In January 2015, CDC technical staff commenced working with ministries of health (MOHs) and other partner country counterparts to assess baseline capacities related to 11 GHSA technical areas. By June 2015, annual country work plans had been developed, detailing activities through which CDC would assist countries in achieving their first-year objectives in each technical area. The level and nature of CDC support varied across activities depending on technical assistance needs, inputs from other collaborators, and host country and donor financing. CDC staff reported on activity progress on a quarterly basis. Reports indicated the status (i.e., completed, on track, delayed, or canceled) and described progress toward completion of each work plan activity. Reporting information was provided to CDC headquarters–based evaluators 4 times: December 2015, April–May 2016, July–August 2016, and October–November 2016. Results were used to improve and update work plans.

Trained CDC evaluators analyzed quarterly reporting data by technical area, objectives within technical areas, and activities within objectives. In May 2016, CDC evaluators analyzed reporting information for completed activities across all 17 Phase I countries and grouped results into the following categories: 1) real-time surveillance and reporting; 2) national laboratory system and biosafety/biosecurity; 3) workforce development; and 4) emergency management and Emergency Operations Centers (EOCs). This organizational framework reduced the likelihood of missing information because of misclassification, such as if different countries reported related activities in similar, but different, technical areas. For example, national laboratory system and biosafety/biosecurity activities were batched for analyses to ensure all relevant laboratory activities were analyzed together. Activities in other technical areas were analyzed in November 2016.

A CDC evaluator analyzed the completed activity descriptions, objective descriptions, and activity progress data across all Phase I countries for each of the 4 categories. A second CDC evaluator reviewed and validated the first evaluator’s analyses; discrepancies were discussed and resolved by a CDC subject matter expert familiar with GHSA technical areas and overseeing all analyses for consistency. Completed activities were summarized by using common terminology for similar major accomplishments achieved by countries with CDC support. (Data on accomplishments achieved by <6 countries are available but not shown here.) Evaluators provided CDC headquarters and field staff with lists of countries that had achieved each major accomplishment, so they could add a country that had not been identified through reporting data analyses or remove a country from an accomplishment category if appropriate. CDC field staff worked with MOHs in some countries to confirm that the revised language accurately reflected country progress.

In November 2016, this process was repeated for completed activities in all 11 technical areas, resulting in a final list that integrated all accomplishments organized into 4 categories (Tables 1–4). In April 2017, CDC field staff in all 17 countries confirmed that the partner country had achieved these major accomplishments with CDC assistance during April 2015–March 2017. CDC evaluators determined the number and proportion of countries that achieved each accomplishment with CDC support.

Overall, our analysis found that CDC supported 675 accomplishments across all 11 GHSA technical areas in 17 Phase I countries. These accomplishments reflect achievements in >6 countries (Tables 1–4). Eleven countries each achieved >40 of these accomplishments, and each of the 17 countries achieved >18.

During April 2015–March 2017, CDC supported 17 Phase I countries in achieving 675 accomplishments in 11 GHSA technical areas. Although GHSA is still in early stages of implementation, CDC’s support to countries has helped improve their capabilities, especially in the cross-cutting areas of public health surveillance, national laboratory systems, workforce development, and emergency response management. Accomplishments in these technical areas have also contributed to the countries’ progress in the other GHSA technical areas and IHR 2005 core capacities.

Robust surveillance networks linked with laboratory testing can enable early detection of public health threats before they escalate into outbreaks and threaten communities, nations, and the world. CDC’s efforts to build country capacity to detect potential outbreaks focused on increasing the numbers of diseases captured by surveillance and reporting systems, expanding these systems to include additional subnational jurisdictions and community-level surveillance, and strengthening processes to improve the timeliness and efficiency of communication across all levels.

