Healthcare policy and delivery systems

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 Discussion:

 “Nurses often serve as frontline health care workers (HCWs), and as such are key to detection activities. (Mason et al; 2021).”

How can nurses and nursing organizations engage their communities in constructive ways when public health threats are imminent?

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MAKE DISCUSSION USING THIS CHAPTER OF THE BOOK THAT IS AS AN ATTACHED DOCUMENT


Infectious disease in a highly connected world: Nurses’ role to prevent, detect, respond

Catherine M. Dentinger, Amy R. Kolwaite

“With Ebola back in the Democratic Republic of the Congo, this year’s World Health Assembly sees the threat of pandemic diseases and the fragility of global health security once again at the forefront of the global health leaders’ minds.”

71st World Health Assembly, May 21, 2018 (retrieved from www.devex.com/news/what-to-watch-at-this-year-s-world-health-assembly-92787)

Not long ago, infectious diseases were thought to be well controlled through hygiene measures, vaccines, and antimicrobial medications, but that perspective has shifted. In the past 35 years, we have experienced infectious disease outbreaks in which global spread of severe infections has occurred due to an increasingly interconnected world. Timely detection of and efficient response to these events is key to limiting their magnitude and duration; this requires sustained attention, international engagement and coordination, and reliable resources. Nurses, the largest sector of the global health care workforce, are integral to preventing, detecting, and responding to these infectious disease threats.

Context

“Vaccines and antibiotics have made many infectious diseases a thing of the past; we’ve come to expect that public health and modern science can conquer all microbes. But nature is a formidable adversary.”

Dr. Tom Frieden, Centers for Disease Control and Prevention (CDC), February 2016

By the 1960s, advances in public sanitation, immunizations, and antimicrobials led to large declines in morbidity and mortality from infectious diseases in some countries and toward what was thought to be their eventual elimination as a human health concern (Burnet, 1962). However, just 20 years later, the human immunodeficiency virus (HIV) pandemic challenged that perspective. Since the first cases of what would become known as acquired immunodeficiency syndrome (AIDS) were described in the United States in 1981 (CDC, 1981), HIV infection has become endemic in most countries. An estimated 36.9 million people are infected worldwide, and 1.7 million new infections occurred in 2016 (Joint United Nations Programme on HIV/AIDS [UNAIDS], 2019). Across the subsequent decades, viruses including Zika, West Nile, Monkeypox, Chikungunya, Nipah, Ebola, and Dengue have become endemic or caused transmission in areas where they had not previously circulated (Hennessey, Fischer, & Staples, 2016; Parola et al., 2006; Reed et al., 2004; CDC, 1999a, 1999b, 2000, 2003, 2010; World Health Organization [WHO], 2014). During the 2002–2003 severe acute respiratory syndrome (SARS) coronavirus outbreak, we learned just how quickly a respiratory virus causing severe disease could spread across the world (Ruan, 2006). Resurgences of disease caused by measles virus, vaccine-derived poliovirus, and Vibrio cholera have occurred following natural disasters, migration, political conflict, and declines in vaccination rates (Cerda & Lee, 2013; Gardner et al., 2018; Macdonald & Hebert, 2010; CDC, 2013b). In addition, the prevalence of multidrug-resistant pathogens has increased due to many factors, including insufficient infection control and inappropriate antimicrobial use for human therapeutic interventions and as growth promoters in animal feed (Bronzwaer et al., 2002; Davies & Davies, 2010; Smith, Harris, Johnson, Silbergeld, & Morris, 2002; CDC, 2013a, 2013d; van Panhuis et al., 2013). Influenza viruses, which frequently mutate during replication and occasionally exchange entire genes, continue to cause substantial annual global mortality and intermittent pandemics (Dawood et al., 2009; Shinde et al., 2009; Subbarao et al., 1998). In short, the era of hubris with respect to infectious disease control was brief.

Pathogen introduction, transmission, and adaptation in human populations result from a complex interaction of host, agent, and environment and the adaption of microorganisms to pressures that are not completely understood (Enright et al., 2002; Jones et al., 2008; Wolfe, Dunavan, & Diamond, 2007). Lederberg et al. coined the term emerging infectious disease (EID) in 1992 to name this process and to expand the efforts needed to understand and respond to it (Lederberg, 1992; CDC, 1994). Conditions identified to date that facilitate the emergence of novel pathogens or the reemergence of infections that had been well controlled include population growth, urbanization, displacement, and poverty; climate change and ecosystem alterations; rapid global travel and commerce; and widespread use of antimicrobials. In addition, the intentional release of infectious pathogens also remains a concern (Arguin, Marano, & Freedman, 2009; Hollingsworth, Ferguson, & Anderson, 2007).

