Publications

On February 10 and 11, 2021, the Johns Hopkins Center for Health Security hosted a virtual meeting of the Southeast Asia Strategic Multilateral Biosecurity Dialogue. Due to health risks stemming from the COVID-19 pandemic as well as associated restrictions and protective measures implemented around the world, the dialogue meeting originally scheduled to be held in Cebu, Philippines, during 2020 was postponed. To continue the productive dialogue between the participating countries, a virtual meeting was held to specifically address challenges and lessons from the countries’ experiences with COVID-19.

The trajectories of infectious disease and racial injustice in the United States have been inextricably entwined for centuries. Smallpox, for example, is thought to have arrived with Europeans to the Americas in the 16th century bringing devastating effects to Indigenous populations.¹ By the 17th century, numerous reports detail efforts by colonists to deliberately infect Native Americans, becoming one of the earliest documented histories of intentional biological warfare. Further links between infectious disease and racial injustice can be traced to the 1721 smallpox epidemic that ravaged Boston. During this time, the Puritan minister Cotton Mather advocated widely for inoculation, a procedure wherein dried pus from a smallpox patient was scraped into a healthy person's skin to build immunity.² Mather had learned of inoculation from an enslaved man named Onesimus, who brought knowledge of the practice from Africa. After Zabdiel Boylston, a local physician, successfully tested the procedure on his own son and 2 enslaved household members, he and Mather launched a public inoculation campaign. However, they encountered pushback from White Bostonians, some of whom questioned the validity of African medical practices and speculated that inoculation was a ploy to kill slaveowners. Another physician, William Douglas, went so far as to satirically advocate for using inoculation as a weapon against Native Americans, proposing cash rewards for each death.^2,3 Ultimately, though, only 1% to 2% of inoculation recipients died of smallpox during the outbreak, compared to 15% of Bostonians who were infected naturally.³

One of the lessons learned from the COVID-19 pandemic is the utility of an early, flexible and rapidly deployable disease screening and detection response. The largely uncontrolled spread of the pandemic in the United States exposed a range of planning and implementation shortcomings, which if they had been in place before the pandemic emerged, may have changed the trajectory. Disease screening by detection dogs show great promise as a non-invasive, efficient, and cost-effective screening method for COVID-19 infection. We explore evidence of their use in infectious and chronic diseases, the training, oversight, resources required for implementation, and potential uses in various settings. Disease detection dogs may contribute to the current and future public health pandemics; however, further research is needed to extend our knowledge and measurement of their effectiveness and feasibility as a public health intervention tool and efforts are needed ensure public and political support.

To understand operational challenges involved with responding to US measles outbreaks in 2017–19 and identify applicable lessons in order to inform preparedness and response operations for future outbreaks, particularly with respect to specific operational barriers and recommendations for outbreak responses among insular communities.

The worldwide SARS-CoV-2 pandemic has taken a heavy toll on ICUs worldwide. This review expounds on lessons learned for ICU preparedness during the pandemic and for future mass casualty events.

Nuismer and Bull¹ argue for the development of self-disseminating vaccines for cost-effective immunization of animal reservoirs to prevent zoonotic spillovers. The authors suggest two approaches: ‘transferable’ vaccines, non-contagious vaccines applied to animals and spread through behaviour such as grooming, and ‘transmissible’ vaccines, replication-competent virally vectored vaccines with potential for indefinite transmission across populations.

High quality epidemic forecasting and prediction are critical to support response to local, regional and global infectious disease threats. Other fields of biomedical research use consensus reporting guidelines to ensure standardization and quality of research practice among researchers, and to provide a framework for end-users to interpret the validity of study results. The purpose of this study was to determine whether guidelines exist specifically for epidemic forecast and prediction publications.

In response to the protracted Ebola virus outbreak in the Democratic Republic of Congo, the international public health community called for increased attention, coordination, and resources to support the response. The use of real-time modeling and analytics to support public health decision-making (also known as “outbreak science”) has been an important capability that has grown during previous outbreaks [1–3]. Despite the informative role that infectious disease models played in the recent DRC outbreak [4–7], cross-talk within the infectious disease modeling community and between infectious disease modelers and model stakeholders, such as health agencies, may be limited. Lack of communication can reduce the potential use of modeling capability to inform outbreak prevention and mitigation strategies. For example, mathematical modelers may not be aware of questions that would be particularly useful for guiding the response, such as the location and staffing of Ebola treatment units. On the other end, public health teams may not be aware of outbreak features that may signal improvement or worsening of incidence or increased potential for spatial spread.

