Fifteen years of the Pandemic Influenza Preparedness (PIP) Framework: expanding and strengthening the Global Influenza Surveillance and Response System (GISRS)

When the PIP Framework was adopted in 2011, many countries lacked a National Influenza Centre (NIC) and, where testing existed, there were concerns about the consistency of results across laboratories. The PIP Framework's explicit goal is to strengthen the World Health Organization (WHO) GISRS as a fair, transparent and effective global network. Fifteen years on, the impact is clear: 34 new WHO-recognized NICs have been established, extending virus detection and sharing capabilities to previously uncovered areas. Today, 158 NICs operate in 136 WHO Member States, up from 124 laboratories in 2011. This expansion is supported through the implementation of the Partnership Contribution High-Level Implementation Plans and strong Member State commitment to GISRS.

All six WHO regions have benefited from the establishment of new NICs. More than one-third of the newly WHO-recognized NICs are in the WHO African Region, significantly strengthening virus detection capacity on a continent that previously had limited NIC coverage. In 2023, the South-East Asia Region became the first WHO region to achieve 100% NIC coverage.

Each NIC serves as a national hub for influenza surveillance, collecting specimens, conducting virus detection, and sharing viruses and data with the GISRS. By expanding this network to additional countries, WHO has enabled earlier detection of outbreaks and more representative global tracking of influenza, fundamentally strengthening preparedness.

Investment in NICs also reinforces broader health system capacity. Influenza laboratories are frequently leveraged to detect other respiratory threats, as demonstrated during the COVID-19 pandemic, and contribute directly to the core capacities required under the International Health Regulations (IHR 2005). As stated in the Global Influenza Strategy 2019-2030, "influenza serves as an ideal pathogen to build capacities for all major areas of (IHR 2005) functionality".

These efforts advance the global health emergency preparedness and response agenda by strengthening laboratory systems, surveillance capacity and cross-border collaboration.

Alongside the expansion of the laboratory network, WHO has focused on ensuring that all laboratories within the GISRS uphold a high level of quality in virus detection. In 2007, WHO introduced the External Quality Assessment Programme (EQAP) for influenza virus detection with polymerase chain reaction (PCR). With support from the PIP Partnership Contribution, the programme was significantly expanded and strengthened.

The GISRS EQAP functions as a proficiency testing system: once a year, WHO distributes panels of blinded samples containing influenza viruses, and more recently, other respiratory viruses, to participating laboratories. Laboratories are required to test the samples and rapidly report their results. Performance is subsequently evaluated, and tailored feedback is provided, supported by corrective actions such as training and mentoring.

Over the past 15 years, participation in the GISRS EQAP has increased steadily. In 2011, laboratories from 127 countries, areas and territories returned GISRS EQAP results. By 2024, participation had expanded to 162 countries, areas and territories, representing a 28% increase in global coverage and highlighting global commitment to quality-assured GISRS surveillance.

More than 200 laboratories worldwide now participate in the GISRS EQAP. These include NICs, national influenza laboratories in the process of obtaining WHO recognition, as well as other GISRS laboratories, including WHO Collaborating Centres and H5 Reference Laboratories. The broad participation ensures that the majority of countries in all WHO regions, are integrated into a single, systematically evaluated quality assurance framework.

Notably, the scope of the EQAP has grown beyond seasonal influenza. As GISRS itself evolved to monitor emerging threats, the EQAP began to include zoonotic influenza viruses and recently, SARS-CoV-2 and respiratory syncytial virus (RSV), to ensure laboratories can accurately detect a range of respiratory pathogens. During the COVID-19 pandemic, NICs effectively tested for influenza and SARS-CoV-2, ensuring quality surveillance in GISRS.

Crucially, the GISRS EQAP provides a common performance benchmark for laboratories with very different resource levels. A small island laboratory and a large regional reference center are measured against the same standard, instilling confidence that data are comparable across the network.

Consistent investment in GISRS has strengthened a more connected, reliable global laboratory network. Member States benefit from this system for the early detection of influenza and emerging respiratory threats. As the world prepares for future pandemics, a quality-assured GISRS remains a critical foundation for an equitable, timely and effective global response.