In early 2020, COVID-19 exposed differences in public health laboratory systems’ testing abilities. Focusing on Germany, the USA and the UK between 1900 and 2020, this article argues that studying the distinct evolution of laboratory infrastructures is critical to understanding the history of infection control and the limits of template-based reforms in global health. While each analysed laboratory infrastructure was shaped by a unique national context, neoliberal visions of lean public services and declining resources led to significant reform pressure from the 1970s. The US Center of Disease Control’s model of epidemic intelligence provided an attractive template to integrate resources and focus planning on preparedness scenarios. It also helped justify cuts to local laboratory infrastructures. Effects were uneven: in the USA and the UK, improved integration failed to compensate for local laboratory cuts and loss of autonomy. By contrast, Germany’s subsidiary principle allowed for limited federal integration while leaving local services mostly intact. The reliable functioning of public health laboratories is a cornerstone of modern disease control. This became particularly obvious amidst the early spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Until the licensing of the first COVID-19 vaccines in late 2020, the classic public health tools of testing, contact tracing and isolation were the most effective means of containing the novel virus. On 16 March, World Health Organization (WHO) director Tedros Adhanom Ghebreyesus acknowledged this by calling on all nations to ‘test, test, test’.This article complements and goes beyond these analyses by using COVID-19 as an opportunity to survey the longer-term technological trends, epidemiological ideals and political trajectories shaping public health laboratory systems in (West-)Germany, the UK and the USA. Drawing on Susan Ley Star and Karen Ruhleder’s seminal work on invisible infrastructures that become visible in times of crisis,After providing an overview of the unsystematic origins of public health laboratories in all three countries, the article’s first part traces the factors shaping the evolution of (West)-German, the UK, and the US laboratory networks between ca. 1930 and 1970. During this period, laboratories in all three countries became integrated into increasingly sophisticated networks of microbial processing, storage and exchange. Each network evolved to meet the needs of distinct biosecurity concerns, political environments national health systems, as well as in response to competition from commercial or hospital-based laboratory services. However, a shared underlying ideal centred on integrating the national provision of specialised reference services with routine microbial testing and public health work at the local level.Coordinating these laboratory networks and the growing amount of microbiological data produced by them required significant fiscal investment and new forms of information processing. During the 1950s, the US Center of Disease Control (CDC) responded to the challenge of coordinating autonomous state laboratory networks by developing a new organisational template of epidemic intelligence and integrated disease reporting. Rather than producing high volumes of microbiological data, the focus was on pooling, sorting and transforming various streams of information on disease prevalence into actionable intelligence.Part two of the article traces the domestic adoption and subsequent spread of the US epidemic intelligence template to other countries. Starting in the 1970s, authorities in the USA and the UK used the template to justify focused investment in high-tech laboratories for individual pathogens, automated sample processing, electronic reporting systems, centralised epidemiological coordination and rapid response capabilities. Reforms were, in part, driven by visions of real-time surveillance and a strategic reorientation of infection control towards hypothetical preparedness scenarios. However, in both countries, they were also a reaction to neoliberal ideals of lean public services, declining resources for routine communicable disease control, and cuts to public health laboratory services. The result was a growing imbalance of national capabilities, an outsourcing of laboratory services to the private sector and a relative loss of influence on the part of traditional public health microbiologists.Focusing on the 1990s, part three reconstructs how their growing expertise in molecular typing, electronic reporting and epidemic intelligence allowed centres of excellence like the American CDC and the UK’s Colindale campus to serve as international models for a cost-effective, sentinel-based laboratory approach to microbial disease surveillance. It simultaneously tracks how outside of these centres of excellence, streamlined reporting capabilities not only failed to compensate for, but also helped justify further cuts to local public health infrastructures and routine diagnostic services. As described in part four, the growing structural weaknesses of Anglo-American laboratory infrastructures were not fixed by brief funding surges in response to public health emergencies. They were also not picked up by international preparedness reviews that had been shaped around ideals of pandemic preparedness and epidemic intelligence and were dominated by experts from both countries.Subsidiriatätsprinzip) of Germany’s federal constitution, which holds that decisions should be made at the most decentralised level, meant that states continued to have considerable influence and that powers for Berlin came at the price of federal resources for local and state authorities and laboratories. This system not only helped retain local testing capabilities, but also allowed for a certain flexibility of responses should national centres of excellence be overwhelmed. The article concludes by reflecting on what insights the technical and political history of laboratory infrastructures and surveillance ideals may hold for post-COVID infection control.In all of this, (West-)Germany provides an interesting contrast to the Anglo-American history of central integration and local erosion. Following the public health establishment’s close involvement with Nazi racial hygiene, the post-war years saw competencies handed back from the federal centre to state and communal authorities. Despite Cold War competition over health indicators, public health remained a relatively neglected policy area and the sub-par performance of West Germany’s fragmented laboratory services served to highlight the advantages of more integrated systems. A major push to strengthen and integrate public health and laboratory systems occurred in the wake of reunification. Advised by the US experts, Germany began to integrate communal and state-based laboratory networks and (re-)establish the Robert Koch Institute (RKI) as a coordinating hub of epidemic intelligence. Despite this push for centralisation, the subsidiary principle  and Medical Research Council (MRC) (est. 1913) only slowly began to consolidate preventive and research activities during the interwar period.Biosecurity fears triggered a gradual move towards more systematised laboratory coverage. Concerns about the weaponisation of bacteriological agents had existed since the emergence of pure culture techniques around 1880. However, they were heightened during the 1920s as a result of German agents’ wartime attempts to infect Allied livestock and post-war bioterrorism allegations against Irish Republicans.The EPHLS was mobilised as part of the newly centralised Emergency Medical Services 1 week before the declaration of war on 3 September 1939. An integrated network of 19 laboratories was set up across England and Wales with provincial laboratories reporting back to a central laboratory headquartered away from enemy aircraft in Oxford . DespiteSalmonella enterica serovar Typhimurium and Staphylococcus aureus; ‘Moore swabs’ were developed to isolate and trace bacteria in sewer and water systems; centralised ‘finger print registries’ for typhoid carriers were established; and microbial taxonomies were refined.Salmonella and Staphylococci.In the absence of bacteriological attacks, EPHLS research also developed new laboratory technologies: national phage-typing schemes were rolled out for typhoid, paratyphoid, In marked contrast to parallel developments in the US, epidemiology was not a dominant discipline within the early PHLS. Despite having conducted interwar research in experimental epidemiology,A dedicated PHLS Epidemiological Research Laboratory was eventually established under the directorship of W. Charles Cockburn in 1946. Similar to the American CDC, Cockburn’s office began to gather national disease data—first on salmonellosis and then on other diseases—and provided expertise on the efficacy of pertussis vaccine roll-outs and clinical trials involving experimental polio and rubella treatments and prevention. A weekly joint publication of microbiological and epidemiological information began to be published from the late 1950s onwards.Parallel developments in the USA would transform this relatively passive mode of national epidemiological analysis into a new template of active epidemic intelligence centring on integrated data gathering, centralised analysis, and rapid outbreak response capabilities. The new template would not only shift the relative influence of public health microbiologists and epidemiologists in favour of the latter group, but also prove a successful international export.Similar to the UK, the US public health laboratories had emerged in an unsystematic fashion from the late nineteenth century onwards. In 1887, a National Hygienic Laboratory  was established at the Marine Hospital in Staten Island. By 1907, all the US states had boards of health, which were supplemented by local and county health departments.However, in a noted difference to England and Wales, responsibility for infection control was not transferred to the federal level but continued to rest with individual states. This meant that federal officials focused efforts on strengthening inter-state surveillance and assisting state-level programmes with earmarked funds and expert services.Despite improved interwar coordination, state-based responsibility meant that there remained considerable variation in the quality, number and speed of laboratory services. Free official public health laboratory services were unevenly distributed with poorer and rural areas enjoying less coverage than wealthier and metropolitan areas. Responding to these gaps, a growing number of commercial mail order and hospital-based pathology laboratories offered for-profit tests for various diseases. Quality concerns led to attempts by professional societies to regulate commercial services via approved laboratory lists and training curricula.Problems were compounded by blurred state-level responsibilities. In 1940, a PHS survey came to the ‘somewhat startling’ realisation that ‘within a single State as many as 18 separate agencies contribute something to the health activities’ and that ‘no jurisdiction’ had less than ‘6 agencies involved’.Morbidity and Mortality Weekly Report.For the US infectious disease control to improve, there was a need to boost coordination between federal and state authorities, expand laboratory services and standardise laboratory testing and reporting protocols. Similar to the UK, the Second World War provided an important stimulus. Domestically, disease control was an important part of wartime efficiency drives and justified investment in public health and laboratories systems. Externally, the global nature of the war and concerns about Japanese