Emergency Response: The Center for Health Security Confronts a Global Pandemic

On New Year’s Day 2020, Caitlin Rivers, PhD, MPH, a Senior Scholar at the Johns Hopkins Center for Health Security, opened her inbox to find an email from Senior Analyst Matt Watson sharing a post from ProMED, a global reporting system for infectious disease outbreaks. The email quoted Chinese reports of “a pneumonia of unknown cause” that appeared to have originated in a seafood market in Wuhan, the capital of Hubei Province, China. The email included references to the severe acute respiratory syndrome (SARS) outbreak of 2002–2003, coupled with the assertion that “citizens need not panic.”

“I had a bad feeling about it,” Rivers said.

Before long, Rivers, whose research interests include emerging infectious diseases and epidemiological modeling, and her colleagues at the Center began tracking the rapidly evolving situation in China and publishing an external newsletter on the subject. At the time, little scientific detail was available in the Western press about the viral pneumonia rapidly spreading through Wuhan. So Rivers and the team gathered information from whatever sources they could find, including using Google to translate updates from China’s Ministry of Health.

Eventually, the pathogen responsible for the outbreak was identified as a novel coronavirus. The newsletter that the Center now published twice a day, every day (once a day on weekends) evolved into the COVID-19 Situation Report, a go-to source of information on the SARS-CoV2 pandemic for nearly 140,000 subscribers. Quickly, the Center and its experts became a crucial resource for scientists, policymakers, and the public who were seeking guidance on how to cope with the greatest global public health crisis in more than a century.

Rapid Response

It was not immediately clear that the situation in Wuhan would become a global pandemic like the one the Center had modeled the previous October in the tabletop exercise known as Event 201. (The eerily prescient pandemic simulation at the heart of that exercise featured a novel coronavirus that leapt from animals to humans.)

Yet, as details accumulated—of human-to-human transmission, of healthcare workers falling ill, of the disease’s impact on the human body—the picture began to change.

“It had all the characteristics of an epidemic that we would have a maximum level of concern about,” said Center Director Tom Inglesby, MD.

At which point, Ingelsby and his colleagues collectively leapt into action.

By late January, as case counts rose across Asia and the first novel coronavirus infections were confirmed in the United States, Senior Scholar Eric Toner, MD, issued warnings in American media that the initial outbreak was already out of control. “My message was that this was almost certainly going to be a pandemic, and we really needed to prepare,” he recalls.

Toner, who has for decades studied hospital capacity, reached out to the office of the Assistant Secretary for Preparedness and Response (ASPR) in the US Department of Health and Human Services (HHS) and offered to help ready the country’s healthcare systems and health departments for the storm ahead.

As a result, in mid-February, when the number of confirmed COVID-19 cases in the United States was still in the low double-digits, Toner, Inglesby, and Center Deputy Director Anita Cicero, JD, cohosted a meeting with ASPR officials and hospital executives across the country who were briefed on the need to brace for a severe pandemic. Later that month, Toner and colleagues from Johns Hopkins and Harvard published a paper warning that American hospitals might not have enough ventilators on hand to deal with an impending surge of COVID-19 patients—a situation that came became a dark reality during the first surge in New York City. Throughout the spring and summer, Toner and other Center experts—including Contributing Scholar Tener Goodwin Veenema, PhD, MPH, MS, RN, FAAN, an internationally recognized authority on disaster nursing and public health emergency preparedness—issued recommendations for adapting the healthcare system to the current pandemic while improving preparedness for future ones.

Meanwhile, on February 5, 2020, Senior Scholar Jennifer Nuzzo, DrPH, SM, testified before the US House of Representatives Committee on Foreign Affairs about the emergence and spread of the virus, at the time known as 2019 nCoV. It was the first of many invited appearances that Center experts would make on Capitol Hill as they sought to inform and advise lawmakers and congressional staffers on topics ranging from testing and contact tracing to the appropriate timing of shutdowns and reopenings. These topics covered only some of the areas that Center experts researched and analyzed over the course of 2020.

In her testimony, Nuzzo began by summarizing what was then known about the novel coronavirus. She evaluated the international response to the outbreak, discussed the implications of recently imposed travel restrictions, and praised countries such as Thailand and Vietnam for conducting epidemiological investigations that helped identify the spread of the disease—efforts that were only made possible, she pointed out, by years of US support for infectious-disease surveillance abroad. She then pointed to worrying trends such as a lack of global capacity to cope with pandemics and offered proposals for enhancing American readiness to respond to the virus and mitigate its spread.