Population growth, urbanization, displacement, and poverty

“Annawadi itself was nothing special in the context of the slums of Mumbai. Every house was off-kilter, so less off-kilter looked like straight. Sewage and sickness looked like life.”

Katherine Boo, Behind the Beautiful Forevers: Life, Death, and Hope in a Mumbai Undercity

The United Nations (UN) estimates that 55% of the world’s growing population live in urban areas compared with 30% in 1950; most of this growth and urbanization is occurring in Asia and Africa (UN, 2018b). Migration of rural populations, often those in search of economic opportunity, has resulted in rapid growth of communities that have minimal social or health services, and inadequate housing and sanitation. These densely populated, poorly serviced areas pose challenges for preventing, identifying, and controlling infectious diseases (Afsana & Wahid, 2013). As human populations expand into new habitats and ecosystems, or closer to livestock and live animal markets, the potential for zoonotic disease transmission increases (Finucane & Spencer, 2013; Weaver, 2013; Yang, Utzinger, & Zhou, 2015). This is thought to have played a role in pathogen introduction into human populations including novel influenza viruses, HIV, Ebola virus, hantavirus, and tick-borne organisms such as those that cause ehrlichiosis and Lyme disease (Muehlenbein, 2012). Natural disasters, including those related to climate changes, and violent conflict also force rapid and unanticipated population movement (Haines, Kovats, Campbell-Lendrum, & Corvalan, 2006; McMichael, Woodruff, & Hales, 2006; Rajabali, Moin, Ansari, Khanani, & Ali, 2009). In June 2016, the United Nations High Commission on Refugees (UNHCR) estimated that 65.5 million people have been forcibly displaced (UN, 2018a). Displaced persons often relocate into haphazardly formed communities with limited access to basic services and may have poor baseline health and nutritional status and low vaccination rates. These characteristics may increase their risk of acquiring disease having poor outcomes and facilitating disease transmission (Gayer, Legros, Formenty, & Connolly, 2007; Henke-Gendo et al., 2009; Possas, 2016). Furthermore, in these communities, the public health infrastructure needed to respond to a threat is often lacking resulting in outbreaks that can rapidly escalate. For example, in refugee camps in the South Sudan, an outbreak of hepatitis E virus infection related to poor sanitation and contaminated drinking water sickened more than 5000 individuals and caused several deaths among pregnant women (CDC, 2013c). Outbreaks of diseases that were once eliminated or controlled can quickly resurface. The Syrian Arab Republic, which had been poliomyelitis free since 1999, experienced outbreaks of vaccine-derived poliomyelitis following the interruption of vaccination programs because of civil war (Mbaeyi et al., 2018; WHO, 2013). In contrast, when pathogens with epidemic potential are introduced in areas with a strong public health infrastructure, the outbreak can be effectively controlled. When individuals with cholera arrived in New York City from the island of Hispaniola, they were quickly identified and treated, and public health officials were immediately notified and could begin investigations; no secondary cases occurred (Newton et al., 2011).

Climate change and ecosystem alteration

“Everything we do has microbial consequence.”

Nicholas Ashbolt, PhD, School of Public Health, University of Alberta, 2013

As environmental conditions change, the distribution of microorganisms and their vectors may be altered, resulting in new exposures to pathogens. Climatic changes favoring wider distribution of the vector, Aedes aegypti and Aedes albopictus mosquitoes, for example, combined with rapid urbanization, may play a role in facilitating dengue virus infections (Colon-Gonzalez, Fezzi, Lake, & Hunter, 2013; Morin, Comrie, & Ernst, 2013). As the distribution of these mosquitoes has expanded, viral transmission is no longer limited to tropical and subtropical areas (WHO, 2012). Vector expansion can result in pathogen exposures in populations with no underlying immunity, potentially resulting in high rates of disease and new clinical presentations. Introduction of Zika virus into an immunologically naive population in rural Brazil in 2016 may have played a role in the high numbers of Zika virus congenital syndrome in their population (Possas, 2016).