biowarfare justified creating centralised epidemiological coordination and medical intelligence capabilities.The biggest innovation to come out of the 1940s reordering of the US public health was a national centre of epidemiological and bacteriological expertise. Originating in wartime malaria and typhus control programmes, the CDC was established as the Communicable Disease Centre in 1946. As an initially obscure federal department outside Washington DC, the young agency had to convince Congress, the PHS, and individual states to finance its activities and transfer powers.Although some have described it as a ‘dumping ground’… the continued watchfulness over the distribution and trends of incidence through the systematic collection, consolidation and evaluation of morbidity and mortality reports and other relevant data. Intrinsic in the concept is the regular dissemination of the basic data and interpretations to all who have contributed and to all others who need to know. The concept, however, does not encompass direct responsibility for control activities. These traditionally have been and still remain with the state and local health authorities.Headed by famed epidemiologist Alexander Langmuir, the CDC epidemiology branch built on wartime models of ‘medical intelligence’ by conceiving of infectious disease surveillance as a form of systematised intelligence gathering and analysis. In contrast to the traditional focus of public health surveillance on tracing the transmission of pathogens between individuals, Langmuir focused on surveying larger  populations.Although Langmuir was careful not to infringe on state competencies, this did not mean that he thought of surveillance as a passive activity. At his behest, a dedicated CDC Epidemic Intelligence Service (EIS) was formed in 1951. With deliberate overtones of military intelligence activities, the EIS was tasked with coordinating responses to disease outbreaks—and biological attack—that exceeded local and state capabilities. A cadre of EIS officers could rapidly deploy while Atlanta provided centralised coordination. The EIS’ logo summed up this combination of ‘boots on the ground’ field epidemiology, centralised analysis and increasingly international ambition by depicting a globe straddled by a sole.Kaiserreich, German bacteriology had achieved international renown but remained decentralised outside of Prussia and the military. By 1911, there were over 50 official bacteriological institutes across the German states.Gesetz zur Vereinheitlichung des Gesundheitswesens), there were 740 official public health departments (Gesundheitsämter) across Germany. Local and state-level departments and hygiene institutes frequently employed bacteriologists to screen populations for venereal disease, tuberculosis, and other perceived threats to public and racial health. There were also close connections between leading bacteriologists at the Reichsgesundheitsamt, the military and the RKI at the national level.In contrast to Britain’s centralised laboratory infrastructure and the US model of state-based systems and service-like federal coordination, West Germany’s public health laboratory infrastructure was deliberately decentralised. During the Bundesländer) and powerful municipalities (Kommunen).Gesundheitsämter)—often with their own public health laboratories—10 state health departments (Landesgesundheitsämter), over 1,300 statutory health insurers covering about 90 per cent of the population, and powerful practitioner and hospital associations.Bundesgesundheitsamt),Bundesgesundheitsministerium, est. 1961), and the Conference of Health Ministers of the Federal States (Gesundheitsministerkonferenz). Below the federal level, some states like Bavaria had integrated public health laboratory services while others relied on communal arrangements for laboratory provision with loose coordination via state health departments.Their enthusiastic support of Nazi racial hygiene meant that large parts of the German public health and bacteriological establishment fell into disrepute after 1945. In West Germany, prime responsibility for public health laboratories and infection control was decentralised and firmly re-embedded in the Federal Republic’s 10 states  on national prevalence levels. It also acquired competencies for the national surveillance of immunisation programmes (1985), began offering teaching and training in communicable disease epidemiology (1988), and used the resulting ‘cadre’The obvious template for reform seemed to be the CDC’s model of epidemic intelligence. In 1977, Britain emulated the US agency by founding the PHLS Communicable Disease Surveillance Centre (CDSC) under the leadership of Nicol Spence Galbraith. Recruited in 1976, Galbraith had previously worked as an MoH and area medical officer in the London area and had long argued for a centrally financed and coordinated national epidemiological service along the lines of the CDC.ad hoc nature of 1970s PHLS lab closures had increased discrepancies between a better served south and a more poorly served north; fiscal constraints were forcing the PHLS to press NHS authorities for more compensation of microbiological services; and the new Thatcher administration included the PHLS in its programme of cost cutting reviews.The rise of the CDSC as the PHLS’ epidemiological ‘nerve centre’British Medical Journal in 1985, former PHLS director James Howie warned against demoting the PHLS to a consulting epidemiological service and breaking up a laboratory network that connected London to the rest of the country. Contrasting Britain and the USA, Howie was adamant that the ‘peripheral’ contacts provided by its extensive laboratory infrastructure made the PHLS more resilient and attuned to local problems than other systems. Planners should strengthen both epidemiological and microbiological services rather than demoting one in favour of the other:So the PHLS is at a crossroads. Starved of funds, it can maintain its national laboratory service only at the expense of curtailing its epidemiological activities – or conversely maintain or increase its epidemiological activities only at the expense of the laboratory service. (…). What seems plain is that [NHS] district health authorities have neither the incentive nor the powers to get going measures of action and investigation covering regions wider than their own. (…). [The PHLS] is admired and envied for its effective peripheral contacts by its counterpart in the United States (…). Those who would break the essential PHLS links between centre and periphery – who are they? Do they really know what they are doing?In 1985, a Department of Health and Social Services (DHSS) review recommended a radical transfer of the PHLS’ 52 area and regional public health laboratories  to NHS hThe DHSS review’s call for strengthened central epidemic intelligence prompted a merger of the PHLS Epidemiological Research Service and CDSC (1985). However, medical criticism, rising numbers of disease outbreaks, and the contemporary HIV/AIDS crisis made the Thatcher government decide to maintain the wider PHLS laboratory network.Developments in the USA highlighted the dangers of neglecting investments in routine local public health laboratory services in favour of a limited number of national and regional hubs of excellence. Internationally, the CDC remained a poster child of microbiological and epidemiological expertise due to its rapid outbreak responses, research on classic and new pathogens , and prominent role in the wider global smallpox eradication effort.However, outside of Atlanta, US politicians’ commitment to routine infectious disease control was waning. In the fiscal year 1973/1974, there were 12,295 clinical and public health laboratories in the USA. Around 3 per cent (392) of these were official state and local public health laboratories, which performed ca. 70 million laboratory tests per year .Initially, it seemed as though the CDC in Atlanta might escape some of these domestic pressures. Promoted from the rank of PHS Division to Bureau in 1968, the agency profited from rising health spending by the Johnson and Nixon administrations and acquired new competencies in areas unrelated to communicable disease including nutrition, occupational safety, smoking and environmental health.The CDC’s expansion into new areas was not without challenges. After moving from success to success during the first decades of its existence, the 1970s saw the CDC experience a series of setbacks and financial pressures. Starting in 1974, successive US administrations responded to surging inflation and economic stagnation (stagflation) by imposing limits and cuts on federal expenditure. In 1976, the CDC suffered additional damage due to its advocacy of mass vaccination against swine flu (H1N1), which resulted in the sacking of its long-standing director David J. Sencer and major organisational reorganisation. In line with the Surgeon General’s 1979 call for a second public health revolution centring on preventive health, the CDC was renamed into Centers for Disease Control and Prevention and focused more of its increasingly constrained resources on lifestyle and environmental issues.Following Ronald Reagan’s election, Sencer’s successor William Foege was forced to administer severe cuts of federal public health funding.Gesundheitsämter were responsible for most laboratory testing and public health enforcement; state offices compiled data, aided outbreak responses and administered health programmes; federal activity mostly focused on the political coordination of state programmes. Epidemiological oversight was limited. According to a 1976 survey of venereal disease control, public health workers lacked power in relation to insurance-financed clinicians. Many clinicians did not adhere to updated 1970 disease reporting requirements and had monopolised lucrative treatments. The small number of local Gesundheitsämter offering consultative and laboratory services referred patients to local practitioners. Systematised laboratory testing was limited, disease incidence was under-reported, and data was insufficient to allow for effective contact tracing.While the USA and UK thus saw fiscal pressures, declining interest in infectious disease, and an increasing focus on centralised epidemic intelligence erode resources for local and national public health laboratory services, West German arrangements highlighted the dangers of lacking epidemiological integration and local fragmentation. Throughout the 1960s and 1970s, post-war arrangements had remained relatively static: local Gesundheitsämter but to ambulatory care physicians, who were reimbursed by sickness funds. This further diluted officials’ capacity to expand, collate and act on laboratory testing data. It also eroded the wider public health workforce. Between 1970 and 1996, the number of physicians working in West German public health services decreased from 4,900 to 3,300, the number of dentists from 2500 to 800, and the number of social workers from 4,000 to 2,500.Post-war resistance of the West German states to federal centralisation gradually diminished from the 1970s onwards. However, attempts to update disease reporting, improve integration and expand coverage with 1972 ‘guidelines for federal state law on public health’ and 1977 ‘Concerted action in the public health sector’ failed to resolve problems.Bundesgesundheitsamt recruited 50 experts to develop recommendations on nosocomial infections. However, in contrast to contemporary Anglo-American programmes, resulting guidelines on architecture and technical procedures did not cite systematic reviews or clinical studies.Lack of political interest and planning towards ‘intensifying protection against illness’By