<?xml version="1.0" encoding="UTF-8"?><!DOCTYPE article PUBLIC "-//NLM//DTD JATS (Z39.96) Journal Publishing DTD v1.2 20190208//EN" "http://jats.nlm.nih.gov/publishing/1.2/JATS-journalpublishing1.dtd"><article xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink" article-type="systematic-review" dtd-version="1.2" xml:lang="en">
    <front>
        <journal-meta>
            <journal-id journal-id-type="pmc">F1000Research</journal-id>
            <journal-title-group>
                <journal-title>F1000Research</journal-title>
            </journal-title-group>
            <issn pub-type="epub">2046-1402</issn>
            <publisher>
                <publisher-name>F1000 Research Limited</publisher-name>
                <publisher-loc>London, UK</publisher-loc>
            </publisher>
        </journal-meta>
        <article-meta>
            <article-id pub-id-type="doi">10.12688/f1000research.162513.1</article-id>
            <article-categories>
                <subj-group subj-group-type="heading">
                    <subject>Systematic Review</subject>
                </subj-group>
                <subj-group>
                    <subject>Articles</subject>
                </subj-group>
            </article-categories>
            <title-group>
                <article-title>Emergency response to the COVID-19 pandemic and beyond: Qualitative content analysis</article-title>
                <fn-group content-type="pub-status">
                    <fn>
                        <p>[version 1; peer review: 1 approved with reservations]</p>
                    </fn>
                </fn-group>
            </title-group>
            <contrib-group>
                <contrib contrib-type="author" corresp="yes">
                    <name>
                        <surname>Ha</surname>
                        <given-names>Kyoo-Man</given-names>
                    </name>
                    <role content-type="http://credit.niso.org/">Conceptualization</role>
                    <role content-type="http://credit.niso.org/">Formal Analysis</role>
                    <role content-type="http://credit.niso.org/">Investigation</role>
                    <role content-type="http://credit.niso.org/">Methodology</role>
                    <role content-type="http://credit.niso.org/">Validation</role>
                    <role content-type="http://credit.niso.org/">Writing &#x2013; Original Draft Preparation</role>
                    <role content-type="http://credit.niso.org/">Writing &#x2013; Review &amp; Editing</role>
                    <uri content-type="orcid">https://orcid.org/0000-0002-2087-5707</uri>
                    <xref ref-type="corresp" rid="c1">a</xref>
                    <xref ref-type="aff" rid="a1">1</xref>
                </contrib>
                <aff id="a1">
                    <label>1</label>Faculty of Resilience, Rabdan Academy, Abu Dhabi, 114646, United Arab Emirates</aff>
            </contrib-group>
            <author-notes>
                <corresp id="c1">
                    <label>a</label>
                    <email xlink:href="mailto:kmanha@ra.ac.ae">kmanha@ra.ac.ae</email>
                </corresp>
                <fn fn-type="conflict">
                    <p>No competing interests were disclosed.</p>
                </fn>
            </author-notes>
            <pub-date pub-type="epub">
                <day>14</day>
                <month>3</month>
                <year>2025</year>
            </pub-date>
            <pub-date pub-type="collection">
                <year>2025</year>
            </pub-date>
            <volume>14</volume>
            <elocation-id>295</elocation-id>
            <history>
                <date date-type="accepted">
                    <day>6</day>
                    <month>3</month>
                    <year>2025</year>
                </date>
            </history>
            <permissions>
                <copyright-statement>Copyright: &#x00a9; 2025 Ha KM</copyright-statement>
                <copyright-year>2025</copyright-year>
                <license xlink:href="https://creativecommons.org/licenses/by/4.0/">
                    <license-p>This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p>
                </license>
            </permissions>
            <self-uri content-type="pdf" xlink:href="https://f1000research.com/articles/14-295/pdf"/>
            <abstract>
                <p>The Earth continues to suffer from the impact of the coronavirus disease 2019 (COVID-19) outbreak even now, particularly due to the absence of appropriate theoretical frameworks for related emergency responses. In this study, we provided a simplified model for the emergency response to the coronavirus infection. We employed a qualitative content analysis, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 checklist and flow diagram. Specifically, we examined eight underlying factors (leaders&#x2019; inability, focus on economic recovery, controversies regarding the usage of face masks, unprecedented reliance on herd immunity, hasty research and development, late decision-making, coordination failure, and occurrence of natural hazards) and eight selected overarching factors (global leadership, national policies, individual strategies, culture, research and development, timing, communication, and contingency). Considering these factors, we proposed the &#x201c;Earth as a comprehensive system&#x201d; approach, under which elements of the pandemic response are comprehensively included to facilitate problem-solving, social support, strategic use, assistance from various professionals, and education. The operational mechanism of this approach clearly emphasizes unified efforts for responding to a pandemic by systematically including various interdependent components of the Earth.</p>
            </abstract>
            <kwd-group kwd-group-type="author">
                <kwd>coronavirus infection; comprehensive emergency management; modeling technique; natural hazards; education</kwd>
            </kwd-group>
            <funding-group>
                <funding-statement>The author(s) declared that no grants were involved in supporting this work.</funding-statement>
            </funding-group>
        </article-meta>
    </front>
    <body>
        <sec id="sec1" sec-type="intro">
            <title>1. Introduction</title>
            <p>In the 21
                <sup>st</sup> century, the outbreak of pandemic diseases, such as the H1N1 virus in 2009 and COVID-19 in 2019, has generally been unpredictable and recurring (
                <xref ref-type="bibr" rid="ref9">Bonacina et al., 2023</xref>; 
                <xref ref-type="bibr" rid="ref39">Mishara et al., 2020</xref>), thus exposing human society to various risks and vulnerabilities. Particularly, as COVID-19 was a newly discovered disease, almost no region succeeded in efficiently responding to it during the initial response period, and various stakeholders found the fight against the coronavirus infection extremely challenging (
                <xref ref-type="bibr" rid="ref30">Hemo &amp; Islam, 2024</xref>).</p>
            <p>Theoretical frameworks (i.e., approaches and models) are vital in integrating related facts about a pandemic into various concepts of emergency response, as they help shape a coherent whole or formulate causal interconnections among various facts (
                <xref ref-type="bibr" rid="ref36">Kenyon, 2020</xref>). Appropriate theoretical approaches are required to portray accurately all the significant determinants in the response to pandemics while also indicating the relative importance of multiple determinants or facilitating effective operations to address dire pandemics.</p>
            <p>COVID-19 (including the Omicron variant and its subvariants) is spreading rapidly around the world even today. Thus, a comprehensive strategy is needed to combat this pandemic (
                <xref ref-type="bibr" rid="ref1">Alauddin et al., 2020</xref>; 
                <xref ref-type="bibr" rid="ref38">Mattiuzzi &amp; Giuseppe, 2025</xref>). Therefore, besides considering all geographical regions, the field of pandemic management must account for all aspects of personnel, transmission, tactics, resources, research findings, and other details. However, the number of adequate theories focusing on this specific context is meager, despite a wealth of relevant literature (
                <xref ref-type="bibr" rid="ref3">Al Khalaf et al., 2024</xref>). Thus, the creation of a comprehensive framework for the prompt reaction to the COVID-19 pandemic is a crucial component of research (as a research question). This was one of the primary motivations behind the current study.</p>
            <p>This study&#x2019;s aim was to develop a theoretical framework for an appropriate emergency response to the COVID-19 outbreak. As a model, such a framework would mitigate not only the physical but also the social impact of the coronavirus infection. The eight key underlying factors that could influence this framework were examined first, after which the same number of overarching factors were outlined. The results were then integrated into a guiding framework applicable to all nations.</p>
        </sec>
        <sec id="sec2">
            <title>2. Literature review</title>
            <sec id="sec3">
                <title>2.1 Pandemic management</title>