CDC worked with health, agriculture, defense, and other ministries to broaden the types of pathogens and syndromes that can be detected by improved surveillance systems. As a result of CDC’s GHSA work, countries that previously had systems to monitor a limited range of potential public health threats are now better able to detect animal-to-human disease spillover, healthcare-associated infections, and other potential outbreaks by monitoring more diseases and syndromes systematically and frequently. Early detection of public health threats can lead to timely interventions to prevent escalation into major outbreaks (19–21). Phase I countries have already used improved surveillance data to inform prevention efforts. For example, increased surveillance of vaccine-preventable diseases resulted in community immunizations to prevent further spread of measles and other diseases in 13 countries, including Guinea, Indonesia, and Liberia, where vaccination coverages are low. Furthermore, CDC worked with Phase I countries to incorporate hands-on experience investigating potential outbreaks into FETPs.

Surveillance capacity-building efforts also focused on expanding geographic coverage. Public health surveillance and laboratory capacity have typically been concentrated in urban centers, limiting countries’ abilities to detect outbreaks in rural areas (20,22). CDC assisted Phase I countries with establishing integrated surveillance systems that share data across healthcare facilities, subnational jurisdictions (e.g., districts), and MOHs. CDC helped countries train surveillance officers throughout multiple levels of countries’ health systems. In addition to training field epidemiologists through FETPs, CDC helped countries enlist the help of community leaders in detecting threats early by training them on community-based disease surveillance and reporting to complement healthcare facility surveillance. Community-level disease monitoring has been shown to influence intervention efforts and reduce the incidence of disease and prevalence of premature death. For example, community health workers in West Africa used surveillance data to target immunizations and reduce the number of cases of vaccine-preventable meningococcal disease by half (23,24). These efforts aim to prevent outbreaks at the source before spreading rapidly within large cities or to other countries.

National laboratory systems are integral for assessing public health threats and targeting outbreak response efforts. Laboratory testing of specimen samples is necessary to confirm suspected public health threats identified through disease and syndromic surveillance (25). Timely confirmation of public health threats relies upon laboratory systems that link central reference laboratories with peripheral laboratories, securely and rapidly transport specimens from patients to laboratories, and efficiently report accurate test results from laboratories to patients and MOHs (26). CDC’s assistance has been vital to providing countries with diagnostic capabilities and establishing specimen transport systems to decrease the time from specimen collection to testing at a certified national public health laboratory. This work is necessary to confirm public health threats so response efforts can be directed appropriately. CDC’s training of laboratory technicians will empower countries to confirm potential outbreaks of a broader set of pathogens more accurately and expediently.

CDC worked with other US government entities and partner countries’ ministries of health, agriculture, and defense to address potential biosecurity threats, such as by ensuring that countries keep inventories and management plans for dangerous pathogens stored in laboratories. Countries applied CDC’s expertise to ensure proper laboratory management and biosafety certification, which are imperative for ensuring the integrity of the national laboratory system. This work is critical for preventing national and international public health emergencies by preventing potential biosecurity threats.

Trained field epidemiologists, laboratory technicians, and emergency responders are crucial for detecting and responding to public health threats early and effectively, and EOCs with incident management systems are essential for response coordination (27). In July 2014, when the major EVD outbreak was worsening in West Africa, CDC-trained disease detectives performed contact tracing on 894 contacts of EVD case-patients in Lagos, Nigeria (27); only 11 deaths in Nigeria resulted from this EVD outbreak, although models estimated thousands of deaths would have occurred without timely investigation and emergency management (19). This example illustrates the potential impact of GHSA implementation. Training disease detectives and developing effective incident management can mean the difference between small outbreaks that are quickly and effectively controlled and larger outbreaks with substantial global health implications. CDC established new FETPs in 16 Phase I countries to rapidly train disease detectives. CDC worked with Phase I countries to establish EOCs and train emergency response staff. A component of the training involved activating the EOC for exercises or real public health emergencies. These activations incorporated a multisectoral approach to bring together public health, animal health, border security, and other sectors. These efforts strengthen capacities and test countries’ abilities to respond to public health threats effectively and rapidly.