the end of the 1980s, post-war laboratory infrastructures had thus evolved in very different directions. In both the USA and the UK, budgetary pressures, a redirection of attention away from infectious disease, and visions of integrated epidemic intelligence had strengthened central epidemiological oversight but weakened local public health laboratory services. By contrast, lack of epidemiological oversight and integration of local and state laboratory infrastructures was hampering infection control in West Germany.Budgetary and political pressure on post-war laboratory infrastructures accelerated during the 1990s. Pressures occurred amidst growing scientific warnings about public health systems’ ability to deal with surging rates of antimicrobial resistance (AMR), nosocomial and food-borne infections, and the accelerating HIV/AIDs pandemic. In the USA and the UK, health officials and experts tried to mobilise resources by framing infectious disease hazards as national biosecurity threats. Building on the now firmly established international template of epidemic intelligence, advocates claimed that identified threats could be tackled with improved mathematical forecasting, networked sentinel laboratories and molecular ‘real-time’ surveillance, and centralised intelligence and response capabilities. Resulting preparedness plans did not sustainably strengthen either domestic laboratory infrastructures or microbiological capacity in the foreign locations they were also targeting. Instead, they concentrated resources on high priority pathogens and individual hubs of excellence. Focusing on microbiological surveillance in Africa and South Asia, anthropologists, microbiologists, and historians have highlighted how ring-fenced, time-limited, and targeted surveillance programmes hollowed out laboratory capacity for other pathogens.For the UK’s PHLS, the period around 1990 proved particularly challenging. During the 1980s, HIV/AIDS and fatal outbreaks of salmonellosis at a mental health unit at Wakefield’s Stanley Royd Hospital (1984) and of legionella at Stafford General Hospital (1985) had triggered a wider review of public health services. Headed by Chief Medical Officer (CMO) Donald Acheson, the review’s influential 1988 report stressed the value of epidemiological oversight and stated that the 1974 NHS reorganisation had fragmented public health at the community level. MoHs had once provided a public health anchor point for local authorities, general practitioners, PHLS laboratories and hospitals. However, after this office was disbanded in 1974, ill-defined responsibilities had led to a neglect of local preventive health and communicable disease control.Evidence submitted to us demonstrates almost universal support for the PHLS and its epidemiological ‘nerve centre’ the CDSC. (…). We are concerned to learn that if there were a recurrence of serious outbreaks (…) in more than one part of the country at the same time, or if a single outbreak spread to more than one major centre of population, the current system would be unable to cope.In the case of infectious disease control, coordination between local PHLS laboratories, NHS services and local authorities was compromised by the absence of overarching epidemiological oversight. It was ‘extremely important (…) that someone within the health authority is responsible for linking the vital work undertaken by microbiologists and control of infection teams within hospitals with cases of infection occurring outside’.To strengthen communicable disease control, the 1988 Acheson report recommended re-embedding epidemiological expertise at the local level by creating the post of a medically qualified District Control of Infection Officer ), who would provide advice for local public health and clinical services. A second new post, the Director of Public Health (DPH), would work with the CCDC, coordinate preventive health at the district level and submit public health annual reports.While the Acheson report revitalised community public health,Lancet warned: ‘At a time when the British government seems keen to be penny wise and pound foolish, the message (…) to those who would further pare down an already rationalised PHLS is leave well alone.’On the occasion of its 50-year jubilee in 1996, the PHLS thus remained in direct command over a network of 49 microbiology laboratories organised into nine regional groups with devolved budgets and could also draw on information supplied by NHS laboratories.Existing public health laboratory infrastructures faced even graver pressures in the USA. The cuts in 1980s to federal and state public health budgets and attempts to commercialise microbiology services had resulted in a marked decline of public health laboratory capacity.Alarmed, the Institute of Medicine (IoM) published a damning analysis in 1988: ‘disarray of public health’Emerging Infections: Microbial Threats to Health in the United States, the review warned that the USA had no ‘comprehensive national system for detecting outbreaks of infectious disease (except for food- and waterborne diseases)’ and that there was a ‘lack of coordination among the various US government agencies’ and ‘between government agencies and private organisations’.Co-chaired by Nobel Laureate Joshua Lederberg, a second IoM review issued an even sterner call for action in 1992. Titled Emerging Viruses, the 1992 IoM report is now seen as a landmark publication of a new age of biosecurity politics, preparedness scenarios and hopes for ‘real-time’ surveillance.Originating in a 1989 conference on In the case of US laboratory infrastructures, ‘smart’ investment in a select number of specialist hubs and threats legitimised cuts to the more expensive traditional system of local public health laboratories with broad non-specialist testing remits. Hopes that new electronic networks, databases, and molecular typing technologies would be able to maintain effective disease surveillance despite growing gaps of baseline microbiological coverage underestimated how difficult this transition would be for many smaller laboratories. During the 1980s, pilots like the CDC’s 1984 Epidemiologic Surveillance Project or the WHO’s 1988 WHONet for AMR had highlighted the potential of information technology to standardise and accelerate clinical and laboratory reporting.The Hot Zone stoked public concerns about deadly ‘foreign’ pathogens like Ebola,In the absence of effective advocacy, the defunding of the US public health laboratory infrastructures was accelerated by the polarisation of health politics following the Clinton Administration’s 1993 attempt to establish universal health coverage.Privatisation was another challenge. In contrast to the UK where commercial operators had been displaced by the NHS and PHLS,Escherichiacoli and non-typhoidal Salmonella (PulseNet).The CDC continued to try to compensate for eroding local and state capabilities by improving the efficacy of existing laboratory networks and by investing in new molecular typing technologies and IT systems. In 1996, it established a network of electronically linked sentinel laboratories that could detect spikes of disease and employ PFGE molecular typing for Subsidiaritätsprinzip), which stipulated that regulation by higher authorities should only occur where problems exceeded the abilities of lower ranking authorities, the result was a cautious series of public health reforms that simultaneously aimed to strengthen epidemic intelligence at the federal level, state-based epidemiological and laboratory competencies, and interstate collaboration. Although many components of East Germany’s health system were decentralised following reunification, parts of its high-performing microbiology infrastructure like the Institute for Experimental Epidemiology in Wernigerode were incorporated into the RKI. In Berlin, the status of health politics was upgraded with the separation of the Federal Ministry of Health (Bundesgesundheitsministerium) from the Federal Ministry of Youth, Family, Women and Health in 1991. Below the federal level, an increasing number of German states responded to national and international pressure by adopting statutory principles for public health and rationalising service provision—including laboratory services—at the communal level.Germany once again diverged from Anglo-American trends. In the 1980s politicians had also tried to contain rising health expenditure, streamline processes and introduce market elements in the form of ‘manacled competition’.Bundesgesundheitsamt and state officials had failed to halt the distribution of untested HIV-contaminated products by a company called UB Plasma until October 1993.More ambitious reforms occurred after an international scandal shook the German infectious disease establishment. In 1987, West Germany had launched an Immediate Action Programme to Combat HIV/AIDS, which created ca. 700 specialist positions in public health offices and laboratories throughout the country. However, HIV/AIDS protection and testing infrastructures remained patchy. In 1993, the German public was shocked to learn that around 2,000 haemophiliacs and 600 transfusion recipients had contracted HIV due to contaminated blood and blood products.Bundesgesundheitsamt was dissolved. Its combined powers for drug regulation and communicable and non-communicable diseases were distributed to the Federal Institute for Drugs and Medical Devices (Paul Ehrlich Institut), the Federal Institute for Consumer Protection (Bundesamt für Verbraucherschutz und Lebensmittelsicherheit) and the RKI. The latter institution now also incorporated Germany’s AIDS Centre and Institute of Social Medicine and Epidemiology and thereby became Germany’s primary hub for communicable disease control.The HIV scandal and concerns about multidrug resistant and emerging diseases prompted the largest shake-up of German infectious disease control since 1945. In 1994, the 118-year-old Gesundheitsämter.After four decades of relative neglect, the combined effects of reunification, scandals, and EU integration made decision-makers in Berlin firmly commit to strengthening and integrating Germany’s decentralised hinterland of ca. 360 state and communal Contagion (2011) but failed to refocus decision-making on the robustness of underlying public health laboratory infrastructures.Concerns about the functionality of public health and laboratory systems acquired new urgency as a result of the 2001 anthrax attacks and the 2003 SARS-CoV pandemic. Large-scale reforms occurred in each analysed country. Injections of public money, public health reforms and new genomic technologies dramatically boosted authorities’ ability to quickly identify and react to emerging outbreaks. On both sides of the Atlantic, planners continued to hope that targeted high-tech surveillance in specialised laboratory hubs and integrated epidemic intelligence would be able to stop outbreaks in their tracks. What would happen if this line of defence failed was the subject of numerous outbreak movies like In Britain, the decade between 2003 and 2013 saw the biggest shake-ups of infectious disease surveillance since the creation of the EPHLS in 1939. The first shake-up was the result of the Blair Administration’s attempt to reform British health, social care and consumer protection whilst also devolving powers to the national governments of Wales, Northern Ireland and Scotland. In the wake of the 1996 mad cow disease (BSE) crisis, a new Food Standards Agency (est. 2000) was placed in charge of monitoring the food chain. One year later, the Department for Environment, Food and Rural Affairs assumed responsibility for agriculture and environmental health and the creation of 303 NHS Primary Care Trusts (PCTs) led to a