Global travel and commerce

Globally, air travel has increased dramatically; the International Air Transport Association estimates that 3.8 billion individuals traveled by air in 2016 and that this number will nearly double by 2035 (International Air Transport Association, 2016). Humans travel for work and family obligations, to obtain health care services, and for leisure and may contribute importantly to the spread of disease (Hollingsworth et al., 2007). The 2002–2003 SARS epidemic highlighted just how quickly this can happen for respiratory pathogens, but travel can play a role in the transmission of other pathogens as well. In 2005, carbapenem-resistant Enterobacteriaceae (CRE) was isolated from a person hospitalized in France who had recently been hospitalized in the United States (Naas, Nordmann, Vedel, & Poyart, 2005). In 2008, a novel CRE isolate was cultured from a Swedish traveler who had recently been hospitalized in India (D. Yong et al., 2009).

Global commerce also influences the introduction of pathogens into populations. For example, much of the global food supply is grown, processed, and distributed via multinational networks that connect livestock and agricultural enterprises to processing, packaging, and distribution centers worldwide. The complexity and massive volume of these operations create opportunities for the introduction and rapid spread of pathogens and make detecting and controlling them challenging (Leibler et al., 2009). Products contaminated with microbial pathogens may be consumed far from their origin, resulting in widespread and difficult-to-trace outbreaks. In 2011 an outbreak of Listeria monocytogenes associated with cantaloupe from one U.S. farm sickened at least 147 individuals in 28 states, 33 of whom died (Cartwright et al., 2013; McCollum et al., 2013). In Europe, the same year, a novel strain of Escherichia coli that sickened nearly 4000 people and caused 53 deaths was eventually linked to seeds imported from Egypt, sprouted on a farm in Germany, and consumed throughout Europe (Buchholz et al., 2011). A single factory may process the same food item under different brand names, complicating investigations and recalls. In 2011, salmonella-contaminated peanut butter from a single processing plant sickened people in 20 U.S. states. Although only one brand of peanut butter was associated with illness, the plant produced peanut butter under different brand names (CDC, 2013e).

These are just a few examples of recent disease outbreaks that illustrate the complexities of human pathogen ecology. They also highlight the need to develop collaborative global partnerships that support timely and effective responses.

Global concern, global action

International health regulations

International cooperation to control infectious disease threats has a long history. The dawn of the modern era of these efforts is perhaps the International Sanitary Conference that was held in Paris in 1851 to address a cholera pandemic; these efforts continued as steamship use accelerated the introduction of plague, yellow fever, and cholera in ports around the world (Howard-Jones, 1974). Across the decades, as health threats changed, the rate of travel increased multifold, and gaps in control became apparent, efforts have had to be updated. The WHO, founded in 1948, has generally served as the coordinating body for these efforts.

After the 2002–2003 SARS coronavirus outbreak, the WHO adopted revised International Health Regulations (IHRs) in 2007. The IHRs are legally binding on WHO member states (Tappero et al., 2017; WHO, 2007). These regulations include goals for global surveillance for specific diseases as well as for responding to public health events of international concern (PHEIC). All member states are required to develop, strengthen, and maintain core surveillance and response capacities, facilitate cross-border cooperation, and provide logistic and financial support to improve capacity for these activities (WHO, 2007). The IHRs also promote improved coordination between different sectors, including agricultural authorities such as the Food and Agriculture Organization and the World Organization for Animal Health to reduce the potential for outbreaks from food, livestock, and wild animal sources (Newell et al., 2010; Pavlin, Schloegel, & Daszak, 2009).

Achieving the goals of the revised IHRs has been challenging, particularly in low-resource countries or those facing political instability and conflict. These areas are often the most at-risk for an infectious disease threat and least able to implement and sustain core activities (Guha-Spair, Hoyois, Wallemacq, & Below, 2016). Furthermore, the IHRs have not addressed the underlying health infrastructure weaknesses or the limited access to care and goods in many of these areas, both of which affect IHR adherence (Heymann et al., 2015). In addition, the revised IHRs have not adequately addressed appropriate global governance. For example, when Indonesia was unable to obtain influenza vaccine developed based on a strain they submitted for required surveillance, they stopped submitting strains altogether (Fidler, 2008). This left an important gap in global avian influenza surveillance; more importantly, it revealed inadequacies in governance and health rights. In response, pandemic influenza preparedness policies were updated to include a doctrine of equal benefits from equal sharing (WHO pandemic flu prep sharing viruses, 2007) (Fidler & Gostin, 2011).

