Publications

This article describes implementation considerations for Ebola-related monitoring and movement restriction policies in the United States during the 2013–2016 West Africa Ebola epidemic.

As the COVID-19 pandemic continues to progress, most jurisdictions have implemented physical distancing measures to reduce further transmission, which have contributed to reductions in numbers of new cases. As chains of transmission begin to decline, along with new COVID-19 cases, there will need to be decisions at the state level about how to transition out of strict physical distancing measures and into a phased reopening

While health-care providers have used incentives in an attempt to motivate patients to obtain vaccinations, their effect on vaccination rates has not been systematically evaluated on a large scale. In this study, we examined whether mobile applications may improve population vaccination rates through enhanced communication and incentives education. Our study is the first randomized controlled trial assessing the effect of large-scale messaging combined with individualized incentives on influenza-vaccination rates. In this trial, we delivered messages regarding influenza vaccinations to 50,286 adults, aged 18 through 65, then compared the subsequent vaccination rate, the effectiveness of the message content and the timing. Multiple rounds of messaging occurred over a seven-week period during the 2016 flu season, after which vaccination rates were observed for one week. Participants were randomly assigned to one of three messaging approaches: conspicuous (highlighting the amount of rewards to be received for obtaining a flu shot); generic (promoting vaccinations with no mention of rewards); or no-message. Evidence of vaccination obtainment was indicated by medical and pharmacy claims, augmented by patients self-reporting through the mobile wellness app during the study period. Of the people assigned to receive messaging, 23.2% obtained influenza vaccination, compared to 22.0% of people who obtained vaccination in the no-messaging control arm. This difference was statistically significant (p < 0.01). The research revealed that messaging effectiveness decreased after each successive batch sent, suggesting that most participants responsive to messaging would become activated immediately after receiving one alert. Interestingly, in this large-scale study, there were no significant differences between conspicuous incentives and generic messaging, suggesting an important area for future research.

In order to save lives, reduce COVID-19’s burden on our healthcare system, ease strict social distancing measures, and confidently make progress toward returning to work and school, the United States must implement a robust and comprehensive system to identify all COVID-19 cases and trace all close contacts of each identified case. It is estimated that each infected person can, on average, infect 2 to 3 others. This means that if 1 person spreads the virus to 3 others, that first positive case can turn into more than 59,000 cases in 10 rounds of infections.

The immediate priorities of our national efforts to address the COVID-19 epidemic are appropriately aimed at suppressing chains of transmission through community-wide measures like stay-in-place orders and at surging hospital capacity to expand our ability to care for the rising number of sick patients. At the same time that we confront the current crisis, we must plan for the future by putting in place tools to enhance our ability to conduct effective surveillance, containment, and case management. As incidence of COVID-19 declines, case-based interventions will again become an option. Building those capabilities now will enable us to move beyond the extreme and disruptive physical isolation measures in place across the United States.

This report provides a road map for navigating through the current COVID-19 pandemic in the United States. It outlines specific directions for adapting our public-health strategy as we limit the epidemic spread of COVID-19 and are able to transition to new tools and approaches to prevent further spread of the disease. We outline the steps that can be taken as epidemic transmission is brought under control in different regions. These steps can transition to tools and approaches that target those with infection rather than mitigation tactics that target entire populations in regions where transmission is widespread and not controlled. We suggest measurable milestones for identifying when we can make these transitions and start reopening America for businesses and families.

This strategy aims to slow transmission of the novel coronavirus and interrupt its spread. In metropolitan areas where cases are increasing, this strategy should delay and reduce the peak number of cases. In metropolitan areas where case numbers may be stable or declining, this strategy should accelerate the decline, creating more opportunities for decisions to relax social distancing policies.

The recommendations will require significant resources for implementation. Metropolitan areas should consider establishing public-private partnerships to coordinate and support this work.