significant restructuring of community-level public health. Taking over from the 95 now dissolved district health authorities, PCTs were tasked with providing and commissioning primary, community and secondary health services. Preserving integrated infection control abilities did not rank high on reformists’ agenda. Instead, the creation of PCTs fragmented the post-1988 realignment of local and district-level epidemiology, microbiology, clinical, and local authority services as well as the existing public health workforce of CCDCs and DPHs.Getting Ahead of the Curve report.The PHLS did not escape reformism either. In 2003, the now 64-year-old organisation was disbanded and merged into a new Health Protection Agency (HPA). The HPA was the brainchild of CMO Liam Donaldson and his 2002 Getting Ahead of the Curve recommended ending the traditional separation of local public health and clinical microbiology and concentrating public health resources on the centralised provision of specialist services. Control over all local PHLS laboratories should be transferred to the NHS—thereby essentially implementing the 1985 DHSS recommendations and creating a CDC-like agency with one centre and a few regional hubs. Rather than controlling public health microbiology at the local level, the HPA would act as a coordinating centre of epidemic intelligence and provide microbiological reference, consulting and rapid response services to the NHS, British government and local authorities. It was envisioned that HPA experts would closely coordinate with NHS Pathology Services in England, who would now provide all local microbiology services and report relevant public health data to the HPA. Should it be required, additional NHS testing could be commissioned. Reformers hoped that transferring the distinct network of PHLS laboratories to the NHS would rationalise local microbiology services and improve diagnostic, assurance, and reporting standards via centralised NHS oversight. They also hoped that NHS PCTs, Strategic Health Authorities and laboratories would not only support the HPA during outbreaks but also devote sufficient resources towards maintaining routine public health microbiology outside of emergencies.In a radical move, The HPA was formally established on 1 April 2003 with four bases at Colindale, Porton Down, F2 Crossref missing There is real and general concern about the capacity to deliver enhanced surveillance or to mount an acute response. (…). There appear to be no plans as yet for providing any material incentive for NHS laboratories to rise to the public health challenge, and a fear that in local tussles about funding, money will be diverted from public health purposes.The creation of the HPA was greeted with mixed feelings by PHLS staff.… it should not be assumed that a recurrence of SARS is therefore unlikely, or that a further outbreak would be controllable. (…). If there are weaknesses or deficiencies it should not be thought that they can or should be repaired by quick fixes each time an acute threat materialises. Such expenditures fail to build the infrastructure needed to maintain a comprehensive capacity for rapid and technologically appropriate response to new pathogens, and over time they distort facilities and so hinder the effective management of the laboratory.Similar to problems within the CDC, it was also unclear whether HPA management would neglect infectious disease over chemical, radioactive or chronic disease threats.Mortimer’s warnings proved prescient. Later remembered as a ‘painful birth’,The effects of losing local public health laboratory services were compounded by confused official responsibilities for infection control. PCTs were charged with protecting community public health but relied on professionals in the HPA’s headquarters and HPUs for response management. Local authorities were responsible for protecting the public from infectious disease and appointing a CCDC. However, CCDCs were no longer responsible to the NHS DPH but were employed by the HPA as part of its HPUs. Meanwhile, the HPA was dependent on PCTs, NHS England Pathology Services and local authorities for routine clinical and microbiological data generation and for mounting outbreak responses.The 2008 financial crash exacerbated problems with severe funding cuts for the HPA. Between 2009 and 2013, HPA staffing decreased from 4,100 to 3,700 (9.7 per cent). Meanwhile, the agency’s core budget declined by over 26 per cent from £193 million (2009/2010) to £142 million (2012/2013). In response, the HPA became increasingly dependent on extramural grants and private funding for special programmes and research. Similar to the USA (see below) and parallel developments in international health,In 2010, the new Conservative government launched a policy of fiscal austerity. Despite successful HPA responses to the 2006 polonium killings and 2009 H1N1 pandemic,The creation of PHE was part of the second shake-up of British health care within a decade. The 2012 Health and Social Care Act abolished New Labour’s PCTs and stripped the NHS of its responsibility for local public health services, which were returned to local authorities. According to the new doctrine of democratic localism,(Re)-implementing effective localism was undermined by ongoing budget cuts. To maintain outbreak preparedness and routine public health services, PHE relied on support from the NHS and local authorities. This included sufficient funding for local public health laboratory services and reporting by NHS Pathology Services as well as the ability and willingness of local authorities and NHS managers to adhere to formal public health outcome frameworks.Ahead of the biggest pandemic event since 1918, the once formidable public health laboratory infrastructure in England was smaller than at any point since 1939. Despite access to cutting-edge molecular typing, world-renowned experts, and integrated electronic reporting, the UK’s centre of epidemic intelligence in Colindale had reduced political autonomy to act in the name of public health, less contact with local microbiological and public health services, and little surge testing capacity to fall back on should its national and regional reference laboratories be overwhelmed.The growing centre–hinterland divide and discrepancy between preparedness rhetoric and actual laboratory capacity were mirrored in the USA. Between 1999 and 2020, a brief effervescence of public health funding and reform was followed by a prolonged phase of budget and personnel problems. In 1999, a review by the non-partisan Government Accountability Office (GAO) reported ongoing gaps in the US laboratory surveillance and disease reporting. Almost half a century after their creation, it remained voluntary for states to adopt the annually reviewed list of notifiable diseases issued by the CDC and Council of State and Territorial Epidemiologists. While this arrangement enabled states to opt out of testing for diseases that were rare in their territory and focus resources on a national 'core list' of reportable diseases, it also created surveillance gaps for emerging threats like hepatitis C and AMR.Powerless to override state decision-making, the CDC tried to mobilise financial resources and increase the efficiency of existing public health laboratory networks by stressing biosecurity scenarios. A 1999 CDC report declared that Americans were ‘a Nation at risk’.Outside of Atlanta, the APHL tried to use Congress’ Healthy People 2010 initiative to promote a broader vision of public health laboratory capacities. Although it also referenced bioterrorism threats, its 2000 consensus vote on core functions of state public health laboratories only listed emergency response capabilities on place 8 of 11 – below the provision of diagnostic, surveillance, reference, quality assurance, and data management services.… vulnerable and outdated health information systems and technologies, an insufficient and inadequately trained public health workforce, antiquated laboratory capacity, a lack of real-time surveillance and epidemiological systems, ineffective and fragmented communications networks, incomplete domestic preparedness and emergency response capabilities, and communities without access to essential public health services.The 2001 World Trade Centre and anthrax attacks created further momentum for the enactment of preparedness-oriented reforms of the US public health laboratory infrastructures. According to the IoM, 2001 had revealed:Salmonella in animals, FoodNet for the surveillance of foodborne diseases, and OutbreakNet for PFGE data sharing.During fiscal year 2002, the Bush Administration increased already rising federal preparedness spending. Of the $2.9 billion bioterrorism appropriations bill signed on 10 January 2002, $1.1 billion were dedicated to upgrading bioterrorism preparedness, infectious-disease surveillance, network integration, and hospital surge capacity.Whether the surge of preparedness funding, which peaked in 2004, was sufficient to shore up baseline US public health capacity was debatable.Before [H1N1], the federal government would have to make a lot of tests, and we’d send them out, and people would use them … With people being able to do their own PCR, we could put up the recipe and let people make that themselves. It’s a much more robust approach for people able to ramp up testing for a novel pathogen.Despite these problems, the USA mounted an effective response to the 2009 H1N1 pandemic. New molecular capabilities meant that it took only 2 weeks from the identification of the novel virus to the creation, emergency FDA authorisation, manufacture, and distribution of a rapid RT-PCR-based test. Rapid FDA licensing had in part been possible because of prior CDC and BARDA investment in a platform technology (five target assay) for rapid influenza testing that could be quickly modified. In line with its preparedness protocols, the USA had also stockpiled reagents.The fact that non-governmental academic, private and clinical laboratories could validate ‘homebrew’ tests against a published gold standard had stopped public health laboratories from being overwhelmed by a flood of specimens.E. coli molecular typing results to CDC’s PulseNet database within four working days.The resilience of this public health laboratory infrastructure faced accelerating threats following the 2008 financial crash. With the US states experiencing severe fiscal pressure, public health laboratories were forced to reduce or commercialise testing services. Federal decision-makers did little to counteract these cuts. In 2009, a large part of the Obama Administration’s $5.8 billion of H1N1 surge funding was spent on vaccination and only a small percentage of funds reached laboratories.Challenges for public health laboratories increased following the enactment of the Obama Administration’s 2010 Affordable Health Care Act. Medicare and Medicaid had been significant revenue sources for public health laboratories. However, the vast increase of people eligible for basic testing raised fears about the future of direct public financing, necessitated a significant upgrade of public billing systems, and increased competition with commercial laboratories—with state laboratories still required to maintain core functions and provide services to uninsured Americans.Infektionsschutzgesetz) came into force in 2001. In line with previous reforms, key public health competences remained in the hand of state and communal authorities, but the 2001 law enhanced authorities’ ability to respond to outbreaks with improved vaccination, surveillance and police powers—including the right to impose quarantine and job bans. The federal centre in Berlin was empowered to impose federal control in