RISKS OF EPIDEMIOLOGICAL SAFETY AS A FACTOR OF MODERNIZATION OF THE NATIONAL HEALTH SYSTEM MANAGEMENT

RISKS OF EPIDEMIOLOGICAL SAFETY AS A FACTOR OF MODERNIZATION OF THE NATIONAL HEALTHCARE SYSTEM MANAGEMENT

Kristina Krivets

Doctoral student of the Doctor of Business Administration (DBA) program in Healthcare Al-Farabi Kazakh National University,

Kazakhstan, Almaty

The coronavirus pandemic has shown the world that in order for health systems to be resilient to health-related shocks, especially such as COVID-19, public policy responses must take into account both direct and indirect threats. An important role is played by changing the management system of the healthcare industry, taking into account the need to increase the level of epidemiological safety.

Strengthening this line of policy allows:

a) To reduce the burden on the healthcare system as a whole;

b) To protect people from direct and indirect threats of pandemics or other crises in healthcare system.

According to the Chief Sanitary Doctor of the Russian Federation (RF) A. Popova, epidemiological safety implies the management of risk factors of biological nature in order to reduce their negative impact on the health of patients and staff of healthcare organizations [1].

By now, there is no single concept of the “epidemiological safety risk” in science. In general terms, “risk” is a category involving the occurrence of any adverse events. “Epidemiology” (from the Greek epidemos common among the people + logos doctrine) is a medical science that studies the regularities of the epidemic process and develops measures to control infectious human diseases.

“Risk of epidemiological safety” (RES) is defined in the literature as the probability of epidemiological hazards under the condition of their interaction, entailing the aggravation of the epidemiological situation [2]; the potential for aggravation of the epidemiological situation in a certain territory (endemic, enzootic - the risk territory) at a certain time, among certain risk contingents [3].

Thus, on the one hand, the risk of epidemiological safety is the probability of aggravation of the epidemiological situation in a certain territory at a certain time, and on the other hand, it is the management of risk factors of different nature.

The risk based approach is understood in the literature as a method of organizing and exercising government control (supervision), when in the cases provided for by law, the choice of the intensity (form, duration, frequency) of control measures, measures to prevent violations of mandatory requirements is determined by assigning the activities of a legal entity, individual entrepreneur and (or) production facilities used by them in the implementation of such activities to a certain risk category or a certain hazard class (category).

From the point of view of the risk-based approach, when determining the risk of epidemiological safety, it is necessary, first of all, to identify the key factors (criteria) for assessment. The criteria for assigning objects of supervision to risk categories should take into account the probability of non-compliance by legal entities (LE) and individual entrepreneurs (IE) with mandatory requirements and the severity of the potential negative effects of possible non-compliance with these requirements [4].

Scientifically based risk assessment reduces the probability of occurrence and spread of infectious diseases regulated by the International Health Regulations (2005) [5]. In the same document, objective and subjective assessment of the risk of epidemiological surveillance are highlighted.

Many criteria and methods for assessing epidemiological safety risks have been proposed in world science, and a significant number of empirical studies have been conducted. For example, W. S. Ajisegiri and colleagues [6], based on 18 criteria reflecting geographical, socio-economic, health indicators and parameters, developed a system for assessing the risk of outbreaks of Ebola with severe consequences.

F. M. Shearer and colleagues [7], based on the incidence of yellow fever in 1970–2016, taking into account the data on vaccination, created a mathematical model, which identified the risk areas of yellow fever infection in 47 countries.

M.V. Zabashta, K.S. Zakharov and others [8] identified administrative areas with different risks of infection and the probability of stable natural focus of the West Nile fever (WNF) in the Russian Federation. K.S. Zakharov, in particular, found that for the effective prevention of human diseases in the focus of WNI, it is necessary to implement a single set (system) of measures aimed at sanitary-engineering improvement of facilities, increase the readiness of medical institutions in terms of clinic and treatment, public awareness efforts, control of the number of virus carriers [9, p. 5].