                <p>A pandemic refers to an epidemic of an infectious disease that spreads over a broad region and affects a large number of people. Several pandemics have impacted human societies throughout history, including tuberculosis, smallpox, the Black Death, the Spanish flu, and COVID-19. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) first (officially) caused COVID-19 in Wuhan, China, at the end of 2019 (
                    <xref ref-type="bibr" rid="ref31">Hu et al., 2021</xref>). Since then, the COVID-19 outbreak has had catastrophic consequences for humankind as it spread rapidly through global connectivity.</p>
                <p>Some pandemics are caused by animal viruses, such as Ebola, Zika, and SARS-CoV-2, being transmitted to humans. The diseases caused by these viruses are known as zoonoses. Humans generally have little to no immunity against them. Considering that COVID-19 is a zoonosis, no patient was safe from it. Furthermore, as COVID-19 was a newly discovered disease, no established or clear guidelines were initially available regarding response measures against this disease in terms of medical science or emergency management.</p>
                <p>Pandemic management is the managerial function of coping with a pandemic to reduce related vulnerabilities. Similar to other types of emergency management, the lifecycle of pandemic management comprises four phases: emergency prevention/mitigation, preparedness, response, and emergency recovery (
                    <xref ref-type="bibr" rid="ref19">FEMA, 2006</xref>). The emergency response phase begins when an outbreak becomes imminent. This phase addresses not only the short-term but also the direct effects of the pandemic, considering that dire pandemics with infectious agents and toxins occur within a relatively short period.</p>
            </sec>
            <sec id="sec4">
                <title>2.2 Previous studies</title>
                <p>Many scholars and practitioners have discussed the societal implications of the COVID-19 outbreak in terms of pandemic management, including Deborah Lupton, Richard Horton, Julie Swann, and Anthony Fauci. Their studies frequently utilized government reports (
                    <xref ref-type="bibr" rid="ref53">Watson, 2020</xref>; 
                    <xref ref-type="bibr" rid="ref54">WHO, 2020</xref>). Several international organizations, including the World Health Organization (WHO), World Bank Group, Organization for Economic Co-operation and Development, and World Economic Forum, addressed this issue for their own purposes, and their individual efforts significantly reflected the need for a rapid response to the COVID-19 outbreak.</p>
                <p>Most of the aforementioned scholars and practitioners support certain principles of pandemic management. Similarly, in the whole-society approach, various stakeholders in a society progressively deal with unpredictable and wide-ranging threats to their regions over time (
                    <xref ref-type="bibr" rid="ref52">USAID et al., 2021</xref>). These stakeholders aim to link traditional partners, such as emergency managers, firefighters, and civil engineers, as well as nontraditional partners, such as health workers, farmers, soldiers, and ordinary citizens.</p>
                <p>Moreover, the whole-society approach supports the role of multiple sectors in society, rather than only one or two stakeholders, during an emergency response to a pandemic. This approach facilitates the participation of diverse sectors in pandemic management, including government institutions at all levels, the health sector (e.g., healthcare services and public health), non-health sectors, voluntary organizations, families, and individuals.</p>
                <p>The importance of comprehensive emergency management has often been emphasized in COVID-19 research. The U.S. National Governors Association introduced the term &#x201c;comprehensive emergency management&#x201d; as a guideline for the newly established Federal Emergency Management Agency (FEMA) during President Jimmy Carter&#x2019;s administration (
                    <xref ref-type="bibr" rid="ref42">National Governors&#x2019; Association, 1979</xref>). Since then, comprehensive emergency management has been a fundamental principle in pandemic management, regardless of national boundaries. Particularly, the idea has evolved into one of the guiding concepts for pandemic management in the field.</p>
                <p>Comprehensive emergency management comprises four major elements. While stakeholders include various professional entities&#x2014;such as governments, the private sector, non-governmental organizations, and local communities, each with their own priorities&#x2014;comprehensive emergency management transcends organizational boundaries and addresses all types of emergencies, including natural disasters (or natural hazards) and man-made emergencies. It also encompasses all four phases of emergency management. Finally, it addresses all types of risks, including the physical and social impacts of an emergency (
                    <xref ref-type="bibr" rid="ref12">Carson, 2024</xref>).</p>
                <p>The term &#x201c;integrated policy&#x201d; has a context similar to that of comprehensive emergency management (
                    <xref ref-type="bibr" rid="ref55">World Bank Group, 2020</xref>). Integration entails forming various networks or interrelationships among stakeholders in pandemic management. The integrated policy incorporates not only the public sector but also the private sector and other groups in the fight against the COVID-19 outbreak. Simultaneously, such policies flexibly collect, collate, and analyze information, data, and experiences from multiple sectors to achieve effective pandemic management.</p>
                <p>Governments and organizations establishing and subsequently embracing e-health systems during the COVID-19 outbreak is a good example of integrated policy (
                    <xref ref-type="bibr" rid="ref14">Chilunjika &amp; Chilunjika, 2023</xref>). The COVID-19 pandemic has profoundly altered the delivery of health services around the world and the legislative actions taken to combat it. E-health systems, which provide quick, easy, safe, and efficient care options while reducing the spread of viruses, have now become essential tools for guaranteeing people&#x2019;s continuous access to healthcare. Through interoperable networking, e-health systems have the potential to strengthen public health systems globally (
                    <xref ref-type="bibr" rid="ref34">Jilani et al., 2023</xref>).</p>
                <p>A multidisciplinary approach requires various disciplines to address specific research questions, including medicine, public health, psychology, law, climatology, and engineering. To define an unexpected problem or provide a revolutionary solution beyond traditional boundaries, multidisciplinary research in this context is required in complicated fields (
                    <xref ref-type="bibr" rid="ref22">Gomez-Cantarino et al., 2024</xref>). Nevertheless, some scholars have explained the rationale behind not opting for a multidisciplinary approach in certain areas, such as pushing further within a subject, mastering a specialty, or working on single-discipline-based research. Scholars with a strong belief in disciplinary approaches have emphasized the issue of logical sequences within the same subject.</p>
                <p>The field of pandemic management has also recognized the significance of a multidisciplinary approach to the COVID-19 outbreak in terms of capacity enhancement, risk assessment, and all activities in the emergency management cycle (
                    <xref ref-type="bibr" rid="ref46">Romei et al., 2020</xref>). While creating a comprehensive framework, scholars have encountered various challenges and alternatives during data interpretation, program evaluation, and decision-making. Notably, a multidisciplinary approach is known to be applicable to pandemic management.</p>
                <p>Based on the above principles, the modeling approach has been widely applied in several cases (
                    <xref ref-type="bibr" rid="ref48">Shearer et al., 2020</xref>). Modeling helps represent the abstractions of a complicated reality. For example, 
                    <xref ref-type="bibr" rid="ref56">Fox and Kilbourne (1973)</xref> proposed a pandemic simulation model to examine the effects of extensive school vaccinations. In 2009, many official documents elaborating related models included various assumptions regarding pandemic management. During the outbreaks of the H1N1 virus, West African Ebola virus, and other diseases over the last decade, a few models have contributed to improving emergency response capabilities in some regions.</p>
                <p>Creating an appropriate model can solve specific problems in pandemic management. Although some models, such as computer and mathematical models, can be complicated and difficult to understand, others, which include diagrams, pictures, and flowcharts, tend to be simpler and easier to grasp. Considering that knowledge and information regarding the COVID-19 outbreak should be accessible or easily understandable to the general public, a simplified model is preferred in this research field.</p>
                <p>Additionally, the proposal of a theoretical framework(s) is considered one of the most significant aspects of the research field (
