In the midst of a growing public health care emergency with the coronavirus and more than 15 years after the SARS epidemic, an international study shows that no country is fully prepared to deal with a potentially deadly outbreak.

The findings from the Global Health Security Index , a joint venture by the Nuclear Threat Initiative and the Johns Hopkins Center for Health Security that released its data in October 2019, indicate that health security is "fundamentally weak" globally, according to a news release .

Overall, only nine of the 195 countries surveyed were described as most prepared for rapidly responding to and mitigating the spread of an epidemic or pandemic. Those countries include Brazil , Finland , Netherlands , Portugal , South Korea , Switzerland , Thailand , the United Kingdom and the United States . The remaining countries were either labeled as more prepared or least prepared, with many of the least prepared countries located in Africa and the Middle East . The average country score was just 38.4 on a zero to 100-point scale.

"The results are alarming: All countries – at all income levels – have major gaps in their capabilities, and they aren't sufficiently investing in biological preparedness," said Ernest J. Moniz, co-chairperson and CEO of the Nuclear Threat Initiative, in a written statement. "The bottom line is that global biological risks are growing – in many cases faster than health systems, security, science and governments can keep up."

The report also found that only 11% of health systems show plans to dispense medical countermeasures during health emergencies and fewer than 5% of surveyed countries show a requirement to test their emergency operations center at least annually.

"It's a problem everywhere," said Jennifer Nuzzo, an associate professor at the Johns Hopkins Bloomberg School of Public Health and co-leader on the report. "There are simply not enough doctors and nurses to manage routine medical demands," let alone a surge from a crisis, she said.

The index assigned one of three grades – most prepared, more prepared and least prepared – to the 195 countries based on their ability to handle actions such as exercising response plans, emergency response operation and risk communication. The countries were also graded on their overall ability to rapidly respond to and mitigate the spread of an epidemic.

"In part, we base the index on transparency," said Jessica Bell, a senior program officer at the Nuclear Threat Initiative and another co-leader of the report. "We felt that that was really key to building a better conversation about preparedness and response."

While most East Asian countries were ranked in the middle for epidemic response and mitigation, two countries stood out as being most prepared: Thailand and South Korea. Thailand, ranked fifth for rapid response capability, received the highest possible score for all measures except for trade and travel restrictions and exercising response plans.

Nuzzo said Thailand likely scored well because of its "world-class" health programs – especially in epidemiology – and the "very, very close" relationship between Thailand's health authorities and the U.S. Centers for Disease Control and Prevention. Bell agreed, noting the country's "longstanding relationship" with the global health community.

South Korea, Nuzzo said, was tested by the Middle East Respiratory Syndrome (MERS) outbreak in 2015 and "put in hard work since then" to become a "global leader."

The outbreak of the novel coronavirus, which originated in the Chinese city of Wuhan in December and by Feb. 10 had sickened more than 40,000 and claimed more than 900 lives makes the index relevant today, according to the co-authors.

"I absolutely hate that we are seeing some of the findings and lessons in this event," Nuzzo said. "Hospitals are kind of the weak link in all this."

Nuzzo noted that over-capacity at hospitals and shortages of medical supplies make crises such as the coronavirus outbreak difficult to mitigate. And Bell added that the "importance of communication" is an important lesson to learn because while there were plans in place for responding to the coronavirus, there is "not a lot of publicly available data" with regard to exercising the plans.

" China has not participated in the joint external evaluations" from the World Health Organization, she said.

But Bell added that her team is calling attention to the index's published data and recommendations in response to the outbreak. Nuzzo said the study is intended to be longitudinal so that improvement can be measured in the future, noting that even country income was "surprisingly" not associated with preparedness.

"If we focus entirely on gaps, we get into the pessimistic stage."