E.G. Yanovich and E.A. Moskvitina [10], summarizing a large block of studies of the intensification of the epidemic process during infectious diseases, found that to determine the risk areas it is necessary to use a set of indicators (epidemiological, epizootological, microbiological, demographic, etc.), in fact - risk factors.

Many studies have been devoted to assessing the risk of epidemiological safety of food products [11], drinking water [12], recreational water use [13], for the detection of various viral infections.

For example, in Kazakhstan, a retrospective epidanalysis of the total population of Kazakhstan for 2008-2018 was conducted for the incidence of measles. The greatest increase in morbidity was noted in 2015, an increase of 13 times compared to 2014 and a sharp decrease in 2016 to 0.69 per 100 thousand population. At the same time, 72.7% of all measles cases were registered in Nursultan in 2018 (484 measles cases per year in Kazakhstan). The Resolution of the Chief State Sanitary Doctor of the Republic of Kazakhstan No. 6 dated 07.08.2019 introduced additional immunization against measles and rubella to persons aged 20 to 29 years, including special contingents, as well as vaccination of children from 9 months of age.

According to scientists, there are natural centers of infections on the territory of Kazakhstan, in particular Crimean-Congo hemorrhagic fever (CCGL), which invades the Zhambyl, Turkestan and Kyzyl-Orda regions. Natural centers of CCHL are expanding into adjacent territories, as evidenced by the results of monitoring of contamination and individual facts of positive PCR results for CCHL virus in ticks in Almaty and Karaganda regions [14].

According to Kazakh researchers [15], given the huge territorial variability of climatic and geographical features within administrative units (districts), it is almost impossible to draw a single and unambiguous conclusion about the epidemic risk to public health for certain infectious diseases in the republic. The presence of natural centers of particularly dangerous pathogens, in particular, such as plague, tularemia, anthrax, hemorrhagic fever, etc., does not cover the entire territory of the country, they are rather "tied" to the territory of individual administrative units (regions, districts). Scientists emphasize that for the effective operation of national epidemiological surveillance systems and timely response to epidemic threats at the point of their detection (at the regional and district levels), it is important to be able to give a scientifically based assessment of existing epidemic risks to the population and a forecast of the situation. In this regard, the emphasis is placed on the fact that current and retrospective sanitary-epidemiological and socio-economic data will be combined into a new tool for epidemiological surveillance and risk management, called the Regional Sanitary-Epidemiological Passport (RSEP) for each district of Kazakhstan, providing opportunities for short-term (2-3 years) and long-term (3-5 years) forecasting.

The proposed by scientists Electronic Integrated Disease Surveillance System (EIDSS) will serve as the key tool in the methodology in addition to the functions of the RSEP as a national system of epidemiological electronic surveillance for collection, processing and analyzing data on 64 diseases of 269 organizations in the country. EIDSS is designed to improve national disease surveillance by providing a secure method to collect, exchange and analyze a variety of information in a single integrated database with electronic transfer of relevant information to global data repositories of international organizations.

But the problem of monitoring and assessing the risks of epidemiological safety is not only in the territorial variability of natural, climatic and geographical features. Currently, such monitoring of various viral agents is difficult due to their great diversity (more than 200 viruses). It is difficult to analyze the changes in their characteristics that cause the occurrence of dangerous epidemic situations, outbreaks, epidemics, pandemics, significant socio-economic losses. The problem also arises in relation to the monitoring and analysis of the routes of viral infections [16].

Since 2017, Russian experts have proposed calculation of the potential risk of harm to health by a certain type of activity, which is carried out by a legal entity or individual entrepreneur at one or several production facilities, as follows [17]:

where  - potential risk of harm to health by type I activity of a legal entity or individual entrepreneur;

 - potential risk of harm to health by type I activity at i-th production facility.

At the level of a medical organization, Kazakhstani specialists understand risk management as a continuous process carried out by management bodies, heads of structural divisions and employees in order to identify potential events that may affect the organization's activities, maintain the degree of their impact within acceptable limits for the organization, and used in strategic and operational management to ensure sufficient confidence in achieving strategic and operational goals.