                    <xref ref-type="bibr" rid="ref23">Grant &amp; Osanloo, 2014</xref>). By literally or metaphorically integrating a wide range of knowledge into the research, a theoretical framework can serve as a structure for research questions, objectives, and alternatives. Therefore, supported by a theoretical framework, an organized flow of emergency responses to the COVID-19 outbreak may be more easily understood by the general public.</p>
            </sec>
            <sec id="sec5">
                <title>2.3 Features of this study</title>
                <p>This study proposes the &#x201c;Earth as a comprehensive system&#x201d; approach toward a more efficient response to the COVID-19 outbreak than the one currently in place. This approach views the emergency response to the COVID-19 outbreak as an organic system or a unitary whole comprising interdependent factors (
                    <xref ref-type="bibr" rid="ref13">Chand, 2023</xref>). The term &#x201c;comprehensive&#x201d; flexibly includes all those factors. The phrase &#x201c;Earth as a comprehensive system&#x201d; implies that the entire field of pandemic management (or the Earth) comprehensively responds to the outbreak of COVID-19 as a robust system while also enhancing pandemic management principles, modeling techniques, and theoretical frameworks.</p>
                <p>What distinguishes this study from others is its potential merits, in that it attempts to include all the major factors of the COVID-19 emergency response into the framework. Specifically, the &#x201c;Earth as a comprehensive system&#x201d; approach explores important factors regarding pandemic management more comprehensively than previous studies, as the approach is not oriented toward an individual or institutional goal but a universal one. Therefore, the theoretical model proposed in this study will be easy to understand and comprehend for any individual, institution, or nation that urgently requires a big picture of the emergency response to the coronavirus infection.</p>
                <p>&#x201c;Earth as a comprehensive system&#x201d; offers an innovative perspective of pandemic management. However, many components of the model have already been identified in previous studies (
                    <xref ref-type="bibr" rid="ref2">Aljuneidi et al., 2023</xref>). Still, the distinctive feature of this work is the way it unifies and integrates these components into a coherent model that views the emergency response to COVID-19 as a global, interconnected system rather than a collection of discrete or sector-specific initiatives. The goal of this approach is to provide a more approachable and internationally relevant viewpoint by eschewing a limited emphasis on individual or institutional outcomes.</p>
            </sec>
        </sec>
        <sec id="sec6" sec-type="methods">
            <title>3. Methods</title>
            <sec id="sec7">
                <title>3.1 Qualitative content analysis</title>
                <p>A qualitative content analysis comprises three steps: preparation, organization, and reporting (
                    <xref ref-type="bibr" rid="ref17">Elo et al., 2014</xref>). In this study, the preparation step included data collection (e.g., collecting textual data on pandemic management and COVID-19), sampling (e.g., choosing appropriate emergency management principles and one country from each of six continents), and selection of the unit of analysis (e.g., using appropriate search words, such as coronavirus infection, emergency response failures, and system approach). Thus, a major criterion for text exclusion/inclusion was a work&#x2019;s relation to the pandemic management principles, COVID-19 outbreak, emergency response frameworks, system approach, six continents, and others.</p>
                <p>The organization step includes categorization (e.g., creating four categories&#x2014;stakeholders, foundational attributes, core functions, and environment&#x2014;from the eight overarching factors) and interpretation (e.g., classifying the eight underlying factors into eight overarching factors and interpreting other text data for the main theme). This step is critical for structuring text data to align with the study&#x2019;s objectives and allows for an in-depth examination of the interaction of these factors within pandemic management.</p>
                <p>Lastly, the reporting step offers improved results and process reporting (this includes summarizing systematic results and processes in the suggested Earth system model, for example) (
                    <xref ref-type="bibr" rid="ref18">Fabiano et al., 2024</xref>). Simultaneously, this step highlights the importance of disclosing methods and findings transparently to enhance reproducibility and rigor in the analysis. Providing insights for future studies on a worldwide, systemic approach to pandemic management entails synthesizing findings to represent the comprehensive framework used.</p>
            </sec>
            <sec id="sec8">
                <title>3.2 Text analysis and synthesis</title>
                <p>This study focused on text analysis and synthesis out of the three steps mentioned above. Likewise, to create a theoretical framework for the emergency response to the COVID-19 outbreak, we initiated the identification of important issues (i.e., the eight underlying factors) on various websites. These eight issues usually comprise the negative aspects of the topic. Two criteria were considered for selecting the eight issues. First, each issue had to have significant implications in terms of the emergency response, particularly based on the subjective perspective of the author and the evaluation of each website. In short, these underlying factors were selected because they could broadly influence and directly contribute to response inefficiencies. Second, to achieve comprehensiveness, at least one issue had to originate from each of these six continents: South America (Brazil), North America (the United States), Europe (Sweden), Asia (China), Africa (South Africa), and Oceania (Australia). Russia and several international organizations were included because of their unique and significant features.</p>
                <p>We identified eight overarching factors that, when combined, made up the &#x201c;Earth as a comprehensive system&#x201d; approach, building on the eight underlying factors. The selection of the overarching factors was based on their representation of core qualities that could balance challenging problems by promoting a comprehensive framework for pandemic response (
                    <xref ref-type="bibr" rid="ref4">Arani et al., 2024</xref>). This Earth perspective aims to bridge isolated actions into a unified response framework, addressing the pandemic&#x2019;s complexities through synergy.</p>
                <p>To capture the essential aspects of global emergency response, these overarching factors were organized into four categories: stakeholders (three key participants), foundational attributes (two basic characteristics), core functions (two critical emergency functions), and environment (major circumstances). These four categories thoroughly covered the who, what, how, and where of emergency response, ensuring that every important component was considered. These categories provided a comprehensive basis that could be applied to a variety of international contexts.</p>
                <p>Both PRISMA checklist and flow diagram were used in this work to support the entire methodology approach (please see Data Availability Statement) (
                    <xref ref-type="bibr" rid="ref24">Ha, 2025</xref>). The qualitative content analysis in this study is substantially more transparent, accurate, and comprehensive, thanks to the PRISMA checklist and flow diagram (
                    <xref ref-type="bibr" rid="ref33">Innocenti et al., 2022</xref>). Several databases and search engines, such as SCOPUS, ProQuest, PubMed, Web of Science, Oxford University Press, and 
                    <ext-link ext-link-type="uri" xlink:href="http://Google.com">Google.com</ext-link>, were employed in the process. In the end, 54 texts were included in this study, which comprised research articles (38), books (1), government documents (9), and webpages (6).</p>
            </sec>
        </sec>
        <sec id="sec9" sec-type="results">
            <title>4. Results</title>
            <p>The problems caused by the eight underlying factors are directly addressed and resolved by the eight overarching factors. &#x2460; Leaders&#x2019; inability highlights the necessity of a global leadership that coordinates response activities across national boundaries, as &#x2461; a predominant focus on economic recovery implies the need for national policies balancing public health and economic stability. &#x2462; Controversies regarding face mask usage and &#x2463; reliance on herd immunity underscore the significance of individual strategies and adaptive culture in aligning public health initiatives with empirical data and cultural norms.</p>
            <p>Furthermore, &#x2464; Hasty research and development (R&amp;D) points to the need for strict, ethical R&amp;D practices to guarantee efficacy and safety. &#x2465; Late decision-making emphasizes the importance of timely reactions to developing crises. While &#x2466; coordination failure highlights the need for communication systems that promote collaboration among all stakeholders, &#x2467; the occurrence of natural hazards necessitates contingency planning to prepare for simultaneous catastrophes.</p>
            <sec id="sec10">
                <title>4.1 Underlying factors for the Earth emergency</title>
                <p>