In sum, Nuzzo conveyed the latest evidence-based understanding of the nature of the threat; pointed out flaws in the response to that point; advocated for investing in the resources necessary to effectively address not only the current outbreak, but the next one; and offered concrete suggestions for improving the situation.

As the pandemic continued to unfold and present new challenges, the Center’s experts maintained that multidimensional stance: responding to the crisis of the moment, while keeping an eye on the future, and offering evidence-based guidance and policy recommendations for both the near and long term. By mid-February 2020, for example, Inglesby and Cicero were briefing members of Congress on the state of the outbreak and on issues that Congress and the administration should be prepared to address.

“In some ways it would be nice to be able to stay in crisis response and do the long-range thinking later. But when there are major crises, there are windows that open for change,” Inglesby said. “The Center needed to analyze what was going on, explain it to people, identify particular problems, and work with policymakers to identify both short-term and longer-term, sustainable solutions.”

Or, as Rivers puts it: “If you’re always reacting, you’ll never get ahead.” Wherever possible, the Center’s experts looked for opportunities to change the landscape of preparedness, even in the middle of the crisis response. In late March 2020, Rivers published a report she and a team had started working on before the pandemic, proposing investments in infectious disease modeling to support public health decision making during and beyond COVID-19. Among other things, the report recommended establishing a national center for epidemic forecasting and outbreak analytics that would resemble an epidemiological version of the National Weather Service. President Joseph P. Biden called for the creation of this epidemic forecasting center in his first days in office, and Congress later provided funding.

One Problem After the Next

The dual focus on responding to the immediate crisis and considering long-term strategies was evident even as the pandemic reached its first chaotic peak in the spring.

In addition to fielding a barrage of requests for media comment, Center experts continued to brief legislators and staffers on Capitol Hill and participated in numerous calls with HHS and the World Health Organization (WHO), while also trying to address as many looming issues as they could. As a WHO collaborating center on health security, the Center seconded a Senior Analyst to the organization for over 6 months to support its pandemic response. It also deployed 2 staff members to assist HHS with hospital preparedness and Operation Warp Speed, the US government’s rapid development COVID-19 vaccine program.

“We were scanning ahead to see what issues were coming to the fore,” said Inglesby. “That was our modus operandi in the early months: one problem after the next, or a lot of concurrent problem solving.”

In March 2020, for example, just as states were beginning to issue stay-at-home orders, Rivers and Senior Scholar Crystal Watson, DrPH, MPH, an expert on risk assessment and crisis decision making—together with Center colleagues and several former US Food and Drug Administration (FDA) officials at the American Enterprise Institute—wrote the first report that laid out a phased approach to safely reopening.

Less than a month later, the Center issued a report that offered practical guidance to governors on how to assess the risk of viral transmission as they began contemplating ending state shutdowns. Soon after, the Center issued an operational toolkit designed to help businesses understand their own risk of transmission and how to reduce it. Similar to a toolkit that the Center later made available to colleges and universities, this business-oriented toolkit was based on a risk-assessment tool for mass gatherings that Watson and Senior Analyst Lucia Mullen, MPH, originally developed for WHO—a tool that was ultimately used by organizations ranging from the United Nations to the International Olympic Committee.

Those efforts immediately caught the attention of US federal, state, and local officials. DC Mayor Muriel Bowser, for example, established an advisory group that followed the Center’s phased reopening recommendations and sought the counsel of Cicero, Watson, and Rivers. Inglesby advised Maryland Governor Larry Hogan on the state’s reopening plans. Officials from Florida to Colorado also reached out to the Center for guidance.

“We really transitioned from a group that performed research and did education and advocacy work to a group that had to find solutions for real-world problems that were unfolding minute by minute,” Cicero said. “We were accustomed to planning for large-scale disasters rather than isolated or localized outbreaks, and in responding to COVID-19, we drew heavily on our past work related to mitigating the impacts of globally catastrophic biological risks.”

 

Contact Tracing and Testing

Even as they looked ahead to the inevitable end of the initial shutdown period, Center scholars were also focused on improving surveillance and mitigation efforts.

The Center’s National Coronavirus Response: A Road Map to Reopening, for instance, emphasized the need for contact tracing—a crucial tool for containing infectious disease outbreaks, yet one that in the early days of the pandemic was implemented far more vigorously abroad than it was in the United States.

“It seemed like such a fundamental component of the response that just wasn’t being attended to,” Watson said.