the case of disease events of national significance. State-level and federal disease reporting requirements were unified and upgraded with Berlin now able to demand laboratory and disease surveillance data that included personal information during emergencies.Of the three analysed countries, Germany was the only one to mostly strengthen laboratory services between 2000 and 2020. Driven by EU requirements and demands for integrated European surveillance networks, a new infectious disease law (E. coli (EHEC) epidemic exposed ongoing communication gaps between different states. A new electronic notification system (Deutsches Elektronisches Melde- und Informationssystem für den Infektionsschutz) was trialled between 2016 and 2020.As the federal epidemiological centre, the RKI focused more resources on curbing nosocomial infections, increasing vaccine coverage (by incorporating Germany’s permanent vaccine commission), and improving infectious disease surveillance.Repeatedly upgraded after 2001, Germany’s new infectious disease legislation addressed long-standing organisational constraints at the communal and state level whilst also integrating national networks and strengthening federal oversight. This did not mean that variations in state public health arrangements ceased or that the RKI in Berlin became dominant. A further attempt to centralise and rationalise regulations and competencies was rejected by states in 2005.On the eve of COVID-19, assessing the preparedness of different public health infrastructures was thus deceptive: Anglo-American centres of excellence wielded significant international influence, had developed sophisticated molecular typing and electronic notification systems for existing laboratory assets, and had fine-tuned a model of epidemic intelligence that could rapidly deploy experts and stockpiled equipment to quell localised outbreaks. Despite ongoing cuts and reforms, responses to the 2003 SARS and 2009 H1N1 outbreaks engendered confidence that Anglo-American public health systems could protect citizens from new or familiar pathogens.However, beyond the centre, the wider state of public health laboratory infrastructures was worrying. Since the late 1970s, decades of budget reductions and attempts to streamline laboratory services had eroded local testing and microbiological expertise. Routine laboratory services for many infectious diseases had been cut or outsourced and staff shortages were significant. Should centres of epidemic intelligence fail to stamp out an emerging epidemic or pandemic event, there was little hinterland capacity to fall back on to protect the public’s health.These infrastructural weaknesses had been highlighted by multiple reports and exercises like the UK’s 2016 Operation Cygnus.While hindsight is cheap and history provides no simple lessons, focusing on the long-term development of the laboratory infrastructures underpinning public health systems can provide insights for planning going forward. One of these insights is the importance of context and time when it comes to creating and maintaining resilience. As this article has shown, laboratory infrastructures evolved to fit the specific needs, political systems, and infection control visions of their respective national contexts. While the concerns shaping this evolution were often similar, the degree of central control, integration, and efficiency of resulting infrastructures differed: Britain's PHLS evolved its laboratory network to fit around an already existing system of local epidemiology and public health consisting of MoHs and local authorities; the CDC’s concept of epidemic intelligence was developed in response to concerns about biological attack and the need to coordinate autonomous state public health laboratory systems; West Germany’s laboratory system was shaped by existing communal traditions and by the post-war focus on de-Nazifying and decentralising public health.The specificity of each laboratory infrastructure meant that reforming it required careful deliberation of how it fit into the wider public health ecosystem as well as sufficient time and fiscal resources to ensure that vital components could adapt to new challenges and visions of infectious disease control. Both resources were usually in short supply. With attention for infectious disease control declining and post-1960s planners under pressure to cut costs, the CDC template of epidemic intelligence proved an attractive export. The mix of centralised epidemiological oversight, integrated reporting networks, and rapid response capabilities offered significant strategic and cost advantages when it came to moving surveillance from the individual to the population level and targeting a select number of diseases. What was, however, increasingly forgotten was that this ‘lean’ template of epidemic intelligence had only become possible as a result of post-1920s investment in local and state laboratory infrastructures that were capable of supplying large volumes of microbiological data and which were now being pruned in the name of cost-effectiveness. In both the USA and the UK, planners and politicians hoped that technological advances like electronic reporting, automated processing, and—later—molecular typing would compensate for reduced local services. Once established as a default reform pathway, visions of cost-effective epidemic intelligence, real-time surveillance, and preparedness for select biosecurity scenarios overshadowed warnings about gaps in routine public health laboratory services. Funding surges in response to crises like 9/11 were too short-lived and focused on individual pathogens to compensate for these growing infrastructural weaknesses. The German case study is the exception that proves the point. It was the difficulty of pushing bigger reform packages through Germany’s compromise-oriented federal system that gradually created a relatively stable balance between centralised epidemic intelligence and ongoing support for autonomous state and local laboratory networks.Paying close attention to the described case studies is to appreciate the potential of epidemic intelligence in pooling and analysing epidemiological information, the natural limits of specialist hubs when it comes to the provision of routine public health services, and the dangers of one-size-fits-all thinking in international health. Going forward, it means paying greater political and academic attention to the mundane technical infrastructures—like laboratories—that underpin public health both during and outside of outbreaks. Focusing on these mundane infrastructures complicates media narratives foregrounding the role of centralised pandemic decision-making in Atlanta, Colindale, and Berlin. It also provides an important counterpoint to a popular genre of science writing that routinely emphasises the work of lone ‘disease detectives’ and elite scientists within infection control.


A pilot study was conducted for a regional transit authority (RTA) to evaluate the implementation of a customized software to increase ridership, trips, destinations and coordination of rides among four Councils on Aging (COA) using RTA vans to serve rural communities in north central Massachusetts. Baseline and follow up ride data were collected from each COA from Fall 2019  and Fall 2021  and from 59 stakeholder interviews with riders, drivers, dispatchers, and staff from the COAs, RTA, and software company. The evaluation found after 6 months that while the goals of the pilot were not yet achieved, due in part to external factors such as the COVID-19 pandemic and driver shortage, valuable lessons were learned including the importance of balancing provider goals of efficiency and reporting with rider needs of driver hands-on assistance and friendly scheduling support.


The journals of the Genetics Society of America, GENETICS and G3: Genes|Genomes|Genetics, are calling for submissions of papers in the area of Genetic Models of Rare Diseases.Identifying genes associated with rare diseases, and understanding how variants within those genes alter molecular and cellular phenotypes, is a central challenge. The advent of whole exome sequencing (WES) and whole genome sequencing (WGS) has dramatically changed the landscape of human genetics. Sequencing can be used to identify variants in genes that may be disease causing, driving the discovery of rare genetic diseases. These approaches can pinpoint a gene or variant of interest based on the sequence from a few family members rather than extensive family histories. However, the genes and variants of interest often benefit from modeling in cellular assays or genetic model organisms to understand molecular and cellular mechanisms of disfunction. Model organisms have therefore been useful for the discovery of new genetic diseases, and are key to understanding variant effects. It is estimated that the genetic variants for thousands of rare diseases remain to be discovered. Hence, much work lies ahead.A key advantage to modeling a disease gene in genetic model organisms is that the gene or variant function can be explored in depth. For example, molecular effects on metabolome, transcription, translation or protein function can be assayed, or transcriptomes or interactomes can be profiled. These studies can pinpoint disease mechanism, reveal unanticipated gene functions or elucidate specific existing pathways. These discoveries can identify other genes that may cause similar phenotypes, driving the discovery of additional, related rare human diseases. High-throughput assays such as Multiplexed Assays of Variant Effect (MAVEs) have also opened the door to systematic assessment of the functional consequences of genetic variation in human disease genes. Unraveling the mechanism by which variants act can highlight potential therapeutic strategies to help patients. Hence, organisms like yeast, worms, flies, fish and mice (as well as other genetic models) can be particularly useful.This series will highlight ongoing advances in rare disease discovery and mechanisms by presenting key research findings, new discoveries, and reviews or perspectives. We invite high-quality submissions with a focus on model organism-human genetics, genomics, MAVE studies and work that leverages advanced genomic tools for gene identification and editing to address the issues noted above.Series Editors:Brenda Andrews (University of Toronto)Hugo Bellen (Baylor College of Medicine)Douglas Fowler (University of Washington School of Medicine)Philip Hieter (University of British Columbia)other series the journals have published.The Genetic Models of Rare Diseases Series will launch in Summer 2023; though articles will be published online shortly after acceptance via Advanced Access (including the completed proof). Papers will be collected and navigable across the two journals and promoted on social media and other venues, in a manner similar to submit manuscripts by 16 January 2023 and should submit to the journal of choice. Manuscripts will be reviewed and edited through the standard peer review process and according to the usual high standards of the journals. Some manuscripts submitted to GENETICS may be offered a transfer to G3: Genes|Genomes|Genetics instead.Authors are invited to We encourage continued submissions past 16 January 2023 as we intend this series to be an ongoing and growing resource in this area. At submission, please choose the “Genetic Models of Rare Diseases” article type in the submission systems and mention the series in your cover letter.Please share with your colleagues, and do not hesitate to contact any of the series editors or the GENETICS  and G3: Genes|Genomes|Genetics  Editorial Office with questions, suggestions, or presubmission inquiries.