More recent outbreaks, including the 2009 influenza A (H1N1) pandemic, the 2012 emergence of Middle East Respiratory Syndrome Coronavirus (MERS-CoV), and the 2014 Ebola virus disease (EVD) outbreak in West Africa, further highlighted the limited adherence to the IHRs in some areas (Bialek et al., 2014; WHO, 2018). The West Africa EVD outbreak, in particular, reinforced the need for sustained global support for IHRs and a recognition that shifting priorities away from these efforts may have contributed to the delayed and inadequate response (Fink S, 2014). It also forced a revisit of the connection between individual and collective health security: global health security is threatened when individuals do not have access to affordable essential health services, technologies, and medicines (Abramowitz, Hipgrave, Witchard, & Heymann, 2018; Heymann et al., 2015). In short, these events revealed that the revised IHRs require ongoing attention, review, and dedicated resources.

Global health security agenda

In response to the West Africa EVD outbreak, and to support countries to achieve core IHR capacities, the Global Health Security Agenda (GHSA), a partnership of nearly 50 nations, international organizations, and nongovernmental stakeholders, was launched in February 2014 (Frieden, Damon, Bell, Kenyon, & Nichol, 2014). The GHSA supports multilateral and multisector collaborations to strengthen national and international capacity to prevent, detect, and respond to infectious diseases threats resulting from naturally occurring, deliberate, or accidental events. Activities to strengthen these capacities, outlined in 11 action packages, have been agreed upon by all GHSA partners. Prevention activities focus on the systems, policies, and procedures to avoid outbreaks from antimicrobial resistant organisms, zoonotic, and vaccine-preventable diseases. Detection activities target strengthening national laboratory systems capable of accurate, timely surveillance, and reporting; and creating a workforce (e.g., clinicians, veterinarians, epidemiologists, laboratorians, administrators) who can meet relevant IHR core competencies. Response activities include developing Emergency Operations Centers; creating linkages between public health and other sectors; and training rapid response teams to engage international partners during public health emergencies (Frieden et al., 2014).

Role of nurses to prevent, detect, and respond to public health threats

Nurses at all levels of health care systems are vital to the success of the GHSA and to IHR adherence. Across the world, nurses are key to effective prevention activities in settings ranging from intensive care units to areas that lack health facilities altogether. In these settings, they also often serve as the first line of detection (International Council of Nurses, 2011). It was a New York City school nurse who identified a large cluster of students presenting with influenza-like illness to her clinic and alerted public health authorities in the early stages of the 2009 influenza A (H1N1) pandemic (Balter, Gupta, Lim, Fu, & Perlman, 2010; Buehler, 2012; Hartocollis, 2009). Nurses are frequently cited as the most trusted professionals and as such may be uniquely positioned to work with individuals and communities to learn detailed histories, including potential exposures, and hidden concerns that may advance our understanding of transmission risks and reduce stigma that prevent individuals from seeking care (McCarthy N, 2019). Nurses may also be the first to initiate response activities once unusual events are detected. After the first case of EVD presented at her health center in Conakry, Guinea, (before it was widely recognized that the epidemic had moved into the capital), Nurse Koroma, who helped care for the patient, immediately implemented response activities. These activities included reporting the suspected EVD case to the response team in her district, initiating strict infection control at the health center, monitoring those who cared for the case, establishing careful triage of all patients at the clinic entrance, and conducting surveillance and monitoring for suspect EVD cases at the center. Although that first patient, a pregnant woman and her fetus, succumbed to the infection, as did the attending obstetrician and a medical student, no additional cases of health care–associated EVD occurred at that institution during the epidemic (personal communication, Nurse Koroma, Conakry, Guinea, February 2015).

Nurses serve as epidemiologists coordinating with clinicians and laboratorians to confirm diagnoses, investigate cases, trace contacts, administer prophylaxis, conduct outreach to identify additional cases, collect specimens, provide comfort, advocate for resources, manage and analyze data, report results, and use results to design, implement, and test prevention measures (Ho & Parker, 2006). Nurses are also partners in research activities such as during the Ebola vaccine trials in West Africa (Edem-Hotah et al., 2018) and as evidenced in their long-term participation in the Nurses’ Health Study (Morabia, 2016). They serve as health communicators to prepare accurate, effective messages for individuals, families, health systems, and communities and as infection control practitioners to identify, manage, and mitigate health care–associated infections (Baltzell, McLemore, Shattell, & Rankin, 2017; MacIntyre, Chughtai, Seale, Richards, & Davidson, 2014). Nurses also serve as leaders and administrators in health care systems to design and evaluate policies, and they serve on national and international rapid response teams for public health emergencies. Finally, nurses are scientists testing hypotheses to advance knowledge in many areas of health (Grady & Adams, 2015; Hamilton, 2016).