Seeking to remedy that situation, Watson, Cicero, and colleagues developed a national plan for enabling comprehensive COVID-19 case finding and contact tracing. The plan, which called for hiring 100,000 contact tracers across the country, was picked up by a reporter at National Public Radio (NPR) who had recently conducted a national survey on contact tracing. The Center soon partnered with NPR to conduct a series of such surveys over the course of 2020 to collect national data on the workforce status and effectiveness of contact tracing programs in each state. Center experts realized that without sufficient testing and contact tracing programs, the country would not be able to get ahead of the rapidly increasing number of cases and prevent further infections and deaths.

Although the number of contact tracers did not reach 100,000 by the end of 2020, it did nearly double from about 36,000 to nearly 70,000. As members of the Biden-Harris transition team later that winter, Watson and Rivers helped shape a public health workforce initiative that eventually received $7.6 billion in funding through the American Rescue Plan.

The Roadmap to Reopening also highlighted the need for more testing—a topic of critical importance throughout the pandemic, and one that Center experts addressed on many levels.

Senior Scholar Gigi Kwik Gronvall, PhD, an immunologist and founding member of the Center, was struck early on by how badly the American testing effort lagged behind that of other countries. Diagnostic testing was so spotty that by spring 2020, “a lot of people wondered if they had had COVID-19 in the early days and therefore might be immune,” she said. That led to a surge of interest in serological or antibody tests, which can reveal whether a person has been infected in the past, and also led to the proliferation of unauthorized and potentially misleading tests.

“A lot of fraudulent companies jumped into the fray,” Gronvall said.

To address this, Gronvall led the development of the Center’s Testing Trackers, later renamed the COVID-19 Testing Toolkit. Today, this online resource includes comprehensive lists of commercial molecular, antibody, and rapid antigen tests that have received emergency use authorization from the FDA, as well as guides to understanding how these tests work and how accurate they are. But in April 2020, when Gronvall and her colleagues launched the project, the first tracker was simply an Excel spreadsheet containing a handful of reputable antibody tests.

“The team combed through the FDA website for every new detail,” Gronvall said.

Gronvall and her team expanded and refined the trackers, with support from Lyda Hill Philanthropies and the Gordon and Betty Moore Foundation, and published 2 reports on antibody testing and serological surveys that laid out both their limitations for personal use and their value as public health tools for tracking the course of the pandemic and informing decisions about how to manage it—topics that Gronvall herself explained to a congressional subcommittee in June.

“I was terrified that I was going to have to explain positive predictive value to members of Congress,” she said. (She did not.)

Others at the Center, meanwhile, moved quickly to share testing data and explore the benefits and limitations of different testing strategies.

While Gronvall was getting the Testing Trackers off the ground, Nuzzo worked with the Johns Hopkins Coronavirus Resource Center to establish the Testing Insights Initiative to share and analyze COVID-19 testing data—an effort that helped promote the concept of “test positivity” to policymakers and the general public.

Two weeks after Gronvall testified before Congress about antibody testing, Senior Scholar Amesh Adalja, MD, led a report on the need for at-home diagnostic tests.

As a practicing physician in the Pittsburgh area who specializes in infectious diseases, critical care, and emergency medicine, Adalja gave his colleagues a ground-level sense of frontline conditions in the pandemic. He knew from personal experience just how poor the diagnostic testing situation was and how inadequate the initial guidelines on testing were. He and his team proposed using at-home tests as a means of ensuring more rapid, convenient, and equitable access to testing in future pandemics, while simultaneously providing a vastly enhanced surveillance network for detecting emerging infectious diseases in the first place.

 

Collateral Damage

Many of these issues continued to occupy the Center throughout the year. But as spring turned to summer, a host of new problems requiring urgent attention arose.

School closures, for example, had a massively disruptive impact not only on the nation’s economy but also on the wellbeing of children and families across the country, including those of many Center scholars.

“I’ve been very vocal about the school issue as an epidemiologist, but also as a mom who is deeply worried about my kids’ future,” Nuzzo said.

The need to plan for safe school reopenings in the fall quickly emerged as a matter of prime importance. In May 2020, Cicero, Senior Scholar Tara Kirk Sell, PhD, MA, and other Center experts issued a report that summarized the various reopening strategies emerging across Europe and Asia and urged the adoption of a national mandate here in the United States to prioritize and fund research into transmissibility, risk, and mitigation measures in school settings to keep children and educators safe. Many of the Center’s recommendations found their way into the Protect Our Children from COVID-19 Act, which was introduced in the House of Representatives less than 2 weeks later.