                    <italic toggle="yes">4.1.1 Leaders&#x2019; inability</italic>
                </p>
                <p>Among several international organizations, the underfunded WHO is supposed to lead its member states in responding to the COVID-19 outbreak. During the initial phases of the outbreak, although many health experts suspected China as the origin of the novel coronavirus infection, the WHO Director-General, Tedros Ghebreyesus, failed to consider the related information in a timely manner (
                    <xref ref-type="bibr" rid="ref15">Cretois &amp; Marbot, 2020</xref>). Moreover, the leader was overly cautious while considering the change in disease status from an epidemic to a pandemic, which hindered emergency responses in many regions.</p>
                <p>

                    <italic toggle="yes">4.1.2 Focus on economic recovery</italic>
                </p>
                <p>President Jair Bolsonaro of Brazil maintained that economic recovery was more important than human losses during the COVID-19 outbreak. He argued that coronavirus restrictions, such as social distancing and lockdown measures, harmed the national economy and reasoned that people would die without jobs. Consequently, he opted to reopen businesses despite clashes with other politicians. While the Brazilian economy fared better than expected, the number of lives lost and infected individuals increased significantly.</p>
                <p>

                    <italic toggle="yes">4.1.3 Controversies on wearing a face mask</italic>
                </p>
                <p>In the United States, cultural, political, medical, and scientific aspects caused divisions regarding the usage of face masks in public settings during the COVID-19 pandemic (
                    <xref ref-type="bibr" rid="ref35">Kahane, 2021</xref>). One group, including former U.S. President Donald Trump, dismissed the need for a face mask, while another group, including the then U.S. President Joe Biden, emphasized its importance. The Centers for Disease Control and Prevention changed its recommendation from one of not wearing face masks to one advocating their use. Due to unclear guidelines on this issue, the pandemic worsened considerably in the nation.</p>
                <p>

                    <italic toggle="yes">4.1.4 Unprecedented reliance on herd immunity</italic>
                </p>
                <p>In contrast to other nations, Sweden did not implement early or strict measures to protect its population from the coronavirus outbreak. Instead, it took an unconventional path toward herd immunity, allowing a large enough number of people to be infected to develop natural immunity to COVID-19. Thus, Sweden did not make significant efforts to protect its citizens from the COVID-19 outbreak. Although many Swedish authorities self-evaluated herd immunity as common sense, the number of human losses in the country was much higher than that in neighboring nations.</p>
                <p>

                    <italic toggle="yes">4.1.5 Hasty R&amp;D</italic>
                </p>
                <p>Many nations competed in the race to develop effective COVID-19 vaccines and treatments, including Russia, which made efforts to develop vaccines using the Russian Direct Investment Fund. It became the first country to register a vaccine named Sputnik V. However, the small number of COVID-19 cases included in the Sputnik V trial hindered the interpretation of the results by neutral parties due to a lack of information and data about the vaccine (
                    <xref ref-type="bibr" rid="ref11">Callaway, 2020</xref>). Russia was hasty in officially registering its vaccine ahead of other nations, leading to uncertainty regarding its efficacy.</p>
                <p>

                    <italic toggle="yes">4.1.6 Late decision-making
</italic>
                </p>
                <p>Chinese ophthalmologist Li Wenliang worked at a hospital in Wuhan, China, in late December 2019, when he detected a coronavirus infection in his patients (BBC 
                    <xref ref-type="bibr" rid="ref6">News, 2020</xref>). He gained attention after attempting to share this information on several internet platforms. However, local authorities initially dismissed his information as false and later punished him, preventing him from sharing his concerns. Had he been able to share his findings, the human losses due to the pandemic could have decreased.</p>
                <p>