Nurses play a critical role in GHSA prevention activities, as evidenced by their involvement in efforts to reduce the burden of infections caused by antimicrobial resistant organisms (Edwards, Drumright, Kiernan, & Holmes, 2011). Antimicrobial stewardship involves coordinated interventions to improve and measure the prudent use of antimicrobials by promoting the appropriate therapeutic regimen, including right drug, right dose, right duration, and right route of administration. Stewardship and infection control programs are an essential element in improving patient outcomes, reducing antimicrobial resistance, decreasing the spread of multidrug resistant organisms, limiting costs, and preventing the need for additional medications. Nurses are well poised to participate in patient education, assess for adverse drug reaction history, and ensure clinicians are obtaining cultures prior to antibiotic administration. Given their important role, the inclusion of nurses as members of the antimicrobial stewardship team has been endorsed by the CDC, the American Nurses Association (ANA), the American Academy of Nursing, the National Institute of Nursing Research, the International Council of Nurses, and accrediting agencies (International Council of Nurses, 2017; Monsees, Popejoy, Jackson, Lee, & Goldman, 2018).

Nurses often serve as frontline health care workers (HCWs) and as such are key to detection activities. In many areas of the world, including those with fragile health systems, nurses often serve as first line clinicians. In these areas, nurses also serve as trainers to develop and support a workforce, such as community health workers (CHWs), capable of providing basic health and prevention services in their communities. When well trained and supported, these CHWs help to monitor rural communities for unusual infectious events, as they did during the 2017 pneumonic plague outbreak in Madagascar (Razafindrakoto, Kapesa, Andriamihamina, & Dentinger, 2018). Shortages of nurses in much of the world is a great concern for global health security; increasing and supporting these workers is a potential solution to strengthening GHSA and adherence to IHRs (Edmonson, 2015; Edmonson, McCarthy, Trent-Adams, McCain, & Marshall, 2017).

Nurses have been, and will continue to be, critical to responding to infectious disease outbreaks globally. Because nurses are usually involved in local response efforts including patient care, infection prevention and control (IPC), contact management and reporting, they are key to controlling these outbreaks locally and preventing their spread. In 1976, in Zaire (currently the Democratic Republic of the Congo), nurses cared for the first identified EVD patients, became the first cases of health care–associated EVD, and were instrumental in limiting transmission of the virus beyond their community (WHO, 1978). Similarly, in 1997, Hong Kong nurses participated in investigation and response activities to the first known case of human influenza A (H5N1) infection, and during the 2002 monkeypox outbreak in the United States, nurses from the CDC along with their colleagues from affected state and local health departments participated in all aspects of response efforts (CDC, 1998) (C. Dentinger, CDC personal communication).

Case study: Ebola virus disease outbreak: West Africa, 2014

In December 2013, cases of EVD appeared in a village of Guinea, West Africa that bordered Sierra Leone and Liberia (Baize et al., 2014). EVD, one of several viral hemorrhagic diseases, has a high fatality rate and, at the time, no known treatment or vaccine (CDC, 2018). Although EVD outbreaks had occurred in Central and Eastern African countries (e.g., Democratic Republic of the Congo, Gabon, Uganda, Sudan), this was the first identified EVD outbreak in West Africa. It was thought that this cluster would be contained in the remote region of Guinea where it began, as had occurred in previous outbreaks. Instead, for reasons not entirely understood but thought to be related to human movement between the rural areas of Guinea, Sierra Leone, and Liberia and into the urban areas of these countries, cases of EVD began to increase (Gatherer, 2014). The increase in cases quickly overwhelmed the fragile health infrastructure and limited public resources of these countries, some of the poorest in the world. In July 2014, when EVD was diagnosed in a traveler from Liberia in Lagos, Nigeria and subsequently in several of his contacts and care providers, the severity of the outbreak was understood by even those beyond the public health community (Shuaib et al., 2014). This was reinforced when an American physician and an aid worker became infected after caring for patients in Liberia and were transported to the United States for care (Blinder & Grady, 2014).

The EVD outbreak in West Africa highlighted how transmission occurring in health care settings can quickly amplify an outbreak—early in the epidemic, Ebola virus transmission to HCWs occurred in health care facilities that were not Ebola treatment units (ETUs) (Hageman et al., 2016). HCWs had one of the highest rates of EVD in the outbreak, with infection 21 to 32 times more likely than in the general adult population (Olu et al., 2015; WHO, 2015). Assessments conducted early in the outbreak identified substantial lapses in IPC as a main driver for health care–associated transmission (Hageman et al., 2016).