The accomplishments we describe have enhanced global health security, but GHSA relies on strong partnerships to sustain capacity-building efforts. CDC’s work has strengthened collaborations among countries, US government agencies, and international governments and organizations. While emphasizing a multisectoral approach for building GHSA capabilities, CDC uniquely provides direct technical assistance to MOHs, developing their expertise so they can sustain GHSA accomplishments. CDC worked with multiple partners, including national ministries of health, agriculture, and defense, to establish mechanisms for cross-sectoral communication and collaboration that are essential for outbreak prevention, detection, and response but did not exist before GHSA. CDC’s technical assistance complemented efforts by other nations and US government entities, including the US Agency for International Development, the Defense Threat Reduction Agency, and the US Department of Agriculture. Notably, the relatively small US investment in GHSA led to additional investments from other donor nations. For example, South Korea committed $100 million to build global health security capabilities in 13 countries (28).

In addition to technical assistance, CDC contributed to the development of the Joint External Evaluation (JEE) tool, an independent, transparent evaluation that employs 48 indicators to measure progress toward GHSA and IHR 2005 targets (12). A benefit of the JEE is its potential for standardizing metrics and streamlining CDC’s technical assistance across multiple countries. CDC worked with the World Health Organization and other partners to develop a library of achievements needed to advance from one level of capacity to higher levels (29). Most of the accomplishments we describe (Tables 1–4) are among the milestones in the library, with related JEE indicators associated with each. This work demonstrates the feasibility and effectiveness of these activities in the field. The milestones library, together with JEE scores, helps CDC standardize and streamline technical assistance to complement activities planned by other partners. Although the administrative efforts required to undergo the JEE delayed CDC’s activities in some countries, the JEE process has now been operationalized, and countries have built their evaluation capacities by completing these baseline assessments. As of September 2017, a total of 58 countries, including 14 Phase I countries, completed the JEE with CDC support, identifying countries’ IHR 2005 capabilities and the explicit gaps in need of prioritization.

Our report has a few limitations. First, this report is not comprehensive of all CDC’s GHSA achievements. It focuses on CDC-supported country accomplishments in 17 countries, excluding CDC’s GHSA achievements beyond Phase I countries, including in Ebola preparedness countries where CDC prioritized GHSA work to build detection and preparedness capabilities to prevent cross-border spillover of EVD and other disease threats. Also, in initial analyses, evaluators determined that some accomplishments had been achieved by <6 Phase I countries and thus omitted these from the list provided to CDC field staff for validation; however, >6 countries might have achieved some of these by March 2017. Furthermore, CDC field staff validated accomplishments subjectively based on their interpretations of standardized language, potentially resulting in underreporting or overreporting. Despite these limitations, this report describes substantial accomplishments in 17 countries that resulted directly from the technical assistance provided by CDC. These achievements align with GHSA targets, suggesting that CDC has helped these countries move closer to attaining IHR 2005 core capacities, thus creating a safer world.

In conclusion, GHSA was launched with a goal of making the world safer from infectious disease threats by improving countries’ IHR 2005 core capacities (4). CDC’s efforts have been critical as part of a long-term process of building and sustaining global health security capacity in countries with less-developed public health systems. Initial accomplishments have laid the groundwork for further GHSA advancement in these 17 countries, and lessons learned might improve the efficiency of GHSA implementation in additional countries. Ongoing GHSA implementation offers an alternative to the cycle of panic and neglect that describes the current response to pandemic threats (30). The initial successes we describe demonstrate that strategic appropriation of technical and financial resources can accelerate progress toward GHSA targets and global achievement of IHR 2005 core capacities. CDC’s continuing work with partner countries ensures sustainability and further progress rather than regression. Furthermore, investments in global health security have been shown to have positive health, security, and economic impacts (31,32). These improvements in international capacity to rapidly detect, respond to, and control infectious disease outbreaks and other public health threats at their sources translate into enhanced global health security, because fewer public health threats can spread throughout a country and reach other nations, including the United States.