The human and social toll of the coronavirus disease 2019 (COVID-19) pandemic has already spurred several major public health “lessons learned,” and the theme of effective and responsible scientific communication is among them. We propose that Twitter has played a fundamental—but often precarious—role in permitting real-time global communication between scientists during the COVID-19 epidemic, on a scale not seen before. Here, we discuss 3 key facets to Twitter-enabled scientific exchange during public health emergencies, including some major drawbacks. This discussion also serves as a succinct primer on some of the pivotal epidemiological analyses (and their communication) during the early phases of the COVID-19 outbreak, as seen through the lens of a Twitter feed.

Memish and colleagues,¹in their response to our Comment,² perceive conflict between the current best-practice risk management advice on physical distancing and the scientific evaluation of cancelling or continuing mass gathering events during the coronavirus disease 2019 (COVID-19) pandemic. Although we have already acknowledged the need to balance these two considerations in order to maintain public understanding and trust, we do not accept that conflict is inevitable as our approach requires all mass gatherings to be considered in context, including the prevailing advice on physical distancing and movement restrictions. An open and transparent process to explicitly consider the risks of a mass gathering can, in fact, promote public confidence in the decision.

Mass vaccination is a crucial public health intervention during outbreaks or pandemics for which vaccines are available. The US government has sponsored the development of medical countermeasures, including vaccines, for public health emergencies; however, federally supported programs, including the Public Health and Emergency Preparedness program and Cities Readiness Initiative, have historically emphasized antibiotic pill dispensing over mass vaccination. While mass vaccination and pill dispensing programs share similarities, they also have fundamental differences that require dedicated preparedness efforts to address. To date, only a limited number of public assessments of local mass vaccination operational capabilities have been conducted. To fill this gap, we interviewed 37 public health and preparedness officials representing 33 jurisdictions across the United States. We aimed to characterize their existing mass vaccination operational capacities and identify challenges and lessons learned in order to support the efforts of other jurisdictions to improve mass vaccination preparedness. We found that most jurisdictions were not capable of or had not planned for rapidly vaccinating their populations within a short period of time (eg, 1 to 2 weeks). Many also noted that their focus on pill dispensing was driven largely by federal funding requirements and that preparedness efforts for mass vaccination were often self-motivated. Barriers to implementing rapid mass vaccination operations included insufficient personnel qualified to administer vaccinations, increased patient load compared to pill-dispensing modalities, logistical challenges to maintaining cold chain, and operational challenges addressing high-risk populations, including children, pregnant women, and non-English-speaking populations. Considering the expected availability of a severe acute respiratory syndrome coronavirus 2 vaccine for distribution and dispensing to the public, our findings highlight critical considerations for planning possible future mass vaccination events, including during the novel coronavirus disease 2019 pandemic.

The spread of Zika virus throughout Latin America and parts of the United States in 2016 and 2017 presented a challenge to public health communicators. The objective of our study was to describe emergency risk communication practices during the 2016-2017 Zika outbreak to inform future infectious disease communication efforts.

Many kindergarten through 12th grade (K-12) schools in the United States do not have good ventilation. This is a longstanding problem with demonstrably negative effects on student learning. We can and should act to fix this to ensure good indoor air quality for all students, educators, and school staff. During the COVID-19 pandemic, it is even more important that ventilation problems in K-12 schools be addressed now. Along with other mitigation measures, improvements in ventilation in K-12 schools can decrease the risk of SARS-CoV-2 spread.