Nurses were a critical part of response teams formed by staff from the affected countries, WHO, government health and development agencies from several countries, military medical units, and nongovernmental organizations. Some of these nurses formed teams to develop and deliver IPC trainings for HCWs at facilities throughout the region. These trainings included general and Ebola-specific IPC and techniques for effective screening and identification of EVD cases at the entry point of health care facilities. In addition, in Sierra Leone, nurses supported the Ministry of Health and Sanitation to establish a National IPC Program, complete with policies and guidelines. As part of this program, the chief nurse officer of the Sierra Leone Ministry of Health and Sanitation appointed IPC specialists at each of the government hospitals. These specialists, many of them nurses, were responsible for overseeing IPC at their appointed health care facilities. In 2018, these IPC positions remain at Sierra Leone government hospitals, contributing to a strong National IPC Program, equipped and ready to respond in the event of another infectious disease outbreak.

Nurses in the United States and around the world also participated in activities in their home countries. In September 2014, nurses at Emory University Hospital provided care to the first cases of EVD treated in the United States (Lyon et al., 2014). Emory University had a treatment unit designed to manage diseases such as EVD; staff there had trained and practiced responding, and they had 48 hours of warning that two individuals with EVD would be arriving in their unit. Regardless, caring safely for these two individuals was so challenging; it surprised even these well-trained nurses (Ribner, keynote speaker, Infectious Disease Society of America [IDSA] annual meeting, October 2015, Philadelphia, PA). When the nurses in a Dallas hospital cared for the first U.S.-diagnosed case of EVD, they had had none of this preparation; when two of them acquired EVD after caring for the patient, the risks associated with providing care even in well-resourced settings became apparent (Chevalier et al., 2014). In response to the Dallas cases, the ANA, together with the CDC, quickly organized a webinar to share best practices. Nurses and nurse leaders across the country participated in that webinar and then led their communities and institutions to prepare for preventing health care–associated EVD infections; since then, the ANA and CDC have partnered with several organizations to develop the Nursing Infection Control Education Network (ANA, 2019).

In cities such as New York, with large numbers of global travelers, nurses participated on teams to establish four Ebola units where EVD patients could safely be treated, and they provided care in one of those units for the first New York City case of EVD. New York City nurses also screened and monitored travelers returning from Ebola-affected countries, developed tools to reduce stigma, and reassure the population and conducted IPC trainings at clinics and hospitals across the city.

The response to the 2014 Ebola outbreak ultimately included all nurses in Guinea, Sierra Leone, Liberia, and Nigeria, and neighboring countries; those who left their home countries to assist with the response, and those who prepared for potential cases in their home countries. An infectious global public health threat requires nurses from all countries at all levels of the health care system. We will need to share practices that worked and improve those that did not. We will need nurse researchers to rigorously test hypotheses based on observation and collected data.

Conclusion

As human-pathogen interactions evolve in response to population growth and displacement, increased global travel and commerce, environmental changes, and pressure from antimicrobial use, we can expect to encounter increasingly complex webs of infectious disease exposures and transmission. Preventing, detecting, and responding to these events requires multinational, multisector collaboration. Governments, nongovernmental organizations, academic institutions, health care professionals, private industry, and communities must leverage resources to develop effective policies and practices to improve public health infrastructure to prevent, detect, and respond rapidly to infectious threats. Effective prevention strategies, universal access to affordable essential health care, sensitive surveillance systems, and coordinated rapid response must be strengthened globally. Furthermore, nurses’ knowledge, experience, and expertise must be more completely captured to design effective solutions (McGillis Hall & Kashin, 2016).

We face these challenges in a global political atmosphere that poses threats to international cooperation, yet pathogens are unlikely to heed isolationist policies. As noted by journalist Ed Yong, natural disasters may result in communities uniting, but infectious disease outbreaks can cause communities to divide (Yong, 2018). These divisions can result in infections going undetected, allowing them to flourish. Under the most collaborative of times, it takes extraordinary efforts during epidemics to calm the public and engage cooperation. Calls for isolationism will happen, but they must not happen among health care leaders, including among nurses; rather these professionals must responsibly and effectively guide their populations to limit the duration and magnitude of these events, and to prevent human suffering. Ultimately, engagement in global health is not only a humanitarian concern but also a priority for our collective well-being, efficient use of limited resources, and protecting our future. Irrespective of national borders, nursing leadership at every level and in every country is needed to address these challenges.

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