherence to instructions issued during an emergency that required mass antibiotic distribution. Most participants indicated a willingness to actively participate in emergency response and to follow directions issued by authorities and expressed a universal desire for education on both dispensing plans and diseases before an incident occurs. The most trusted sources for information dissemination were mayors,  city health commissioners, and a local cable news outlets.
  • Shapiro JS, Genes N, Kuperman G., et al. (2012). Health Information Exchange, Biosurveillance Efforts, and Emergency Department Crowding During the Spring 2009 H1N1 Outbreak in New York City. Annals of Emergency Medicine, 55(3), 274–79.
    • These authors examine how healthcare practitioners in New York City used health information exchange networks to share clinical data among otherwise unaffiliated providers during the 2009 H1N1 outbreak. Though much work remains to be done to leverage the full potential of health information exchange, health information exchange may prove a crucial tool in unburdening data gathering during a public health crisis.
  • Saunders-Hastings P,  Hayes BQ, Smith R, et al. (2017). Modelling community-control strategies to protect hospital resources during an influenza pandemic in Ottawa, Canada. PLoS ONE, 12(6): e0179315. 
    • This study models the effects various strategies to control an influenza pandemic on hospital capacity. Results show that vaccination, isolation, and personal protective measures to be the most effective strategies. However, all interventions decreased in effectiveness as transmissibility increased and as the outbreak progressed.
  • Sundaram N, Schaetti C, Purohit V, et al. (2014). Cultural epidemiology of pandemic influenza in urban and rural Pune, India: a cross-sectional, mixed-methods study. BMJ Open, 4, e006350.
    • This study sought to identify and compare sociocultural features of pandemic influenza with reference to illness-related experience, meaning and behavior in urban and rural areas of India. The most common perceived causes for illness—‘exposure to a dirty environment’ and ‘cough or sneeze of an infected person’–were more prominent in the urban group. The most widely reported home treatment was herbal remedies and symptom relief was more of a priority for urban respondents. Government health services were preferred in the urban communities, and rural residents relied more than urban residents on private facilities. The important preventive measures emphasized were cleanliness, wholesome lifestyle and vaccines, and more urban respondents reported the use of masks.
  • TariVerdi M, Miller-Hooks E,  Kirsch T. (2018). Strategies for Improved Hospital Response to Mass Casualty Incidents. Disaster Medicine and Public Health Preparedness, 1–13.
    • Mass casualty incidents are a concern in many urban areas. A community’s ability to cope with such events depends on the capacities and capabilities of its hospitals for handling a sudden surge in demand of patients with resource-intensive and specialized medical needs. This paper uses a whole-hospital simulation model to replicate medical staff, resources, and space for the purpose of investigating hospital responsiveness to mass casualty incidents and provides details of probable demand patterns of different mass casualty incident types in terms of patient categories and arrival patterns, and accounts for related transient system behavior over the response period.
  • Teich A, Lowenfels AB, Solomon L, et al. (2018). Gender disparities in Zika virus knowledge in a potentially at-risk population from suburban New York City. Diagnostics Microbiology & Infectious Disease, S0732-8893(18), 30226-28.
    • This study assessed the level of knowledge about Zika virus transmission in an underserved, predominantly Hispanic, mixed gender population living in suburban New York City, many of whom potentially travel to affected regions. Based on a convenience sample of 147 participants, most were aware of Zika virus transmission by mosquitoes, transmission from a pregnant female to the fetus, and to a lesser extent, were aware of sexual transmission. Age, marital status, education, and native language were unrelated to knowledge, but women were significantly more likely than men to know about sexual transmission and about maternal transmission to the fetus. 
  • Williams SH, Che X, Paulick A, et al. (2018). New York City house mice (Mus musculus) as potential reservoirs for pathogenic bacteria and antimicrobial resistance determinants. mBio, 9, e00624.
    • Mice are commensal pests often found in close proximity to humans, especially in urban centers. These researchers surveyed mice from seven sites across New York City and found multiple pathogenic bacteria associated with febrile and gastrointestinal disease as well as an array of antimicrobial resistance genes.
  • von Gottberg C, Krumm S, Porzsolt F, et al. (2016). The analysis of factors affecting municipal employees’ willingness to report to work during an influenza pandemic by means of the extended parallel process model (EPPM). BMC Public Health, 16, 26–38.
    • This study describes results from greater than 1,500 (non-healthcare) employees in a major German city. Results indicated that nearly 20% would not be willing to report in the event of a pandemic, primarily because of perceived risk of infection and risk of infecting loved ones.
  • Yasuda H, Yoshizawa N, Kimura M, et al. (2008). Preparedness for the Spread of Influenza: Prohibition of Traffic, School Closure, and Vaccination of Children in the Commuter Towns of Tokyo. Journal of Urban Health, 85(4), 619-35.
    • In Greater Tokyo, many people commute by train between the suburbs and downtown Tokyo. This study analyzed the simulated spread of influenza in commuter towns along a suburban railroad, using validated methods. The study concludes that the prohibition of traffic was not effective after the introduction of influenza into the commuter towns, but, if implemented early, it was somewhat effective in delaying the epidemic. School closures delayed the epidemic and reduced the peak of the disease, but was not as effective in decreasing the number of infected people. Vaccination of school children decreased the numbers not only of infected children but also of infected adults in the regional communities.
  • Zumla A, Azhar EI, Hui DS, et al. (2018). Global spread of antibiotic-resistant bacteria and mass-gathering religious events. The Lancet Infectious Diseases, 18(5), 488–90.
    • Mass gathering events can provide conditions ideal for bacterial transmission and colonization among attendees through the feco–oral and respiratory routes, because of close contact and overcrowding, and poor hygiene and sanitation. This also holds significance for the increasing threat of antimicrobial resistance (AMR). Defining the global burden of symptomatic and asymptomatic infections, transmission risk, determinants of resistance evolution, and patterns of transmission and spread of AMR will require concerted multidisciplinary collaborative efforts across all continents.