Stark gaps exist between projected health needs in a pandemic situation and the current capacity of health care and medical countermeasure systems. Existing pandemic ethics discussions have advocated to engage the public in scarcity dilemmas and attend the local contexts and cultural perspectives that shape responses to a global health threat. This public engagement study thus considers the role of community and culture in the ethical apportionment of scarce health resources, specifically ventilators, during an influenza pandemic. It builds upon a previous exploration of the values and preferences of Maryland residents regarding how a finite supply of mechanical ventilators ought to be allocated during a severe global outbreak of influenza. An important finding of this earlier research was that local history and place within the state engendered different ways of thinking about scarcity.

The use of infectious disease modeling to support public health decision making, referred to in this report as “outbreak science,” has increased in prominence in the past decade. It has been used in the responses to several major outbreaks, from severe acute respiratory syndrome (SARS) in 2003, to H1N1 influenza in 2009, to the 2 most recent Ebola outbreaks in West Africa (2014-2016) and the Democratic Republic of the Congo (2018-current).

The coronavirus disease 2019 (COVID-19) pandemicpresents countries with major political, scientific, and public health challenges. Pandemic preparedness and reducing risk of global spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are key concerns. Mass gathering (MG) eventspose considerable public health challenges to health authorities and governments. Historically, sporting, religious, music, and other MGs have been the source of infectious diseases that have spread globally. However, the scale of the problem has declined over the years as better public health measures have been implemented at MGs in response to the World Health Assembly's endorsement on Dec 22, 2011, of the 130th Executive Board Decision “Global mass gatherings: implications and opportunities for global health security” that encompassed joint planning, enhancement of health infrastructures, and taking proper pre-emptive and preventive measures to control infectious diseases on an international scale. Since then, many MGs have been held safely and successfully without any major communicable disease issues arising, even for MG events held during three WHO declared Public Health Emergencies of International Concern: the Vancouver 2010 Winter Olympics and the 2010 FIFA World Cup in South Africa during the H1N1 influenza pandemic; the 2015 Africa Cup of Nations Football tournament in Equatorial Guinea during the outbreak of Ebola virus disease; and the Rio 2016 Olympics during the Zika virus outbreak.

Sustained spread of SARS-CoV-2 has happened in major US cities. Capacity needs in Chinese cities could inform the planning of local healthcare resources.

In late December 2019, a cluster of unexplained cases of viral pneumonia occurred in Wuhan, China.1 This initial cluster of patients with what soon became known as coronavirus disease 2019 (COVID-19) heralded the arrival of a new pandemic caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). To date, close to 90 000 cases have occurred in more than 60 countries with approximately 3000 deaths. The World Health Organization (WHO) has declared these events a Public Health Emergency of International Concern.

Effective communication about medical countermeasures—including drugs, devices and biologics—is often critical in emergency situations. Such communication, however, does not just happen. It must be planned and prepared for. One mechanism to develop communication strategies is through the use of prospective scenarios, which allow readers the opportunity to rehearse responses while also weighing the implications of their actions. This article describes the development of such a scenario: The SPARS Pandemic 2025-2028. Steps in this process included deciding on a timeframe, identifying likely critical uncertainties, and then using this framework to construct a storyline covering both the response and recovery phases of a fictional emergency event. Lessons learned from the scenario development and how the scenario can be used to improve communication are also discussed.

Aerial spraying of products to kill larvae or adult mosquitoes is a public health measure used to control vector-borne diseases. In some outbreaks, the intervention has evoked controversy and community resistance. This study evaluated how local opinion leaders in US localities affected by Zika think about community engagement in public health policies for outbreak response. In December 2017 through March 2018, 4 focus groups were convened in Houston, TX, New Orleans, LA, Miami, FL, and Brooklyn, NY. They discussed a hypothetical scenario that featured vector control by aerial spraying. Participants (N = 20) more readily accepted this vector control method under 4 conditions: They were informed of alternatives, benefits, and risks for human health and the environment. Public health claims were backed by objective evidence and an authority figure genuinely working in the community’s interests. They received timely notice about how to mitigate toxin exposure. And, aerial spraying helped to protect vulnerable individuals. The community engagement requirements of the local opinion leaders resonate with core principles of recent public health ethics frameworks: namely, personal autonomy, transparency, reasonableness, and solidarity. Participants foresaw problems with community consent in an era of growing social media use and mistrust in governmental and scientific authority. They also debated whether health authorities should use moral-based arguments, in addition to science-based ones, to communicate aerial spraying’s risks and benefits.