Legumes, members of the Fabaceae/Leguminosae family, are the third largest family of higher plants with almost 20,000 species belonging to 650 genera, and are ubiquitous all over the world. Among all legumes, pulse crops or food legumes fall into the four clades of the subfamily Papilionoideae which include aeschynomenoids/dalbergiods, genistoids, hologalegina, and phaseoloids/millettoids. They are distinctive due to their positive impact on agricultural and environmental sustainability and have a prominent role in promoting human and animal health, soil amelioration, cropping system diversification, and sustenance of rural livelihoods , followed by chickpea (125%), urdbean (90%), pigeonpea (51%), and lentil (34%) in the last 15 years  has been modest compared to dramatic increases in cereal productivity  between 1961 and 2017  is the second largest pulse crop, cultivated by smallholder farmers in more than 50 countries. In recent years, remarkable progress was made in developing novel genomic tools in chickpea including the draft genome sequence  on Ca1 associated with physiological P-use efficiency, shoot dry weight, and shoot P content. They also identified genes related to shoot P concentration, physiological P-use efficiency, specific root length, and manganese concentration in mature leaves. Jha et al. identified major QTLs and potential candidate genes for heat stress tolerance and reported a genomic region on CaLG07 harboring QTLs explaining > 30% of the phenotypic variation for days to pod initiation, 100-seed weight, and for nitrogen balance index explaining > 10% PVE.Globally, chickpea  harboring 31, 22, 17, and 32 SNPs with a peak of SNP index = 1 for low bulk for flowering time, high bulk for flowering time, high bulk for 100-seed weight (HSW), and low bulk for HSW, respectively. They developed two markers, viz., Ca6EF10509893 for early flowering and Ca6HSDW10099486 for HSW, and validated them using the candidate SNPs.The MutMap approach targets discovery of mutant genes for assessing gene function and is based on BSA analysis of mutant progenies obtained in the/an FMadurapperumage et al. discussed chickpea as a source of essential fatty acids and focused on plant lipids, their functions, and benefits for human health. They reviewed the chemical analysis of essential fatty acids and possible breeding targets to enrich them which could be possible by phenotyping diverse chickpea germplasm; candidate genes responsible for quantitative trait loci mapping using genome-wide association mapping were identified.Toker et al. reported a new Cicer species proposed as Cicer turcicum and explained its potential to improve various traits in chickpea including heat tolerance and bruchid resistance.Crop wild relatives, landraces, and exotic germplasm are highly useful for introgression of novel variation to widen the genetic base of the elite gene pool leading to incremental gains over the breeding cycles  Wilczek] is a short duration and widely adaptable pulse crop known for its easily digestible high-quality protein  directly controls the plant health and survival  from the Indian gene bank which could be efficiently deployed in lentil improvement programs.Vicia faba L.) is the fourth most important cool season legume consumed locally in Asia, America, and Mediterranean countries. The genome information is scarce in this crop mainly due to the intrinsic difficulties of assembling/annotating its big genome size of 13 Gb  and herbicide tolerance in breeding programs have encouraged breeders and given confidence in marker-assisted selection. Closely linked QTLs for biotic and abiotic stress tolerance are available and could be used to enhance the efficiency of the selection process. Omomowo and Babalola reviewed the constraints and prospects of improving cowpea productivity to ensure food and nutritional security and environmental sustainability, taking a special interest in Africa. They elaborated on recommended methods to achieve extreme growth in productivity. Chu et al. elucidated the role of VaSDC1 in modulation of flavonoid metabolic pathways in seed coat color in adzuki bean (Vigna angularis L.) and genetically mapped it in the interval between simple-sequence repeat (SSR) markers Sca326-12, Sca326-4, and BAgs007 on chromosome 3 using an F4 population.Minor pulses hold tremendous nutritional significance although these are produced and consumed locally and there is generally no exchange of materials between countries unless they are already cultivating and consuming these minor pulses (Ahlawat et al., Of late, there has been a surge in the demand for plant-based proteins globally, even in those countries who have not normally been large consumers of pulses. This warrants a focus on strategies leading to a significant production improvement of pulses and their nutritional quality enhancement. Overall, the 14 articles published in this special issue reported new innovations/contributions toward genetic improvement of pulse crops and the knowledge gained could be further deployed toward development of new superior lines leading to improved genetic gains. The articles also highlight development of new markers, useful marker trait associations, new useful species, etc. Nonetheless, it is also evident that strategically important minor legumes still lag behind other pulses and require a research impetus toward development of new genomic information and deployment of molecular tools for their improvement. Extensive studies are required to quantify precise genetic gains in pulses with respect to yield and nutrition traits which will help in developing strategies for targeted breeding.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This data article includes a dataset developed between 2020 and 2022 to characterize and analyze the state of energy efficiency of nearly zero energy buildings in ten Eastern European countries. The data article refers to the paper' Overview and future challenges of nearly zero-energy building (nZEB) design in Eastern Europe' . The data provides an overview of the status of building energy use, energy savings, and regulations for the newly constructed building stock, including Bulgaria, Croatia, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Romania, and Slovakia. The importance of the dataset lies in its unique approach of data collection that provides detailed information on electricity, gas, oil, coal, and wood used in the investigated countries between 2015 and 2020. The methodology involves compiling and fusing data from national registries and depositories written in ten different national languages. Thus, the data is not available in Eurostat or any EU platform. The methodology followed to produce the data is mainly a literature review of restricted national publications and an extensive questionnaire with 14 national experts involved with the nZEB implementation plans and policies. The data include several parameters, including building energy efficiency thresholds expressed in the form of primary energy use intensity; primary energy conversion factors; renewable energy shares; building envelope performance requirements; mechanical ventilation performance requirements; thermal comfort requirements; construction rates of residential buildings; and heat pumps market penetration expressed as heat pump units per 100 households. The data paper is valuable for scientists to conduct future research to implement energy efficiency measures and renewables towards energy-neutral buildings.  Value of the Data•The data is valuable for the building energy efficiency research community, including building energy professionals, building energy systems inventors, and scientists who seek to build future scenarios for energy efficiency and carbon emissions. Scientists engaged in building science, architecture, mechanical engineering, and climate engineering are secondary research beneficiaries. More importantly, the data allows scientists to design energy policies that translate design data and code requirements for full electric, energy neutral, and carbon-neutral buildings.•The data provide quantitative information on the design requirements of nearly Zero Energy Buildings (nZEBs) across Eastern Europe between 2015 and 2020.The provided data can be used to develop energy conservation measures and build energy models for energy loads in buildings and the future carbon emissions of residential buildings. Provided data account for European carbon neutrality targets.•The data give insight into the implications of nZEB implementations on energy consumption, heating and cooling energy needs, thermal comfort, renewable production, and selected energy efficiency measures.1This study collected data from fourteen stakeholders involved in the ten countries to develop nZEB performance requirements, classify them, and fuse them into shared data. The data is externally deposited in a publicly available repository 1.1Sheet 1: Legislation status in eastern Europe's member states in 2021.Sheet 2: nZEB performance threshold in Eastern Europes’ Member States.Sheet 3: Primary energy conversion factors in Eastern Europe's MS for the year 2020.Sheet 4: Newly constructed households between 2015 and 2020 based on issued permits.Sheet 5: Airtightness requirements for nZEB in the 10 EE countries.Sheet 6: The energy modeling approach used for the nZEB calculation in EE countries.Sheet 7: Mechanical ventilation requirements for nZEB in the ten countries.Sheet 8: Share of fuels in the final energy consumption in the residential sector.Sheet 9: Share of fuels in the final energy consumption in the residential sector for space heating, 2019 (%) Source: Eurostat.Sheet 10: EPBD Cost optimality calculation approach and reference buildings.An example of data visualization from the provided data files is shown in 1.2The report files comprises the above mentioned tables and figures in the Excel Sheet (Table: Dataset01.xlsx). The report describes each table and figure in detail.1.3The file lists the questionnaire used during the data collection stage of the experts.2The European Union is looking to neutralize the carbon emissions of the building and construction sector by 2050. The Fit to 55 legislation package seeks to achieve carbon-neutral buildings by 2030 across Europe This study collected data from sixty reviewed documents and fourteen stakeholders involved in the ten countries to develop nZEB performance requirements, classify them, and fuse them into shared data. The data identify the performance requirements and construction assurance requirements through qualitative and quantitative variables. The methodology is based on an iterative approach of data collection and verification, where literature reviews and experts questionnaires are used to compare the reported facts.Firstly, the methodology reviewed data available on the different European platforms such as the European Commission (EC) Eurostat, European Construction Sector Observatory (ECSO), Building Performance Institute Europe (BPIE), ODYSSEE database on energy efficiency indicators and energy consumption by end-use and their underlying drivers in buildings. And national energy agencies in the ten investigated countries were reviewed. Double checks and reviews took place to make sure the data was valid. Then, the data was sorted and grouped in tables and visualized in figures to cross-comparison between the countries.