By today, in foreign [18; 19; 20] and Kazakhstan science [21], the greatest emphasis is given to predicting the risk of the spread of coronavirus infection as the most pressing and complex problem that threatens the health and well-being of the population in the near future. In particular, special emphasis is given to such issues as the impact of COVID-19 on entrepreneurship [22], reduction of the risk of COVID-19 in hospitals and outpatient clinics [23], risk reduction during diagnostic work with suspicious material containing the COVID-19 virus [24] and others.

Coronavirus infection (COVID-19) is an acute infectious disease caused by a new virus strain of the SARS CoV-2 coronavirus genus with aerosol-droplet and common contact route of transmission, with affinity to lung tissue, proceeding from asymptomatic virus carriage to clinically apparent forms of the disease.

The new coronavirus (2019-nCoV), later renamed as COVID-19, began as an outbreak in China’s Wuhan province and then spread throughout the world in a few months and turned into a pandemic. According to the study, this pandemic is characterized by:

1) rapid spread;

2) spreads among people with low immunity, mainly among the elderly;

3) differential rate of recovery.

The incubation period is 4-5 days, can be extended up to 14 days. A mild course of the disease is observed in 81% of patients, a critical course with high mortality - in 5%. The onset of the disease is acute, with an increase in body temperature, the severity of which varies from 37.5 ° C to 39 ° C or more. Symptoms such as fever, chills, and weakness are present in more than 70% of infected individuals. Half of those infected have a dry nasal cough, only in a third of cases there is sputum attachment, constant pain behind the sternum. Symptoms of shortness of breath occur in 30% of patients with COVID-19, manifested by a growing sense of lack of air, especially in a horizontal position, the application of additional efforts to inhale and exhale.

In 2020, WHO declared COVID-19 a pandemic. This statement meant that the outbreak was affecting more than one country.

Pandemics are not new to humanity. Over the past 600 years, the world has witnessed several outbreaks of disease caused by bacteria and viruses that have claimed millions of lives. The deadliest pandemic, the Black Death, or plague, between 1347 and 1351, led to the deaths of up to 75-200 million people, according to various estimates. Subsequently, pandemics such as the plague (1720), cholera (occurred six times between 1817 and 1923, the seventh pandemic began in 1961), the Spanish flu (1918), and the last of them - coronavirus (2020). While plague and cholera were caused by bacteria, COVID 19 or SARS-COV-2 is a virus that belongs to the genus Coronoviridae. It has the same transmission criteria as Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS). A virus cannot live without a host, but once inside the cells, viral enzymes take on the role of host cells and begin to copy viral genetic constructs. New copies of viral genetic constructs are packed into new protein envelopes to create new viruses.

Pandemics require a coordinated international response [25]. One of such actions is mass immunization of the population. Strong immunization, special programs and effective disease surveillance are necessary to maintain a high level of coverage, as well as to eliminate and eradicate diseases. All people should have access to immunization services, vaccines should be delivered to areas that are geographically, culturally, socially or otherwise isolated, as well as to marginalized groups such as displaced persons and migrants, as well as those affected by conflict, political instability and natural disasters.

The WHO Immunization Agenda 2030 (IA2030 [26]) sets out an ambitious comprehensive global vision and strategy for vaccination and immunization for the decade 2021-2030. It takes into account the lessons, recognizes the continuing and new problems of the incidence of infectious diseases, and uses new opportunities to solve these problems. In IA2030, immunization is seen as a key factor and a fundamental right to the highest attainable physical and mental health, as an investment in the future, creating a healthier, safer and more prosperous world for all. IA2030 is designed to inspire and coordinate the activities of communities, countries, national governments, regional bodies, global agencies, development partners, health professionals, academic and research institutes, vaccine developers and manufacturers, the private sector and civil society.