                    <italic toggle="yes">4.1.7 Coordination failure</italic>
                </p>
                <p>The challenges faced by South Africa included a shortage of personal protective equipment (PPE), such as face masks, gloves, and respirators. However, considering that the nation&#x2019;s social division issues persisted even during the COVID-19 outbreak, the real challenge seemed to be the lack of coordination between stakeholders, as evidenced by the Eastern Cape PPE crisis (
                    <xref ref-type="bibr" rid="ref40">Mugabi, 2020</xref>). The nation continued to struggle with inequality between the rich and poor, as well as between races (black- and white-skinned individuals). The government policy of South Africa was oriented toward those with medical access or economic stability but lacked efforts to coordinate with regional leaders.</p>
                <p>

                    <italic toggle="yes">4.1.8 Occurrence of natural hazards</italic>
                </p>
                <p>
Australia did its best to respond to the COVID-19 outbreak without any contemporary precedents. However, the nation was also affected by natural hazards, such as bushfires, droughts, tropical cyclones, and storms (
                    <xref ref-type="bibr" rid="ref5">Attanayake et al., 2020</xref>). Dealing with the coronavirus infection alone was challenging for the nation, so simultaneously coping with multiple disasters made the pandemic response even more difficult due to a lack of personnel, resources, and strategies. Particularly, dual risks or double threats considerably challenged Australian emergency responses, as seen in the case of the 2020 Black Summer bushfires.</p>
            </sec>
            <sec id="sec11">
                <title>4.2 The Earth as a comprehensive system approach</title>
                <p>

                    <italic toggle="yes">4.2.1 Global leadership</italic>
                </p>
                <p>The WHO leadership needs to fund and organize this approach through an association of the world&#x2019;s high-income nations, since these nations have a shared responsibility due to their greater resources, compared to developing nations. Simultaneously, the organization must assist its member states in responding to the COVID-19 outbreak in a timely manner by decisively providing appropriate guidelines, such as norms, policy alternatives, research agendas, evidence articulation, and technical support. The WHO leadership may refer, in particular, to the World Food Programme, which has helped provide food for many communities affected by the COVID-19 outbreak.</p>
                <p>

                    <italic toggle="yes">4.2.2 National policies</italic>
                </p>
                <p>The COVID-19 outbreak has caused not only human loss but also economic damage. However, national policies should prioritize the issue of human loss, as nothing is more important to society than human lives. Disregarding the issue of human losses and focusing on economic recovery instead to strengthen his bid for reelection in 2022, the Brazilian president indirectly caused the increase in the number of infected individuals and deaths among his people (
                    <xref ref-type="bibr" rid="ref50">Stott et al., 2021</xref>). Thus, Brazilian leaders should first address public health issues before considering unemployment and economic damage, as opposed to the current policy.</p>
                <p>

                    <italic toggle="yes">4.2.3 Individual strategies</italic>
                </p>
                <p>A face mask is a simple object; however, its use became a source of serious controversy in the United States during the COVID-19 pandemic, involving issues such as the impairment of individual freedom and the possibility of local governments mandating its use (
                    <xref ref-type="bibr" rid="ref7">Bir &amp; Widmar, 2021</xref>). The fact that the majority of health experts agreed that wearing face masks helped prevent viral transmission, as supported by scientific evidence, should have convinced Americans of the need to wear face masks during the emergency response to the COVID-19 outbreak. Without awareness of this need, individuals would be less capable of evading the impacts of coronavirus infection.</p>
                <p>

                    <italic toggle="yes">4.2.4 Culture</italic>
                </p>
                <p>Emergency cultures may explain why Sweden depended on herd immunity during the COVID-19 outbreak (
                    <xref ref-type="bibr" rid="ref29">Hassan et al., 2022</xref>). Swedish citizens tend to socialize without drawing attention to themselves. They, even the kings and superstars, do not regard themselves as special. The nation places a high priority on children&#x2019;s rights and ensures that children have free time and large spaces to play. Moreover, the trust between the people and the government is strong. Thus, the Swedish people are willing to follow the lenient policies of public health agencies.</p>
                <p>

                    <italic toggle="yes">4.2.5 R&amp;D</italic>
                </p>
                <p>Governments and industries invested substantial amounts of money in the unprecedented development, manufacture, and eventual commercialization of effective COVID-19 vaccines and treatments. Appropriate research efforts were vital in stopping the worldwide spread of the coronavirus infection. However, some nations, such as Russia, should have conducted their research in a more organized manner, for instance, by implementing mid- or large-sized clinical trials for their COVID-19 vaccine, Sputnik V, instead of relying on small-sized or rushed clinical studies. After the successful development of vaccines and treatments, stakeholders must determine how to quickly and equitably distribute them to those in need in each region.</p>
                <p>

                    <italic toggle="yes">4.2.6 Timing</italic>
                </p>
                <p>Many nations and institutions struggled to make rapid decisions during the initial response to the COVID-19 outbreak due to high levels of uncertainty, time constraints, a lack of standardized predictions, and the complexity of the infection, among other factors (
                    <xref ref-type="bibr" rid="ref27">Hariri-Ardebili &amp; Lall, 2021</xref>). Following the COVID-19 outbreak and the tragic death of coronavirus whistleblower Li Wenliang, the Chinese government honored him as a martyr. However, it failed to make timely decisions to effectively halt the spread of the new disease.</p>
                <p>

                    <italic toggle="yes">4.2.7 Communication</italic>
                </p>
                <p>Various stakeholders have conflicting interests regarding the contentious issue of the COVID-19 emergency response, and none, including the government, has been willing to compromise. Nevertheless, the COVID-19 pandemic thrust everyone in the middle of a public health crisis. Therefore, effective communication and coordination among all stakeholders is essential, which includes holding real-time dialogues, identifying priorities, and utilizing technological tools (
                    <xref ref-type="bibr" rid="ref20">FEMA, 2020</xref>). Without such coordination, the nation would continue to face increasing human losses.</p>
                <p>