•nZEB definitions and carbon emissions requirements;•minimum energy efficiency threshold;•envelope performance requirements;•heating-cooling balance and systems efficiencies;•mechanical ventilation systems requirements and specifications;•thermal comfort models, standards, and thresholds;•overheating calculation approach;•simulation approach;•energy performance certificate requirements;•renewables energy systems and production share onsite or nearby;•construction quality and performance inspection measures.The second step of the methodology is an experts-based questionnaire – a long questionnaire with seven main questions and twenty-three sub-questions allowed to collect specific information on nZEB requirements. The collected information includes climate characterization, minimum energy efficiency, heating/cooling energy needs, thermal comfort limits, renewable energy needs, and construction quality and inspection measures. The survey questions are provided in the data files included the compiled experts' answers. Among the collected data, the following questions provide an overview of the provided information:The shared data include both the questions' raw answers and refined and processed data in the form of comparative Tables and Figures.Recruitment process: Building energy efficiency experts were identified based on a literature review screening. Most of the selected experts represented building physics engineers, mechanical engineers, and architects involved in the national standards development. All interviewed experts had experiences ranging from 6 to 15 years and had worked in national EPBD development. The recruitment continued until we reached saturation and heterogeneity.The continuation of the interviewee recruitments was based on data saturation and interviewee homogeneity. The recruitment processes started in 2020 and ended in summer 2021when insights and answers started to replicate and overlap. Data saturation was used as a factor to judge the repetition of answers by the expert that indicated similar relevant insights.Validation: Qualitative research is primarily subjective as it seeks to understand human perceptions and judgments. However, qualitative research remains the most powerful exploratory scientific method that provides valuable insights and interpretations when bias is avoided. Therefore, validating the questionnaires' is essential to provide reliable and consistent results. The data went through several validation rounds. The study validation emphasized credibility and strengthened the accuracy of the collected data. The following measures were applied to collect and interpret valid information.First, member checking was used to explore the credibility of the results. The experts had to revise and approve their questionnaire answers after transcription. Every questionnaire was returned to the participants to check for accuracy and supported with references.Second, peer examination of the input data was achieved by involving a second expert for the same country. We recruited secondary experts from other national institutions or universities. This provided a second opinion on the coding process to ensure higher credibility for our research outcomes.Thirdly, the prolonged engagement of spending more than 2years (2020–2022) in the field helped us learn or understand the legislative and technical setting of nZEB. Many fact checks and cross-referencing based on the literature review took place with the help European Commission (EC), Eurostat, European Construction Sector Observatory (ECSO), Building Performance Institute Europe (BPIE), ODYSSEE database on energy efficiency indicators and energy consumption by end-use and their underlying drivers in buildings to validate the data.The data is externally deposited in a publicly available repository The above works do not contain information from human subjects, animal experiments or data collected from social media platforms.Shady Attia: Conceptualization, Methodology, Investigation, Data curation, Formal analysis, Validation, Supervision, Visualization, Writing – original draft, Writing – review & editing.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Background: Injury is a major global health problem, causing >5 800 000 deaths annually and widespread disability largely attributable to neurotrauma. 89% of trauma deaths occur in low- and middle-income countries (LMICs), however data on neurotrauma epidemiology in LMICs is lacking. In order to support neurotrauma surveillance efforts, we present a review and analysis of data dictionaries from national registries in LMICs. Methods: We performed a scoping review to identify existing national trauma registries for all LMICs. Inclusion/ exclusion criteria included articles published since 1991 describing national registry neurotrauma data capture methods in LMICs. Data sources included PubMed and Google Scholar using the terms "trauma/neurotrauma registry" and country name. Resulting registries were analyzed for neurotrauma-specific data dictionaries. These findings were augmented by data from direct contact of neurotrauma organizations, health ministries, and key informants from a convenience sample. These data were then compared to the World Health Organization (WHO) minimum dataset for injury (MDI) from the international registry for trauma and emergency care (IRTEC). Results: We identified 15 LMICs with 16 total national trauma registries tracking neurotrauma-specific data elements. Among these, Cameroon had the highest concordance with the MDI, followed by Colombia, Iran, Myanmar and Thailand. The MDI elements least often found in the data dictionaries included helmet use, and alcohol level. Data dictionaries differed significantly among LMICs. Common elements included Glasgow Coma Score, mechanism of injury, anatomical site of injury and injury severity scores. Limitations included low response rate in direct contact methods. Conclusion: Significant heterogeneity was observed between the neurotrauma data dictionaries, as well as a spectrum of concordance or discordance with the MDI. Findings offer a contextually relevant menu of possible neurotrauma data elements that LMICs can consider tracking nationally to enhance neurotrauma surveillance and care systems. Standardization of nationwide neurotrauma data collection can facilitate international comparisons and bidirectional learning among healthcare governments. This disparate trauma-related risk also carries significant economic implications given that the young demographics affected by injuries often tend to be primary income earners for families.6 Traumatic injury is a poorly recognized global public health crisis, representing a major cause of morbidity and mortality in virtually every nation and demographic.Neurotrauma, which is defined as traumatic injury to the head, brain, and/or spine, is therefore a public health concern also of great economic importance to nations of all income levels. Nationwide reduction of the neurotrauma burden in all countries requires public health actions that enable government officials to understand and monitor the local epidemiology of traumatic brain and spine injury. These actions, collectively referred to as “public health surveillance,” include the ongoing systematic collection, analysis and interpretation of data on neurotrauma, and a close integration of that data with its timely dissemination to government offices and ministries that are accountable for injury control and prevention.8 Recognizing the barriers to trauma surveillance in many LMICs, which contribute to an absence or inadequacy of routine data collection at the health facility level, this article focuses on national trauma registries as a prospective source of neurotrauma surveillance data in LMIC contexts. Combining a systematic scoping review of the literature on national trauma registries in LMICs with non-randomized sampling methods, we analyze the data dictionaries of national trauma registries from 14 LMICs on five different continents. By focusing our inquiry and analysis on LMICs, we aim to provide contextually relevant recommendations to other LMIC healthcare governments regarding the most useful neurotrauma data to systematically collect at the district hospital level.9 These results were then augmented with analysis of neurotrauma data dictionaries from an LMIC convenience sample, and “cold contact” sampling of LMIC ministries of health based on contact information available through their web sites. Each of these methods is described below. This study utilized two approaches aimed at understanding current frameworks for national neurotrauma data capture at the district hospital level in LMICs. First, a systematic scoping review of the literature was performed aimed at identifying LMICs with a published experience in national neurotrauma data collection using national trauma registries, and cataloging their neurotrauma data dictionaries.9 The protocol for this review followed the guidelines of the Joanna Briggs Institute for scoping reviews.10 in various LMICs on five different continents . Since not all Ministry of Health (MoH) in all LMICs worldwide could be contacted, 19 countries were randomly chosen based on the results of internet searches. These ministries were directly contacted to find out whether their surveillance programs included a national neurotrauma or trauma registry. Means of communication included directly sending email messages addressed to MoH officials, filling out online contact forms on official MoH websites, and attempting telephone contact whenever MoH telephone numbers were available. In the case of telephone contact, each MoH was called on at least three separate occasions during daytime work hours, accounting for time zone differences as necessary. Any resulting data was included in our cataloging and analysis (see results). Finally, using a similar cold contact sampling method, we contacted global organizations that are currently engaged in advancing TBI care for assistance in identifying LMICs with national trauma or TBI registries. These included the World Federation of Neurosurgical Societies, and the International Neurotrauma Society, and the World Health Organization (WHO). TBI registry data elements identified through these contacts were also cataloged and analyzed, with a goal to augment our final recommendations. Resulting data is reported below. In order to augment the results of our literature review, we used three methods of non-randomized sampling: convenience sampling of researchers, cold contact with ministries of health and cold contact with global organizations that participate in advancing neurotrauma care. These methods are outlined in  In order to assess and reconcile the comprehensiveness of data dictionaries from all identified registries against a global standard, the former were compared to the minimum dataset for injury (MDI) embedded in WHO’s International Registry for Trauma and Emergency Care (IRTEC). Results of this comparison appear in 12 China,15 Fiji,18 Iran,23 Jamaica,25 Malaysia,26 Egypt,27 Pakistan,28 Rwanda29 and Mexico.30 The trauma registry data for Brazil was unobtainable, so we included 9 different countries