Clade X was a day-long pandemic tabletop exercise conducted by the Johns Hopkins Center for Health Security on May 15, 2018, in Washington, DC. In this report, we briefly describe the exercise development process and focus principally on the findings and recommendations that arose from this project.

Clade X was a day-long pandemic tabletop exercise conducted by the Johns Hopkins Center for Health Security on May 15, 2018, in Washington, DC. Many details of the exercise are available online, including videos, background documents, and fact sheets.In this report, we briefly describe the exercise development process and focus principally on the findings and recommendations that arose from this project.

During the 2014-15 domestic Ebola response, US states developed monitoring and movement restriction policies for potentially exposed individuals. We describe decision-making processes and factors in the development of these policies. Results may help health officials anticipate potential concerns and policy influencers in future infectious disease responses. Thirty individuals with knowledge of state-level Ebola policy development participated in semi-structured interviews conducted from January to May 2017. Interviewees represented 18 jurisdictions from diverse census regions, state political affiliations, and public health governance structures as well as the US Centers for Disease Control and Prevention (CDC). Limited and/or changing guidance and unique state-level public health, legal, and operational environments resulted in variation in policy responses. Federal guidance developed by the CDC was an important information source influencing state-level policy responses, as was available scientific evidence; however, other external factors, such as local events, contributing experts, political environment, public concern, news media, and the influence of neighboring states, contributed to additional variation. Improvements in timing, consistency, and communication of federal guidance for monitoring and movement restrictions at the state level—along with balanced approaches to addressing ethical concerns, scientific evidence, and public concern at the state level—are considerations for policy development for future disease responses.

CRISPR, a powerful gene-editing technology, is revolutionizing the life sciences and medical research. The technology has also become democratized. Costs to use CRISPR are low and decreasing, kits are available to make the use of CRISPR straightforward, and there is a rapidly growing scientific literature describing CRISPR methodologies and novel applications. However, like other powerful advances in the life sciences, CRISPR raises biosecurity concerns: it could be misused for harm, and it lowers technical barriers to biological weapons development. This essay describes the history and dissemination of CRISPR as genome-editing techniques have become widespread, outlines potential biosecurity concerns, and recommends actions governments and scientists may take to reduce biosecurity risks. While it is not possible to eliminate biosecurity risks from the misuse of biotechnologies, including CRISPR, steps can be taken to increase security while allowing this powerful technology to remain widely available for beneficent purposes.

The Center for Health Security commends the issuance of the Executive Order on Modernizing Influenza Vaccines in the United States to Promote National Security and Public Health, on September 19, 2019, which has the potential to significantly improve the nation's capacities against influenza. As noted in the executive order, influenza is the preeminent pandemic threat the world faces. Unlike many pandemic threats, however, seasonal occurrences of the infection provide a yearly stress test of our influenza pandemic mechanism. Recent years have seen severe seasonal strains of the virus inundate hospitals, spark spot shortages of antivirals, and expose stark deficiencies in vaccine technology. These events have unfortunately demonstrated that, were a severe pandemic to occur today, the United States is not sufficiently prepared to withstand such an event without major societal disruption.

Vaccines are the cornerstone of the management of an infectious disease outbreak and are the surest means to defuse pandemic and epidemic risk. The faster a vaccine can be deployed, the faster an outbreak can be extinguished. To date, however, the pharmaceutical response to emerging infectious diseases and bioterrorism has been characterized by a “one bug, one drug” approach, in which specific medical countermeasures—effective vaccines and therapeutics—are developed, manufactured, and deployed. This is a process that is often measured in decades.