                    <italic toggle="yes">4.2.8 Contingency</italic>
                </p>
                <p>The contingency issue encompasses unexpected disruptions and problematic situations that may arise in the near future; thus, additional arrangements or plans must be developed for them (
                    <xref ref-type="bibr" rid="ref49">State of Colorado, 2012</xref>). Other unforeseen factors, aside from the previously mentioned seven overarching factors, fall under this contingency category. For instance, in the case of Australia&#x2019;s COVID-19 response, the occurrence of a natural hazard can be considered a contingency that the nation should address through rigorous and advanced planning to manage all risks related to planning, supplies, training, and exercises (
                    <xref ref-type="bibr" rid="ref26">Hariri-Ardebili, 2020</xref>).</p>
            </sec>
        </sec>
        <sec id="sec12" sec-type="discussion">
            <title>5. Discussion</title>
            <sec id="sec13">
                <title>5.1 Four major categories</title>
                <p>The eight overarching factors discussed earlier can be classified into four categories under the &#x201c;Earth as a Comprehensive System&#x201d; approach. Global leadership, national policies, and individual strategies represent the three major stakeholders, while culture and R&amp;D are considered foundational attributes of pandemic management. Timing and communication can be evaluated as core emergency functions, with the issue of contingency being akin to environmental considerations. Specifically, the eight overarching factors were classified into these four categories, either directly or indirectly.</p>
                <p>Despite its breadth, the &#x201c;Earth as a Comprehensive System&#x201d; approach is reinforced by the dynamic interactions among its constituent parts, which adapt to the constantly evolving landscape of international crises (
                    <xref ref-type="bibr" rid="ref41">NASA, 2024</xref>). Each of the eight underlying factors, eight overarching factors, and four categories contributes to the interdependencies that create a coherent framework. When one component changes or adapts, the others realign, forming a resilient structure capable of handling complex pandemic events. Together, these components form an integrated system that adjusts fluidly to new challenges.</p>
            </sec>
            <sec id="sec14">
                <title>5.2 Significant implications</title>
                <p>A high level of uncertainty and complexity characterizes the emergency response to the COVID-19 outbreak (
                    <xref ref-type="bibr" rid="ref32">Inghammar &amp; Kahn, 2024</xref>). Individuals, nations, and international institutions have faced significant challenges in identifying the most effective factors or alternatives for pandemic management (
                    <xref ref-type="bibr" rid="ref44">Reimers &amp; Schleicher, 2020</xref>). In this context, stakeholders may find the &#x201c;Earth as a Comprehensive System&#x201d; approach beneficial, particularly in navigating the various challenges they face in pandemic management. Thus, this approach serves as an effective problem-solving
 tool.</p>
                <p>As a vital framework for pandemic management among multiple stakeholders, the &#x201c;Earth as a Comprehensive System&#x201d; approach can enhance situational analysis, rapid risk assessment, evidence-based emergency management, humanitarian management, and partnerships among major entities concerning the COVID-19 outbreak. Consequently, this approach may directly contribute to reducing human losses, economic damage, and psychological impacts resulting from the pandemic, transcending national boundaries.</p>
                <p>Many stakeholders have made efforts to combat the COVID-19 outbreak within their jurisdictions; however, some attempts remained fragmented (
                    <xref ref-type="bibr" rid="ref21">Forman et al., 2020</xref>). Issues that hindered this included fights between customers and supermarket workers over face mask usage, former U.S. President Trump&#x2019;s offer to buy from CureVac the exclusive rights to its coronavirus vaccine, and France&#x2019;s ban on the export of PPE. Nevertheless, stakeholders can overcome these fragmented efforts by basing their actions on the comprehensive framework of the &#x201c;Earth as a Comprehensive System&#x201d; approach.</p>
                <p>The &#x201c;Earth as a Comprehensive System&#x201d; approach can be implemented in various ways, depending on the situational focus. However, its implementation should prioritize integrating systems thinking into operations and avoiding unintended consequences (
                    <xref ref-type="bibr" rid="ref10">Bradley et al., 2020</xref>). Generally, the main steps for its implementation include overseeing the overall picture of the pandemic outbreak, identifying challenging problems and positive opportunities, synthesizing appropriate solutions by incorporating all factors, implementing these solutions with all stakeholders, and sustaining these solutions globally.</p>
                <p>The concept of resilience in various communities aligns with the &#x201c;Earth as a Comprehensive System&#x201d; approach (
                    <xref ref-type="bibr" rid="ref28">Hariri-Ardebili et al., 2022</xref>). Resilience is defined as the ability to recover quickly from the effects of both natural hazards and manmade emergencies. It reflects the capacity to adapt to different vulnerabilities in situations involving multiple hazards. Recognizing that resilience is a combination of community and individual capacity necessitates the involvement of all parties in the field. Thus, resilience is situated at the center of an interdependent system, whether it be Earth or a comprehensive system.</p>
                <p>The &#x201c;Earth as a Comprehensive System&#x201d; approach shares a context similar to that of social support (
                    <xref ref-type="bibr" rid="ref51">Taylor et al., 2017</xref>). Social support implies that when individuals provide personnel, resources, and other amenities for the benefit of society, it enables specific individuals, nations, or international institutions to respond effectively to the COVID-19 outbreak. For example, individuals maintain their social health during crises by relying on the support of friends or acquaintances. Social support has assisted individuals and organizations in various ways. Similarly, the &#x201c;Earth as a Comprehensive System&#x201d; approach acts as a form of systematic social support by providing societal buffer zones (e.g., integrated networks, mutual aid, etc.) against COVID-19, thereby enhancing the quality of pandemic management in many regions.</p>
                <p>Embracing the &#x201c;Earth as a Comprehensive System&#x201d; approach in various regions requires strategic application by stakeholders. Specifically, this approach should be employed in response to a specific plan. For instance, to manage the pandemic equitably among disadvantaged populations, stakeholders must consider not only economic factors but also equity within the broader framework of the &#x201c;Earth as a Comprehensive System&#x201d; approach. When addressing international cooperation among nations, stakeholders must take into account the diverse national contexts within the Earth system model.</p>
                <p>Alternatively, the &#x201c;Earth as a Comprehensive System&#x201d; approach can assist various professionals, aiding both novice and experienced scholars in conceptualizing, organizing, and conducting related research and assignments. Given that all research is interconnected to theoretical frameworks (
                    <xref ref-type="bibr" rid="ref45">Rocco &amp; Plakhotnik, 2009</xref>), applying the Earth system model as a foundational framework may address the needs of scholars and their contentious questions. When the interconnections among scholars are substantial through the newly established Earth system model, opportunities for increased research, funding, collaborative studies, shared information on research topics, diverse perspectives, technological diffusion, and societal contributions can be realized.</p>
                <p>Similarly, the &#x201c;Earth as a Comprehensive System&#x201d; approach can enable a range of pandemic management practitioners to reach a consensus on various issues related to COVID-19 infections (