in five different WHO regions: Africa (Rwanda), the Americas (Jamaica and Mexico), the Eastern Mediterranean , South-East-Asia (India), the Western Pacific . These countries also represented the full spectrum of World Bank income levels for LMICs, ranging from low- to upper- middle-income countries -9 codes, inclusion of elements that were specific to neurotrauma, use of a trauma severity score. The summary of our literature review appears in 32 Similar to large Chinese hospitals, Iranian registry forms were filled in by “registrars” in the case of NSCIR 20 or by “trained physicians” in the case of INTRD .19 In Fiji, data was entered by “trainee interns”18 or “research assistants and hospital nurses.”17 In Rwanda, a publicly funded prehospital emergency system employed trained nurses and anesthetists to provide emergency care, and submit the data from each clinical encounter.29 Various members of hospital staff were entrusted with the data collection depending on the site, ranging from nursing students to physicians. In large Chinese hospitals, nurses filled in the registry forms whereas in smaller Chinese hospitals, physicians directly collected the data.31 Pakistan,36 and India.33 In contrast electronic data collection and web-based storage was utilized by several national databases including Malaysia,26 Jamaica25 and the Iranian NSCIR,20 all of which used a different custom web-based application. In Rwanda, an electronic secure web-based prehospital registry using a REDCap database, developed at Vanderbilt University in Nashville, Tennessee, USA, had been previously created in collaboration with the authors of the study.29 The neurotrauma-specific data elements tracked by the national registries identified in this review are presented in  The tools for data collection and storage also varied significantly among sites. Countries relying on paper for data collection with subsequent computer entry included Cameroon,). Key informants from our convenience sample included researchers working on the Colombian national TBI registry, and investigators with access to the National Trauma Registry of Cameroon as well as investigators from India’s Indian Registry of Intensive Care. These contacts provided the data dictionaries from their registries upon request. Data elements from Colombia and Cameroon are included in  Cold contact of ministries of health resulted in only one reply among the 19 contacted ministries: the Kenyan MoH. The trauma registry kept by the respondent is, however, regional and therefore did not meet our criteria for national trauma registries. Searching the websites for these health ministries generated comprehensive data dictionaries from India and Myanmar. They were freely available online through the websites of their respective official health ministry websites  study, where epidemiological studies, literature review, hospital-based reports and modeling-driven data generated estimates with significant geographic variations that were not easily explained.45 including: inadequacy of specialized clinical workforce, equipment and infrastructural requirements for data collection, burdensome financial costs associated with registry development and maintenance, lack of adequate healthcare policy implementation, and overwhelming clinical volume.45 Rubiano et al note that comprehensive trauma registries operate in only 29 of 115 countries that report such statistics to the WHO.46 These limitations underlie a chronically, yet critically unmet need for national data collection on TBI in LMICs. While such obstacles will likely require very long-term solutions in LMICs we propose that there are also practical short-term solutions that could improve the quantity and quality of neurotrauma data collection in LMICs. In our study, extensive research has only led us to sixteen national trauma registries in LMICs. Certainly the cause of such data asymmetry is multifactorial47 to collect practical clinical information at the patient level.49 Users can download paper data collection forms or directly input the data electronically for later analysis and quality improvement.50 In an ideal setting, comprehensive surveillance of head, brain and spine injuries would include aggregation of data from hospital records, death certificates, coroner records, and emergency medical service records. However, in the earliest stages, standardized clinical data collection from multiple busy trauma centers throughout the country into a single database is an ideal starting point. In 2019, the WHO released the IRTEC, which is a free web-based platform for global collection of trauma data. It utilizes a validated MDI Comparison of the databases found in our search with the WHO MDI demonstrated several points of commonality but also important deviation that left significant gaps in data collection. Countries such as Jamaica and China, demonstrating a minimum of correspondence to the WHO MDI, may stand to improve upon existing data collection systems by including the missing MDI elements in their trauma registries. Moreover, a collective strategy of standardizing registry data collection across countries, may facilitate international comparisons and bidirectional learning among healthcare governments.51 and the Evaluation Framework for Injury Surveillance Systems.52 In Uganda, the Kampala internet-based TBI Registry was designed in a way that made it possible to be evaluated by the Evaluation Framework for Injury Surveillance Systems.53 Notably, we found that several countries utilized paper collection tools while many others implemented electronic platforms. Additionally, in each country the actual data collection was performed by people with varying medical training backgrounds. We propose that the modality of collection should be context-specific based on the capability and resources of the individual facility and trauma provider. The most important factor is determining choice of data collection that will allow the greatest amount of patient inclusion and data accuracy. To this end, quality assessment and data validation are important components to any clinical registry. Two tools that can be utilized for this include the WHO Trauma System Maturity Index55 This standardization could be achieved by adopting international guidelines and using global platforms such as the WHO IRTEC and MDI, while also employing context specific data collection modalities based on local resources and needs. The potential benefits of employing common data standards are extensive. Such efforts would facilitate data sharing between countries and localities and research collaboration. Quantitative analysis of patient outcomes would allow identification of trends in mortality and morbidity that could lead to quality improvement measures. Additionally, current evidence-based guidelines in trauma and neurocritical care are based nearly entirely on data arising from HICs. As such, it is possible that the guidelines may have limited applicability in limited resource settings, which are the setting for the greatest proportion of traumatic brain and spine injuries worldwide. Greater representation of high quality LMIC trauma data could serve to improve this inequity. In order to strengthen policies for traumatic injuries of the brain and spine, ministries of health should work with local neurosurgeons to prioritize the development of local standards for neurotrauma case definitions and data dictionaries. We acknowledge several limitations of this work. First, our literature review was limited in its ability to identify current trauma registries used in LMICs as authors from those countries or collaborating with investigators in those countries would need to have published their data dictionaries in the international peer-reviewed literature in order for them to be searchable by this method. Second, a lower response rate than desired in our non-random sampling methods limited our sample size of LMIC MoH, as well as our ability to identify whether contacted nations may store data outside of ministries of health, such as through outsourced third parties. Finally, our study was designed to identify neurotrauma-related data elements currently in use in LMICs, and therefore is limited in its ability to report the impact of these data dictionaries on the neurotrauma burden in the countries under study. As more LMICs develop their neurotrauma surveillance capacity and methods, the impact of these government-level actions on national neurotrauma burden presents an important area of public health and health policy research to guide continued efforts in global neurotrauma care.51 The data dictionaries presented in this report may serve as a guide to other LMICs on prospective national neurotrauma registry design, as well as an opportunity for reported LMICs to continue improving upon existing data collection methods. The global burden of neurotrauma affects all countries, yet a disproportionately large percentage of that burden impacts LMICs. Trauma registries are either underutilized, or non-existent in most LMICs despite the acknowledged need for these facility-level data platforms. The absence of this facility-level data translates into an equivalent absence of national data. We recommend the use of nationally standardized trauma registries using the WHO MDI and IRTEC datasets with neurotrauma-specific data elements as a key source of surveillance data for ministries of health. This paper has not been presented at any meetings. Abstracts reporting on the progress of this work were presented as an electronic poster at the 2019 Annual Scientific Meeting of the American Association of Neurological Surgeons, and as an oral presentation at the 2020 Rutgers University Virtual Meeting called, “Global Neurosurgery: Ask Not for Whom the Bell Tolls.” Not applicable. Authors declare that they have no competing interests. EJB conceived and designed this work, acquired, analyzed and interpreted the data, drafted and revised the manuscript, corresponded with reviewers, carried out the revision process, and prepared the final version to be published. AECH co-designed this work, acquired, analyzed and interpreted the data, co-drafted and revised the manuscript, participated in revision and approved the final version to be published. JL critically reviewed the manuscript, edited and co-drafted the work, and approved the final version to be published. JA co-designed this work, analyzed the data, and approved the final version of the manuscript. RBB acquired and analyzed the data, co-drafted the manuscript and approved the final version of the manuscript. EC acquired and analyzed the data, co-drafted the manuscript and approved the final version of the manuscript. JC critically reviewed the manuscript, edited the work and approved the final version to be published. KBP co-conceived and co-designed this work, supervised project development, critically reviewed the manuscript and approved the final version to be published.Studienstiftung des deutschen Volkes, the German Academic Scholarship Foundation. No grant funding was received for completion of this study. During this study, Anna E Hackenberg received scholarship support from Supplementary file 1 contains Table S1 and search query used for literature review.Click here for additional data file.