The coronavirus disease 2019 pandemic may require rationing of various medical resources if demand exceeds supply. Theoretical frameworks for resource allocation have provided much needed ethical guidance, but hospitals still need to address objective practicalities and legal vetting to operationalize scarce resource allocation schemata. To develop operational scarce resource allocation processes for public health catastrophes, including the coronavirus disease 2019 pandemic, five health systems in Maryland formed a consortium—with diverse expertise and representation—representing more than half of all hospitals in the state. Our efforts built on a prior statewide community engagement process that determined the values and moral reference points of citizens and health-care professionals regarding the allocation of ventilators during a public health catastrophe. Through a partnership of health systems, we developed a scarce resource allocation framework informed by citizens’ values and by general expert consensus. Allocation schema for mechanical ventilators, ICU resources, blood components, novel therapeutics, extracorporeal membrane oxygenation, and renal replacement therapies were developed. Creating operational algorithms for each resource posed unique challenges; each resource’s varying nature and underlying data on benefit prevented any single algorithm from being universally applicable. The development of scarce resource allocation processes must be iterative, legally vetted, and tested. We offer our processes to assist other regions that may be faced with the challenge of rationing health-care resources during public health catastrophes.

The CommuniVax Implementation Toolkit is a guide to help state and local jurisdictions set health equity efforts rapidly in motion, starting with a COVID-19 vaccination campaign that delivers systemic benefits to communities of Black, Indigenous, and People of Color (BIPOC). The toolkit is a product of CommuniVax, a coalition of community advocates, health experts, social scientists, and public sector leaders working together to strengthen state and local COVID-19 vaccination campaigns.

Continuing outbreaks, disasters and active conflict are all evidence that the world remains vulnerable to health emer-gencies with significant health, social, economic and political impacts.1 During the COVID-19 pandemic, even countries considered to have strong health security and strong health systems, as measured by conventional metrics, are struggling to provide routine essential health services. The costs related to the pandemic continue to accumulate, and the world has witnessed excess morbidity and mortality from non-COVID-19 conditions. On stimulus pack-ages alone, countries have spent US$ 15 trillion to mitigate the economic and opportunity costs and reduce the impacts on lives and livelihoods.2

Serology (antibody) tests to detect previous SARS-CoV-2 infection have been in high demand from the beginning of the COVID-19 pandemic. The initial shortage of diagnostic tests coupled with asymptomatic infections led to a significant demand for serology tests to identify past infections. Despite serious limitations on the interpretation of a positive antibody test in terms of immunity to SARS-CoV-2, antibody testing was initially considered for release from social distancing, return to employment, and “immunity passports.” The regulatory approach to antibody tests was limited; manufacturers were encouraged to develop and market antibody tests without submitting validation data to the FDA. FDA guidance grew more stringent, but many poor-quality tests were already on the market—potentially inappropriately used for individual decision-making. This is a case study describing COVID-19 serology tests and the U.S. market and describes lessons learned for a future health security crisis.

Coordination of efforts to assess the challenges and pain points felt by industries from around the globe working to reduce COVID-19 transmission in the indoor environment as well as innovative solutions applied to meet these challenges is mandatory. Indoor infectious viral disease transmission (such as coronavirus, norovirus, influenza) is a complex problem that needs better integration of knowledge. Critical to providing a reduction in transmission is to map the four core technical areas of environmental microbiology, transmission science, building science, and social science. To that end a three-stage science and innovation Summit was held to gather information on current standards, policies and procedures applied to reduce transmission in built spaces, as well as the technical challenges, science needs, and research priorities. The Summit elucidated steps than can be taken to reduce transmission of SARS-CoV-2 indoors and calls for significant investments in research to develop knowledge of viral pathogen persistence and transport in the built environment, risk assessment and mitigation strategy considerations including such as processes and procedures to reduce the risk of exposure and infection including building systems operations, biosurveillance capacity, communication, leadership, and stakeholder engagement for optimal response. The findings reflect the effective application of existing knowledge and standards, emerging science, and lessons-learned from current efforts to confront SARS-CoV-2.

With multiple COVID-19 vaccines available, understanding the epidemiologic, clinical, and economic value of increasing coverage levels and expediting vaccination is important.

Few populations have experienced greater harms during the COVID-19 pandemic than residents of nursing homes. Before the introduction of SARS-CoV-2 vaccines, nursing homes accounted for just over 5% of all U.S. COVID-19 cases but represented more than a third of all deaths1. Not all nursing home facilities have been equally affected; an analysis found that death rates were more than 3 times higher in facilities with the highest proportions of non-White residents than in facilities with the highest proportions of White residents2.