Before the COVID-19 pandemic, no vaccine against an infectious disease had been developed in less than a few years, and there was no vaccine against human coronavirus infection (CVI) before the pandemic. There are currently several vaccines for COVID-19, as well as a number of confirmed treatments. Table 1 lists the main COVID-19 vaccines in the world and their characteristics.

Table 1.

Comparative characteristics of the main vaccines against COVID-19 as of 01.08.2021

It follows from the data in Table 1 that Russian vaccines showed the greatest effectiveness during the tests. However, they are not recognized as such in all countries. Russian vaccines are also not recognized by the World Health Organization. Currently , WHO has approved the following vaccines:

1. Sinovac;
2. Sinopharm;
3. Comirnaty (Pfizer and BioNTech);
4. Janssen (Johnson & Johnson);
5. Moderna;
6. AstraZeneca;
7. Covishield;
8. VeroСell / Hayat-Vax (approved on 07.05.2021);
9. CoronaVac (WHO approved on 01.06.2021).

The Sputnik V vaccine is currently being produced in Russia, Kazakhstan, South Korea, Brazil, India and seven other countries. It is noteworthy that among the 69 countries that have registered Sputnik V, there are two EU states - Hungary and Slovakia. The small European state of San Marino has immunized 70% of the population with the Russian vaccine.

Despite the constantly growing list of COVID-19 vaccines, there is still no complete and objective data on their effectiveness. The data on vaccine efficiency are based mainly on claims from the developers themselves, and large-scale empirical studies are few. The situation is aggravated by the fact that in 2021-2021. strains "alpha", "beta", "gamma", "delta" and others were found mainly in countries such as: United Kingdom (alpha, zeta, A.23.1+E484K, B.1.671.2 + K417N, AV.1, B.1.1.7+L452R, B.1.1.7+S494P); South Africa (beta, zeta, B.1.351 + P384L, C.1.2); Brazil (gamma, zeta); India (delta, kappa, B.1.617.3); USA (epsilon, iota in three modifications). The list of discovered new strains also includes Russia, Italy, France, Philippines, Colombia, Peru, Egypt, Nigeria [27]. As new strains appear and their names are promoted in the ancient Greek alphabet, the mortality rate from the virus increases, and there is no data on the effectiveness of vaccines for new strains.

It is noteworthy that a year before the start of the pandemic, in 2019, the Global Health Security Index (GHS) began to be measured. The first study assessed 195 countries and looked at six categories - prevention, detection, response, health system, drive to improve, and vulnerability to biological threats - and assessed countries' preparedness using 140 linked questions. The GHS -2019 [28] provides the following assessment methodology and indicator values ​​by category (Table 2).

Table 2.

Methodology for assessing the Global Health Security Index (GHS), 2019

In preparation for the fall 2021 launch of the second Global Health Security Index, members of the International GHS Index are revising its structure, discussing indicator weighting strategies and assessing how the 2019 GHS Index has changed in 2021, what the outcomes of preparedness and mitigation will be pandemic COVID-19.

As early as the beginning of the pandemic, experts recommended that the best way to prevent and slow down the transmission of the virus is to be well informed about its causes and how it spreads. Although health organizations and state governments have recommended many preventive measures, such as social distancing and personal hygiene, risk communication and awareness raising have been critical strategies. At the community level, the importance of risk awareness and understanding is only increasing in order to strengthen prevention. In this regard, various risk assessment tools are actively used in the form of mobile applications or online surveys. Such tools are designed to analyze the likely risk of respondents based on the information provided about their current health status. Most of the tools mainly focus on the health diagnostic risk aspect, in which the observed symptoms are assessed to be categorized at risk using some platforms that provide geospatial risk analysis based on GIS and the current location of confirmed cases.