                    <xref ref-type="bibr" rid="ref43">Obuobisa-Darko &amp; Sokro, 2023</xref>). Practitioners face considerable pressure regarding numerous challenges, such as a lack of management resources, the presence of invisible constraints, and various political demands. Under these conditions, they may establish a certain level of management standards while fully referencing the &#x201c;Earth as a Comprehensive System&#x201d; approach. Examples include pandemic planning, assessing pandemic preparedness, ensuring medical device safety, securing medical information, and packaging materials for vaccines.</p>
                <p>When considering the pursuit of happiness on Earth, the &#x201c;Earth as a Comprehensive System&#x201d; approach serves as a transformative strategy that will ultimately lead to a sustainable world (
                    <xref ref-type="bibr" rid="ref25">Hariram et al., 2024</xref>). By acknowledging the interdependence of ecosystems, cultures, and economies, this approach prioritizes human welfare and environmental health. Furthermore, fostering cooperation between communities and disciplines will enhance resilience, enabling society to thrive and adapt to future pandemics. Ultimately, adopting this perspective can open the way for a sustainable world in addressing global health issues.</p>
                <p>This study on the &#x201c;Earth as a Comprehensive System&#x201d; approach contributes to the existing literature and enhances the understanding of how the emergency response to the COVID-19 outbreak can be effectively managed by applying the Earth system model. The holistic model proposed in this study broadens the scope of pandemic management by systematically identifying eight underlying factors, eight overarching factors, and four categories within the &#x201c;Earth as a Comprehensive System&#x201d; approach. The findings of this study confirm the generalizability of the system proposed in the literature.</p>
                <p>In terms of education, pandemic management must maintain the quality of education worldwide while also contributing to a peaceful, just, and tolerant human society through the mobilization of educational resources, context-specific solutions, and universal access (
                    <xref ref-type="bibr" rid="ref16">Dickinson &amp; Gronseth, 2020</xref>). All stakeholders have diverse perspectives on the COVID-19 outbreak and are constantly faced with challenges and changes. Education can thus employ the &#x201c;Earth as a Comprehensive System&#x201d; approach as a framework to help students and trainees navigate and overcome the impacts of a pandemic flexibly.</p>
                <p>Many stakeholders are eager to learn about the COVID-19 outbreak. Learning plays a crucial role in supporting these stakeholders and thus helps achieve the goals of pandemic management. However, learning should not be an end in itself; rather, it must be institutionalized (
                    <xref ref-type="bibr" rid="ref47">Sharma et al., 2021</xref>). This establishes the &#x201c;Earth as a Comprehensive System&#x201d; approach as the standard in the field of pandemic management. Related institutionalization can be fully realized through appropriate investments in motivation, resources, and policy.</p>
            </sec>
            <sec id="sec15">
                <title>5.3 Future studies</title>
                <p>Many studies will be developed and subsequently practiced in the future, based on the concept that Earth is a comprehensive system. Researchers will further formalize the &#x201c;Earth as a Comprehensive System&#x201d; into a practical framework that is highly relevant to global health issues (
                    <xref ref-type="bibr" rid="ref8">Biyela &amp; Utete, 2024</xref>). Future research will provide an integrated model in collaboration with the international community while improving multiple aspects of this approach. A fully functional model that is adaptive, data-driven, and flexible for use in actual pandemic management will be closer to realization through the efforts of researchers.</p>
                <p>Future studies will also primarily investigate how socioeconomic and cultural factors have influenced pandemic management (
                    <xref ref-type="bibr" rid="ref37">Mansouri, 2023</xref>). These subsequent investigations will delve deeper into several relevant elements, regardless of geographical limitations. Both individual case studies and comparative perspectives will be employed flexibly. These studies will offer tailored options for specific communities, including important obstacles, optimal strategies, and additional socio-environmental factors.</p>
            </sec>
        </sec>
        <sec id="sec16" sec-type="conclusion">
            <title>6. Conclusion</title>
            <p>This study aimed to provide a theoretical model for improving the current pandemic management responses to the COVID-19 outbreak. By identifying and analyzing eight underlying factors, eight overarching factors, and four major categories, we developed an &#x201c;Earth as a Comprehensive System&#x201d; approach applicable to all nations, thus achieving our intended goal.</p>
            <p>Considering the numerous barriers, alternatives, and implications surrounding coronavirus infection, the key finding of this study was the development of the &#x201c;Earth as a Comprehensive System&#x201d; approach in the field of pandemic management. This approach is not merely a new label in the field; it effectively addresses the root causes of the COVID-19 outbreak. Rather than merely coping with the various symptoms of pandemic response, this approach aims to provide a scientific vision for potential future pandemics, in contrast to existing practices.</p>
            <p>The &#x201c;Earth as a Comprehensive System&#x201d; approach encourages all stakeholders to operate within the overarching framework of comprehensive pandemic management, leading to significant changes in the field, akin to the role of transformation leadership. Multiple professionals, as well as the general public, can apply this approach to tackle challenging issues arising from the COVID-19 outbreak. Particularly, all stakeholders can utilize this approach as a guide for their emergency response from both short- and long-term perspectives.</p>
            <p>This study has several potential merits. First, the developed approach is straightforward and thus easy to apply during the emergency response phase. Specifically, it comprehensively includes critical factors of pandemic management that surpass those analyzed in previous studies. It encompasses personnel, strategies, resources, one country from each of the six continents, and other facets based on a multidisciplinary perspective.</p>
            <p>The limitation of this study is the lack of empirical support during the modeling process. Scholars can develop new emergency response models based on numerical data. When feasible, they may interpret the &#x201c;Earth as a Comprehensive System&#x201d; approach using statistical packages or other empirical methods. All efforts will serve as a foundation for achieving a stronger pandemic response to the COVID-19 outbreak.</p>
        </sec>
        <sec id="sec17">
            <title>Ethics and consent</title>
            <p>Ethical approval and consent were not required.</p>
        </sec>
    </body>
    <back>
        <sec id="sec20" sec-type="data-availability">
            <title>Data availability statement</title>
            <p>No data associated with this article.</p>
            <sec id="sec21">
                <title>Extended data</title>
                <p>Open Science Framework. Emergency response to the COVID-19 pandemic and beyond: qualitative content analysis. The project contains the following underlying data: PRISMA 2020 checklist &amp; flow diagram &#x2013; COVID-19. 
                    <ext-link ext-link-type="uri" xlink:href="https://doi.org/10.17605/OSF.IO/GVJSX">https://doi.org/10.17605/OSF.IO/GVJSX</ext-link> (
                    <xref ref-type="bibr" rid="ref24">Ha K.-M., 2025</xref>).</p>
                <p>Data are available under the terms of the 
                    <ext-link ext-link-type="uri" xlink:href="https://creativecommons.org/licenses/by/4.0/">Creative Commons Attribution 4.0 International license</ext-link> (CC-BY 4.0).</p>
            </sec>
        </sec>
        <ack>
            <title>Acknowledgments</title>
            <p>Not applicable.</p>
        </ack>
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    <sub-article article-type="reviewer-report" id="report423665">
        <front-stub>
            <article-id pub-id-type="doi">10.5256/f1000research.178723.r423665</article-id>
            <title-group>