In addition to considering the risk of transmission and the susceptibility of children to COVID-19, the report also underscored the emotional, psychological, and developmental impacts of school closures.

“There’s a price to be paid for closing schools, and that price can be quite steep,” Cicero said.

It was not the first time that Center scholars had called attention to the broad collateral effects of the pandemic and urged that evidence-based decisions be made.

By late January 2020, for example, Senior Scholar Monica Schoch-Spana, PhD, a medical anthropologist who studies public health emergency management, was already calling attention to the stigmatization of Asian and Asian-American individuals and populations following the Wuhan outbreak. She was also among the first to warn of the disproportionate psychosocial impacts that the pandemic could have on vulnerable and marginalized groups and to advocate planning well in advance for what would most likely be a protracted and messy post pandemic recovery characterized by widespread economic and societal disruption.

“There is more going on in a pandemic than contagion,” Schoch-Spana said.

 

Shots in Arms

That multidisciplinary approach was also evident in the vaccine-related work that Schoch-Spana and other Center scholars and analysts undertook.

The official announcement of Operation Warp Speed on May 15 galvanized efforts to develop and distribute COVID-19 vaccines. But Center scholars had long before begun contemplating the manifold challenges posed by a massive—and massively complex—vaccine rollout.

In April 2020, for example, Center experts published a paper in the journal Vaccine that examined ways of accelerating the manufacture, distribution, and administration of vaccines. At the same time, Toner, who had previously studied the allocation of scarce medical resources during severe pandemics, took the lead on a project to develop an ethical framework for allocating what would at first be a limited vaccine supply.

In collaboration with the Berman Institute for Bioethics, the Bloomberg School of Public Health, and the International Vaccine Access Center, Toner coauthored a report, published in August 2020, that laid out a comprehensive framework for prioritizing vaccine access. The report considered everything from medical risk and economic impact to equity and social justice, including racial and ethnic disparities in COVID-19 mortality and the potential for heightened vaccine hesitancy among communities of color. The report informed subsequent work on vaccine allocation done by the National Academies of Science, Engineering, and Medicine, as well as by the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices.

Schoch-Spana helped shape the report’s recommendations regarding community engagement. But she launched her own vaccine-related project in April, too. Schoch-Spana knew that developing a safe and effective vaccine against COVID-19 would only be the first step in the long and involved process of getting it into people’s arms. “It doesn’t matter if you have a clinically successful vaccine if it isn’t socially acceptable,” she said.

Schoch-Spana organized the Working Group on Readying Populations for COVID-19 Vaccine, together with Emily K. Brunson, a medical anthropologist at Texas State University.

In July 2020, the working group published a report that outlined the obstacles that a vaccination campaign would likely face, along with recommendations for addressing them. These included funding rapid-response social science research to assess people’s feelings about the risks and benefits of vaccination, especially within underserved, marginalized, and vulnerable populations. The idea was to advocate for a well-resourced apparatus for doing social, behavioral, and communications-related research aimed at building a more effective and equitable vaccination campaign.

Schoch-Spana briefed Senate and House staff as well as state and local leaders and the National Vaccine Advisory Committee on the group’s findings. Meanwhile, the working group’s report drew the attention of the Chan Zuckerberg Initiative, which ultimately funded CommuniVax, the national coalition of social scientists, public health experts, and community advocates that Schoch-Spana and Brunson launched in December 2020 to strengthen community involvement in a more equitable rollout and develop suggestions for improving vaccine delivery and communication strategies—topics whose significance became ever more clear as vaccines finally became available.

“That’s what the Center does: scan the horizon and say, ‘Here are some solutions. Let’s try to get ahead of the problem,’” Schoch-Spana said.

 

Pandemic of Lies

The need for clear and effective communication was evident from the very beginning of the pandemic—especially given the confounding effects of misinformation and disinformation, which complicated everything from people’s ability to discern COVID-19 fact from fiction to their compliance with public health guidance.

Sell, who has led projects aimed at understanding and addressing misinformation during infectious disease outbreaks, launched a multipronged effort to combat what WHO termed an “infodemic”: an onslaught of health information and disinformation that makes it difficult for people to find trustworthy sources and reliable guidance. Over the fall and winter, Sell led the development of a special feature of the Center’s journal, Health Security, devoted to various aspects of the COVID-19 infodemic.

“We had a good scientific understanding of what could happen with disinformation around health issues, and we knew it was going to be a huge problem,” said Sell, who was herself targeted by conspiracy theorists in 2020. Her research on the spread of misinformation during the 2014-2016 Ebola outbreak in West Africa taught her and her colleagues that “you can’t really communicate well unless you also manage misinformation and disinformation.”