A number of studies explicitly state that COVID-19 is not only a pandemic, but also an "infodemic" [29]. In this regard, the WHO Epidemic Information Network (EPI-WIN) [30] was launched as a new information platform for the exchange of personalized information. Pandemic data is dynamic and changing rapidly. COVID-19 hotspots (areas with the highest number of cases) are also dynamically changing. This makes it difficult to control the information. Social media in this sense tends to be overwhelmed with posts, many of which are unverified or fake. Accordingly, the use of the media (media) to access information about COVID-19 has increased tremendously around the world. However, only correct information is the key to success in mitigation measures. In particular, the governments of China, Singapore, Russia check fake news and control the spread of rumors. Japan's 26 National Resilience Working Groups include the 2020 Pandemic STOP Strategy Committee, which has provided many recommendations, including risk communication, to better integrate pandemic risks into national resilience to any threat. [31]

Risk mitigation is a complex interdisciplinary decision-making process based on information obtained from risk and exposure assessments. Risk communication involves stakeholders such as risk assessors, managers, media, volunteer groups and communities. Risk communication uses a variety of techniques, ranging from media and social media communication to public engagement. This requires a deep understanding of people's perceptions, problems and beliefs, as well as their knowledge and practice. A. Barry [32] believes that if people have accurate information about the risks they face and knowledge about prevention, they are more actively following the government's recommendations on public safety.

Risk assessment models identify the factors that are necessary for risk assessment and the relationship between these factors, creating a kind of template that risk assessors can use. To assess the individual risk of specific diseases, health risk assessment tools have been developed to indicate the need for a proper risk assessment, including risk factors for health, management, exposure and behavior of citizens.

However, risk communication, in particular the massive dissemination of public health information, can be constrained by cultural issues as well as language barriers, especially for migrant communities. In March 2020, WHO created a WhatsApp group to provide accurate information and reduce risks. Various countries have undertaken communication activities structured on news and information websites / platforms to jointly combat fake news, with the aim of promoting awareness, understanding and compliance with restrictions. As part of such risk awareness strategies, mobile apps have become a tool of informing about risks.

The 16th edition of the Global Risk Report, published by the World Economic Forum [33], highlights the devastating impact of major risks that could change the world in 2021 and the next decade. The report says the COVID-19 crisis has exposed fundamental divergences between assumptions about global and national pandemic preparedness and the reality of crisis management on the ground. The section of the Report under the self-explanatory title "Global Risks 2021: A Broken Future" states that the world is faced with a sudden disruption of social interactions, the widening of the digital divide, dramatic changes in markets and consumer behavior, loss of education and jobs, challenges to democracy and international relations.

COVID-19 has highlighted an urgent need to implement devices, platforms and services to support people at all levels of care. Artificial intelligence (AI) has become more important in this regard. Despite public and expert concerns about privacy, many proprietary applications have begun to aid in personalized risk assessments and contact tracing. For example, study [34] looks at a suite of online risk assessment tools for COVID-19, going beyond symptom detection and patient tracking. These tools provide information on social behavior as well as assess people's adherence to government recommendations. The risk assessment includes exposure to individuals by residence, handwashing and mask wearing behavior, and the current status of compliance with government travel restriction guidelines. Risk assessment tools provide information on awareness in the form of questions that are also used to assess risk based on behavior and adherence to social norms. In addition, some COVID-19 risk assessment tools generate information on anxiety levels in order to understand the need for psychosocial assistance. These tools include, in particular, the following mobile applications:

- Arogya Setu. The app checks for symptoms and notifies users if they are near a positive patient. Tracking is done via Bluetooth and a location-generated graph showing the proximity to any infected person. The app also provides instructions for self-quarantine;

- TraceTogether. This is a contact tracing application that uses Bluetooth to track infected people and notify those who have been in their immediate vicinity in the past 15 days;

- CovidWatch. The app uses Bluetooth signals to detect users when they are near each other and anonymously alerts them if they have been in contact with someone who has tested positive. A unique feature of the application is that any third party, including the government, does not have access to data on who was exposed and by whom;

- Corona DataSpende. This is a German smartwatch app that tracks the spread of the coronavirus by collecting symptoms such as heart rate, body temperature, sleep patterns to detect any early warning signs;

- COVID Safe - Australian app helps state and territory health officials quickly connect with people who may have been exposed to COVID-19.