                <article-title>Reviewer response for version 1</article-title>
            </title-group>
            <contrib-group>
                <contrib contrib-type="author">
                    <name>
                        <surname>Kita</surname>
                        <given-names>Stern</given-names>
                    </name>
                    <xref ref-type="aff" rid="r423665a1">1</xref>
                    <role>Referee</role>
                    <uri content-type="orcid">https://orcid.org/0000-0002-8339-1697</uri>
                </contrib>
                <aff id="r423665a1">
                    <label>1</label>Rabdan Academy, Abu Dhabi, Abu Dhabi, United Arab Emirates</aff>
            </contrib-group>
            <author-notes>
                <fn fn-type="conflict">
                    <p>
                        <bold>Competing interests: </bold>Work at same institution</p>
                </fn>
            </author-notes>
            <pub-date pub-type="epub">
                <day>11</day>
                <month>12</month>
                <year>2025</year>
            </pub-date>
            <permissions>
                <copyright-statement>Copyright: &#x00a9; 2025 Kita S</copyright-statement>
                <copyright-year>2025</copyright-year>
                <license xlink:href="https://creativecommons.org/licenses/by/4.0/">
                    <license-p>This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p>
                </license>
            </permissions>
            <related-article ext-link-type="doi" id="relatedArticleReport423665" related-article-type="peer-reviewed-article" xlink:href="10.12688/f1000research.162513.1"/>
            <custom-meta-group>
                <custom-meta>
                    <meta-name>recommendation</meta-name>
                    <meta-value>approve-with-reservations</meta-value>
                </custom-meta>
            </custom-meta-group>
        </front-stub>
        <body>
            <p>The manuscript proposes an &#x201c;Earth as a comprehensive system&#x201d; framework intended to synthesize lessons from COVID-19 response. It claims to use qualitative content analysis and references PRISMA 2020, identifies eight &#x201c;underlying factors,&#x201d; maps them to eight &#x201c;overarching factors,&#x201d; and groups these into four categories (stakeholders, foundational attributes, core functions, environment).</p>
            <p> The topic is timely and the intent to offer a systems-oriented, cross-sector framing is welcome. However, the current version has substantial methodological and conceptual shortcomings. The paper reads primarily as a conceptual synthesis/commentary but is presented as a PRISMA-guided qualitative review without the methodological transparency required for that design. Claims about contribution and applicability exceed the evidence shown. Major restructuring is needed.</p>
            <p> My observations:</p>
            <p> </p>
            <p> 
                <bold>Methodological fit and transparency</bold>
            </p>
            <p> The manuscript invokes PRISMA 2020 but does not provide the elements necessary for a systematic/scoping review (explicit research question, full search strings and dates per database, inclusion/exclusion criteria, screening flow with reasons for exclusion, dual screening, data charting, risk-of-bias/quality considerations).</p>
            <p> The qualitative content analysis is insufficiently described (no codebook, coding approach, i.e. inductive/deductive, inter-coder procedures, exemplar coded extracts, or audit trail).</p>
            <p> I recommend the author to choose one path: either recast manuscript as a conceptual framework paper (remove PRISMA; rename Methods to &#x201c;Framework development approach&#x201d;; be transparent about how sources informed the framework), or conduct a proper scoping/systematic review (PRISMA-ScR/PRISMA): protocol, reproducible searches, dual screening, data extraction, coding, and comprehensive supplements (included/excluded study lists).</p>
            <p> </p>
            <p> 
                <bold>Conceptual positioning and value-add</bold>
            </p>
            <p> The framework overlaps with established approaches, including comprehensive emergency management, WHO and IHR capacities, One Health, CDC pandemic frameworks, but the manuscript does not demonstrate what is novel or operationally superior. I suggest the author adds a comparison table that explicitly contrasts components, scope, and use-cases against established frameworks; include a logic model/causal diagram and a brief application vignette, showing clealy how the framework guides decisions under an emerging variant.</p>
            <p> </p>
            <p> 
                <bold>Selection of cases and evidentiary balance</bold>
            </p>
            <p> The &#x201c;one country per continent&#x201d; sampling to identify &#x201c;underlying factors&#x201d; is arbitrary and risks selection bias. Several country vignettes are politically sensitive and supported by media/editorial sources rather than balanced syntheses. I suggest either (a) acknowledge these as illustrative examples within a conceptual paper and moderate claims, or (b) for a review, replace or triangulate with peer-reviewed evaluations and official after-action reviews, providing balanced interpretation.</p>
            <p> </p>
            <p> 
                <bold>Overstatement of claims</bold>
            </p>
            <p> Assertions that the approach &#x201c;addresses the root causes&#x201d; and is &#x201c;applicable to all nations&#x201d; are not supported by empirical validation. The author shgould temper claims; frame the model as a heuristic to organize decision-making pending validation. Add a substantive limitations section, which can specify selection bias, context sensitivity, evolving evidence.</p>
            <p> </p>
            <p> 
                <bold>Data availability and supplements</bold>
            </p>
            <p> Stating &#x201c;no data associated&#x201d; is inconsistent with claims of PRISMA-based selection of 54 texts. If retaining a review design, deposit the bibliographic database(s), screening logs, codebook, and any coding outputs in the OSF project and revise the Data Availability statement accordingly.</p>
            <p> </p>
            <p> 
                <bold>Presentation and usability</bold>
            </p>
            <p> The paper would benefit from a visual schema of the framework, and from operational detail. Include: (i) a figure depicting the framework and interdependencies; (ii) a table mapping underlying and overarching factors with rationale and example sources; (iii) indicative metrics/indicators per component to support implementation.</p>
            <p> </p>
            <p> 
                <bold>Minor comments</bold>
            </p>
            <p> 
                <italic>Tighten prose and avoid normative language, such as</italic>
                <italic> judgmenn</italic>
                <italic>ts about specific leaders or countries.</italic>
            </p>
            <p> 
                <italic>Ensure consistent terminology and define each term on first use.</italic>
            </p>
            <p> 
                <italic>Verify all citations and replace &#x201c;reference source&#x201d; web items with peer-reviewed or authoritative documents wherever possible.</italic>
            </p>
            <p> 
                <italic>Consider retitling to reflect the chosen paper type.</italic>
            </p>
            <p>Are the rationale for, and objectives of, the Systematic Review clearly stated?</p>
            <p>Partly</p>
            <p>Is the statistical analysis and its interpretation appropriate?</p>
            <p>Not applicable</p>
            <p>If this is a Living Systematic Review, is the &#x2018;living&#x2019; method appropriate and is the search schedule clearly defined and justified? (&#x2018;Living Systematic Review&#x2019; or a variation of this term should be included in the title.)</p>
            <p>Not applicable</p>
            <p>Are sufficient details of the methods and analysis provided to allow replication by others?</p>
            <p>No</p>
            <p>Are the conclusions drawn adequately supported by the results presented in the review?</p>
            <p>Partly</p>
            <p>Reviewer Expertise:</p>
            <p>Disaster risk reduction, climate and health policy, emergency management, qualitative analysis, and resilience systems.</p>
            <p>I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.</p>
        </body>
    </sub-article>
</article>
