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Is the reporting timeliness gap for avian flu and H1N1 outbreaks in global health surveillance systems associated with country transparency?

Feng-Jen Tsai1*, Eva Tseng2, Chang-Chuan Chan34, Hiko Tamashiro5, Sandrine Motamed6 and André C Rougemont6

Author Affiliations

1 Master program in Global Health and Development, College of Public Health and Nutrition, Taipei Medical University, 250 Wu-Hsing Street, Taipei City 110, Taiwan

2 Department of Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, USA

3 Institute of Occupational Medicine and Industrial Hygiene, Taipei, Taiwan

4 Global Health Center, College of Public Health, National Taiwan University, Taipei, Taiwan

5 Department of Global Health and Epidemiology, Hokkaido University Graduate School of Medicine, Sapporo, Japan

6 Institute of Social and Preventive Medicine, University of Geneva, Geneva, Switzerland

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Globalization and Health 2013, 9:14  doi:10.1186/1744-8603-9-14

Published: 25 March 2013



This study aims to evaluate the length of time elapsed between reports of the same incidents related to avian flu and H1N1 outbreaks published by the WHO and ProMED-mail, the two major global health surveillance systems, before and after the amendment of the International Health Regulations in 2005 (IHR 2005) and to explore the association between country transparency and this timeliness gap.


We recorded the initial release dates of each report related to avian flu or H1N1 listed on the WHO Disease Outbreak News site and the matching outbreak report from ProMED-mail, a non-governmental program for monitoring emerging diseases, from 2003 to the end of June 2009. The timeliness gap was calculated as the difference in days between the report release dates of the matching outbreaks in the WHO and ProMED-mail systems. Civil liberties scores were collected as indicators of the transparency of each country. The Human Development Index and data indicating the density of physicians and nurses were collected to reflect countries’ development and health workforce statuses. Then, logistic regression was performed to determine the correlation between the timeliness gap and civil liberties, human development, and health workforce status, controlling for year.


The reporting timeliness gap for avian flu and H1N1 outbreaks significantly decreased after 2003. On average, reports were posted 4.09 (SD = 7.99) days earlier by ProMED-mail than by the WHO. Countries with partly free (OR = 5.77) and free civil liberties scores (OR = 10.57) had significantly higher likelihoods of longer timeliness gaps than non-free countries. Similarly, countries with very high human development status had significantly higher likelihoods of longer timeliness gaps than countries with middle or low human development status (OR = 5.30). However, no association between the timeliness gap and health workforce density was found.


The study found that the adoption of IHR 2005, which contributed to countries’ awareness of the importance of timely reporting, had a significant impact in improving the reporting timeliness gap. In addition, the greater the civil liberties in a country (e.g., importance of freedom of the media), the longer the timeliness gap.