- Mobile application "Corona 100 m", developed in South Korea, instantly warns users when they approach 100 m from a place visited by an infected person. The app allows users to avoid potentially high risk areas without checking the travel histories of those infected.

- Using healthcare information technology integrated with strong infrastructure, Taiwan has developed a dedicated smart card that provides real-time access to a patient's medical records through a real-time alert system linked to immigration data.

Thus, communicating about the risks of COVID-19 and tracking human behavior in the current environment is an effective and most accurate tool for sharing information on health risks and dangers during a pandemic.

As noted above, with the onset of the coronavirus pandemic, not all countries have health systems ready to detect, prevent and assess epidemiological security risks. To a large extent, modern preparedness is ensured by the quality of legislation, public risk management, the level of digitalization of the healthcare industry and the level of public awareness. First of all, the introduction of new risk assessment tools requires the modernization of national health systems in terms of digitalization. If you take into account the fact that more than four billion people worldwide are connected to the Internet, you can see the opportunities that digital transformation in healthcare offers.

However, the process of digitalization of healthcare systems in the world is proceeding unevenly, which actualizes the revision of the previous goals and objectives in relation to the pace, directions and quality of digitalization. The main thing here is innovation, the goal of which is to rationalize the work of doctors, optimize systems, improve patient outcomes, reduce the number of human errors and reduce costs due to the capabilities of the Internet and mobile devices. In fact, in a recent survey in the US, only 5% of healthcare and pharmaceutical companies said they've gone digital, compared with 15% of companies in other industries.

Taking into account the analysis of a vast array of literature, in our opinion, within the framework of a risk-based approach, the following can be attributed to the number of risk factors for epidemiological safety in conditions of any infectious disease, including the coronavirus pandemic:

- factors of biological nature (for example, origin, structure, identified and potentially possible mutations of the virus);

- demographic factors (age, gender of patients);

- geographic factors (areas of greatest spread of the virus);

- legal factors (compliance with emergency legislation);

- information technology factors (compliance of accounting systems, databases, control and supervision);

- managerial factors (compliance of the management structure of the healthcare system and the level of public management, qualifications of employees, emergency);

- socio-economic factors (compliance with restrictive measures, potential social and economic damage);

- individual factors;

- climatic and environmental factors;

- health parameters of the population (country, region, city, district);

- the quality of treatment and prevention of morbidity.

Summarizing what has been said, it should be emphasized that the concept of "epidemiological safety risk" has a twofold meaning: on the one hand, it is the likelihood of a complication of the epidemiological situation in a certain area at a certain time, and on the other hand, it is the management of risk factors of various nature.

Risks of epidemiological safety act as a key factor in the modernization of the management of national health systems in many countries of the world, since they determine changes in legislation, reorganization of state management structures, new approaches to organizing the activities of medical organizations and requirements for medical personnel, improving the work of epidemiological control bodies and supervision, the introduction of quarantine and other restrictive measures, the use of new information technologies in the form of online platforms, Large databases and equipment.

Strengthening community responses requires a systemic, coordinated and integrated approach to managing epidemiological security risks, both at the global, country and regional levels.

References:

1. Popova A. Epidemiological safety - an integral component of the system for ensuring the quality and safety of medical care // Bulletin of Roszdravnadzor. - 2017. - No. 4. - P. 5-8.
2. Cherkassky BL Risk in epidemiology. - M .: Practical Medicine, 2007 .-- 480 p.
3. Onishchenko GG, Smolenskiy V. Yu., Ezhlova EB et al. Actual problems of biological safety in modern conditions. Part 2. Conceptual, terminological and identification base of biological safety // Bulletin of the Russian Academy of Medical Sciences. - 2013. - No. 11. - P. 4–11.
4. Zaitseva N.V., May I.V., Kiryanov D.A., Kostarev V.G. Scientific and methodological approaches to the risk-oriented model of sanitary and epidemiological surveillance of activities in the health sector // Medical Almanac. - 2017. - No. 4 (49). - S. 29-32.
5. International Health Regulations (2005). - Geneva: WHO, 2006 .-- 78 p.
6. Ajisegiri WS, Chughtai AA, MacIntyre CR. A Risk analysis approach to prioritizing epidemics: Ebola virus disease in West Africa as a case study // Risk Analysis. – 2018. - No 38 (3). – pp. 429–441.
7. Shearer FM, Longbottom J, Browne AJ et al. Existing and potential infection risk zones of yellow fever worldwide: a modelling analysis // Lancet Global Health. – 2018. – No 6(3). -  pp. 270–278.
8. Zabashta MV Environmental and epidemiological aspects of West Nile fever: author. dis. ... Cand. honey. Sciences: 14.02.02. - Rostov-on-Don, 2012 - 22 p.
9. Zakharov KS Formation of natural and anthropurgic foci of West Nile fever in the Saratov region: author. dis. ... Cand. honey. Sciences: 14.02.02. - Saratov, 2019 - 23 p.
10. Yanovich EG, Moskvitina EA Epidemiological risks: significance in regionalization of administrative territories and in activating the epidemic process in infectious diseases // Epidemiology and Vaccine Prevention. - 2019. - No. 18 (6). - From 81–89. https: // doi: 10.31631 / 2073-3046-2019-18-6-81-89.
11. Zaitseva N.V., May I.V. Risk-oriented supervision as a strategic tool for increasing the level of food safety in the consumer market of Russia // Hygiene and Sanitation. - 2020. - T. 99. - No. 12. - С.1398-1406.
12. Meltser A.V., Kiselev A.V., Erastova N.V. Hygienic rationale for assessing the quality of drinking water by indicators of epidemiological safety using the methodology for assessing the risk to public health // Preventive and Clinical Medicine. - 2015. - No. 3 (56). - S. 12-17.
13. Mekhantiev I.I. Sanitary-hygienic and epidemiological aspects of recreational water use by the population of the Upper Don Basin // Public health and environment. - 2020. - No. 12. - (333). - S.23-29.
14. Amireev S., Alekesheva L. Zh. Analysis of the causes of the nosocomial outbreak of the Crimean-Congo hemorrhagic fever in the city of Turkestan of the Republic of Kazakhstan // Journal of Infectology. - 2020. - Vol. 12. - No. 2. - P.26-27.
15. Burdakov A., Kazakov S., Esmagambetova A., Ukharov A., Kopzhasarov D. One Health Epidemic Risk Management in Kazakhstan with Open-Source EIDSS
16. Melekhina E.V., Music A.D., Usenko D.V. Strategy and tactics of antiviral therapy for acute respiratory viral infections and influenza at the present stage // Journal of Infectology. - 2020. - Vol. 12. - No. 2. - P.7-17.
17. Methodical recommendations MR 5.1.0116-17 “Risk-based model of control and surveillance activities in the field of ensuring sanitary and epidemiological welfare. Classification of economic entities, types of activities and objects of supervision according to the potential risk of harm to human health for the organization of planned control and supervision activities "(approved by the Federal Service for Supervision of Consumer Rights Protection and Human Welfare on August 11, 2017); URL: https://www.garant.ru/products/ipo/prime/doc/71681784/#2000 (date accessed: 25.07.2021).