As a result of this experience, when Sell was invited to testify before Congress in early March 2020, she spent much of her time explaining the nature of misinformation and disinformation, its impact on public health response measures, and the role it plays in eroding trust in public health responders and stigmatizing affected communities.

Sell urged legislators to prevent the creation of an “information void” that could be filled with false information by instead rapidly and transparently sharing reputable information—a strategy she herself pursued in the ensuing months as she sought to convey evidence-based guidance on everything from COVID “cures” to infection-control measures in a wide range of media outlets, including conservative ones such as Fox News and Sinclair. (Center faculty were quoted in over 44,000 US news articles in 2020.)

“We need to communicate with folks outside of the echo chamber; to bring people into the tent rather than alienate them,” Sell said.

In a similar vein, Sell, Watson, Rivers, Gronvall, and Nuzzo worked with the Bloomberg School of Public Health to produce a series of video messages for Facebook containing legitimate public health information. One of Sell’s videos, which posted in October 2020 and addressed the topic of updated CDC guidance, garnered more than 1 million views. Another, on sports safety, received more than 500,000 views. A former Olympic swimmer, Sell played a key role last summer in engineering the return of The Basketball Tournament, a competition that carries a $1 million prize, through the adoption of rigorous testing and isolation protocols.

The Center’s commitment to providing reliable information and analysis was also made manifest in the establishment of the Capitol Hill Steering Committee on Pandemic Preparedness and Health Security in October 2020. Intended as an educational vehicle to increase understanding of health security issues among congressional staffers, the Committee secured honorary leaders from both parties in the House and Senate and immediately began offering scientific guidance to aides, lawmakers, government officials, and the general public through monthly webinars featuring experts on topics ranging from vaccine hesitancy to disease surveillance technologies.

A New Phase

As fall turned to winter, many Center scholars joined the Biden-Harris transition team, advising the incoming administration on its COVID-19 response and assisting with an agency review of HHS. Some experts, like Adalja, Cicero and Toner, even offered suggestions for a safe inauguration ceremony. At the same time, the pandemic itself entered a new phase, as another surge threatened many parts of the country with the kind of chaos that New York and New Jersey had seen in the spring.

Inglesby, who had served over the summer on the National Commission on COVID-19 and Criminal Justice (an initiative led by former Attorneys General Alberto Gonzales and Loretta Lynch that sought to contain the novel coronavirus in carceral settings), along with Watson and other colleagues, produced a report on that topic just as case numbers began to rise again. Drawing on the expertise of colleagues from the Johns Hopkins Bloomberg School of Public Health and the Johns Hopkins University School of Medicine, the report provided evidence-based recommendations for reducing COVID-19 risks among those incarcerated and those working in the criminal justice system.

In December 2020, as intensive care units (ICUs) began experiencing bed shortages and hospitals in California were running low on oxygen, Toner and Adalja provided guidance on crisis standards of care and ICU preparedness in hopes of averting the desperate situations that some East Coast healthcare facilities faced in April.

“It was important to say that this was predictable, and that hospitals needed to have robust systems when they crossed over into crisis standards of care,” said Adalja. “Whereas what happened [in the spring] is that hospitals slid into capacity concerns without an official declaration, making it very hard for physicians to operate.”

Reflecting on the end of a year in which every bit of good news (the development of monoclonal antibodies, the imminent arrival of vaccines) was accompanied by fresh challenges (an additional surge, the emergence of variants), the Center’s experts recalled feeling a mixture of fatigue, cautious optimism, and a hint of the surreal, as they continued to fight a pitched battle against an event they had spent most of their careers preparing for and warning against. However, there was satisfaction, too, in knowing that they had done their best to confront a global public health crisis of historic proportions.

“I’m really proud of our team,” Inglesby said. “We worked well together to help protect the country from some of the worst outcomes of this pandemic, and to navigate our way through it in ways I believe helped save a lot of lives.”

Yet their work is hardly over. There is still a lot of work to do to respond to this pandemic and its consequences, and as awful as it has been, the SARS-CoV2 pandemic could have been far worse: the fatality rate could have been much higher, for example, and safe and effective vaccines might not have been so readily available. As a result, Center experts are now challenging themselves and policymakers to prepare for future pandemics of even greater magnitude.

“We were fortunate that this pandemic was not even more devastating, and we need to continue to prepare for that,” Cicero said.