18. Acuto M. COVID-19: lessons for an urbanizing world // Science Direct. – 2020. - No 2(4). https://doi.org/10.1016/j.oneear.2020.04.004 (access date: 25.07.2021).
19. Shaw R, Kim, Y.-k., & Hua, J. Governance, technology and citizen behavior in pandemic: lessons from COVID-19 in East Asia // Prog Disaster Sci. – 2020. – No 6; https://doi. org/10.1016/j.pdisas.2020.100090.
20. Yang Jing, Zheng Ya, Xi Gou, Ke Pu, Zhaofeng Chen, Guo Qinghong, et al. Prevalence of comorbidities and its effect in patients infected with SARS-Cov-2: a systematic review and meta-analysis // Int J Infect Dis. – 2020. – No 94. – pp. 91–95. https://doi.org/10.1016/j.ijid.2020.03.017 (access date: 25.07.2021).
21. Risk maps and prognosis of treatment outcomes for patients with COVID-19 / Edited by Doctor of Medical Sciences, Т.А. Bulegenov. – Semey, 2020; URL: https://semeymedicaluniversity.kz/wp-content/uploads/2020/04/karty-riskov-i-prognozirovaniya-ishodov-lecheniya-pacientov-s-covid-19.-prakticheskoe-posobie.pdf (access date: 25.07.2021).
22. Zhabin A.P., Volkodavova E.V., Kandrashina E.A. Business risk management, or "black swan" COVID-19 as a test for antifragility // Bulletin of the Samara State University of Economics. - 2020. - No. 3 (185). - p. 38-45.
23. Ivanov I.V., Kovalishena O.V., Shvabsky O.R., Kvashnina D.V., Minulin I.B. How to reduce the risk of COVID-19 in a healthcare organization. Checklist of the National Institute of Quality of Roszdravnadzor for assessing the system of epidemiological safety of hospitals and outpatient clinics // Quality management in medicine. - 2020. No. 2. S. 24-28.
24. Tyurin E.A., Chekan L.V., Khramov M.V. Compliance with biological safety requirements to reduce the level of risk when carrying out diagnostic work with suspicious material for the SARS-COV-2 (COVID-19) virus // Health Risk Analysis - 2021. Environmental, Social, Medical and Behavioral Aspects. Together with the international meeting on environment and health RISE-2021. Materials of the XI All-Russian Scientific and Practical Conference with International Participation. Perm, 2021.S. 144-153.
25. Kelland K, Nebehay S. WHO officials rethink epidemic messaging amid pandemic debate, 2020. URL: https://www.reuters.com/article/us-health-coronavirus-whomessaging-insi/who-officials-rethink-epidemic-messaging-amid-pandemic-debateidUSKBN2101AY (access date: 22.08.2021).
26. Immunization Agenda 2030: A Global Strategy To Leave No One Behind, APRI, 2020; URL: https://www.who.int/health-topics/vaccines-and-immunization#tab=tab_1 (access date: 22.08.2021).
27. Comparative characteristics of Gam-Covid-Vac, Sputnik Light, EpiVacCorona and CoviVac vaccines; URL: https://zabrab75.ru/wp-content/uploads/2021/06/Sravnitelnaya_tablicza_po_vakczinam.pdf (access date: 20.08.2021);
28. Coronavirus Vaccines, August 16, 2021; URL: https://medportal.ru/enc/infection/immuno/vaktsiny-ot-koronavirusa/ (access date: 20.08.2021).
29. SARS-CoV-2 variants of concern as of 26 August 2021; URL: https://www.ecdc.europa.eu/en/covid-19/variants-concern (access date 28.08.2021).
30. GHS Index. Global Health Security Index, 2019; URL: https://www.ghsindex.org/wp-content/uploads/2020/04/2019-Global-Health-Security-Index.pdf (access date 25.08.2021).
31. Hua J., Shaw R. Corona virus (COVID-19) "Infodemic" and emerging issues through a data Lens: the case of China. // Int J Environ Res Public Health. – 2020. – No 17. https://doi. org/10.3390/ijerph17072309  
32. WHO. EP-Win Updates; URL: https://www.who.int/teams/riskcommunication/epi-win-updates (access date: 22.07.2021).
33. DeWit A, Djalante R, Shaw R. Building holistic resilience: Tokyo's 2050 strategy // Asia Pac J. - 2020. - No 18(7). pp. 1–15; URL: https://apjjf.org/2020/7/DeWit (режим доступа: 25.07.2021).
34. Barry J.M. Pandemics: avoiding the mistakes of 1918 // Nature. – 2009/ -No 459. Pp. 324–325; URL https://doi.org/10.1038/459324a (access date: 22.07.2021).