Publications

Local health departments (LHDs) help rally communitywide efforts to manage disasters with health impacts. This responsibility emerged as a centerpiece of the nation’s response to the 2001 terror attacks, including federal public health emergency preparedness (PHEP) grants to local and state health agencies. Encouraged PHEP capabilities include risk communication, building coalitions that integrate businesses and community- and faith-based organizations (CFBOs), opening emergency planning to public input, and mobilizing volunteers. National standards for local public health preparedness also feature community preparedness, including multisector partnerships, vulnerable population initiatives, and 2-way exchanges (eg, town hall meetings, public strategy sessions).

The following narrative comprises a futuristic scenario that illustrates communication dilemmas concerning medical countermeasures (MCMs) that could plausibly emerge in the not-so-distant future. Its purpose is to prompt users, both individually and in discussion with others, to imagine the dynamic and oftentimes conflicted circumstances in which communication around emergency MCM development, distribution, and uptake takes place. While engaged with a rigorous simulated health emergency, scenario readers have the opportunity to mentally “rehearse” responses while also weighing the implications of their actions. At the same time, readers have a chance to consider what potential measures implemented in today’s environment might avert comparable communication dilemmas or classes of dilemmas in the future.

In February 2017, the Johns Hopkins Center for Health Security hosted a Track II (non- governmental) dialogue on biosecurity between experts in India and the US in New Delhi, India. The meeting was held in collaboration with the Department of Biotechnology within the Indian Ministry of Science and Technology. This was the second meeting of the biosecurity dialogue; the first was held in Washington, DC in September, 2016.* The effort is supported by the Project on Advanced Systems and Concepts for Countering WMD (PASCC; sponsored by the Defense Threat Reduction Agency, DTRA) of the US Air Force Institute for National Security Studies.

Although the healthcare system is undoubtedly better prepared for disasters than it was before the events of 9/11, it is not well prepared for a large-scale or catastrophic disaster. Just as important, other segments of society that support or interact with the healthcare system and that are needed for creating disaster-resilient communities are not sufficiently prepared for disasters. This report is the culmination of a 2-year project funded by the Robert Wood Johnson Foundation to examine US disaster healthcare with the purpose of identifying changes, innovations, and new efforts that could strengthen the country’s ability to provide medical care in major disasters. In the report, Johns Hopkins Center for Health Security researchers analyze a range of disasters that could confront the United States and consider their impacts on the healthcare system, including how medical care would be delivered in those scenarios, both to victims of the disaster and everyone else. We found that many of the current programs are quite valuable and should continue to be supported, and that several new initiatives should be pursued that would improve the disaster readiness and resilience of the US health sector.

News media plays a large role in the information the public receives during an infectious disease outbreak, and may influence public knowledge and perceptions of risk. This study analyzed and described the content of U.S. news media coverage of Zika virus and Zika response during 2016. A random selection of 800 Zika-related news stories from 25 print and television news sources was analyzed. The study examined 24 different messages that appeared in news media articles and characterized them using theories of risk perception as messages with characteristics that could increase perception of risk (risk-elevating messages; n = 14), messages that could decrease perception of risk (risk-minimizing messages; n = 8), or messages about travel or testing guidance (n = 2). Overall, 96% of news stories in the study sample contained at least one or more risk-elevating message(s) and 61% contained risk-minimizing message(s). The frequency of many messages changed after local transmission was confirmed in Florida, and differed between sources in locations with or without local transmission in 2016. Forty percent of news stories included messages about negative potential outcomes of Zika virus infection without mentioning ways to reduce risk. Findings from this study may help inform current federal, state, and local Zika responses by offering a detailed analysis of how news media are covering the outbreak and response activities as well as identifying specific messages appearing more or less frequently than intended. Findings identifying the types of messages that require greater emphasis may also assist public health communicators in responding more effectively to future outbreaks.

In 2014, the United States launched the Global Health Security Agenda (GHSA) as a 5-year initiative to increase progress toward “a world safe and secure from infectious disease threats.”1 The initial financial commitment was $1 billion. In the years since, important progress has been made. The GHSA has helped to bring political attention to the need to strengthen public health capacities across the globe and has created a mechanism for countries to work collaboratively and make financial commitments to do so.

Biological threats, which range from naturally occurring outbreaks of infectious disease to intentional acts of bioterrorism, pose unique dangers to public health and national security in the United States. Medical countermeasures (MCMs)—drugs, vaccines, diagnostic tests, and other therapies and devices—rank among the most important assets in the nation's arsenal against dangerous pathogens, as well as chemical, radiological, and nuclear threats. Communities with access to vital MCMs are better equipped to detect both accidental and deliberately caused outbreaks quickly, immunize susceptible populations, and treat infected patients, thereby alleviating the consequences associated with infectious diseases: illness and death, economic losses, societal unrest, and strained public health and healthcare delivery systems.

This article examines the biosecurity and biodefense implications resulting from the recent creation of horsepox virus, a noncirculating (extinct) species of orthopoxvirus. Here we examine the technical aspects of the horsepox virus synthesis and conclude that orthopox synthesis experiments currently remain technically challenging—and will continue to be so, even once this work is published in the scientific literature. This limits potential misuse by some types of nefarious actors. We also examine the implications of one stated purpose for the recreation of horsepox virus: the development of a smallpox vaccine. If the development is successful, it could take advantage of US government incentives for the priority FDA review of medical countermeasures (MCMs) against biosecurity threats. However, if this case leads to the determination that this incentive is counterproductive for security, the newly created priority review voucher program should be more clearly defined or limited based on need. Limiting the program could have costs that require further consideration, however, as general incentives for biodefense medical countermeasure development are required for MCMs to be available. Finally, while the recreation of horsepox virus was not technically trivial, nor was it cell-free, this experiment was a de facto demonstration of already assumed scientific capabilities.

Almost a century ago, a new and deadly strain of influenza spread around the world, shutting down schools and businesses and filling hospitals well beyond their capacity. In the end, the 1918 flu pandemic claimed the lives of approximately 50 to 100 million people, and it infected about one-third of the global population. Since then, medical care has vastly improved, and science has made major gains in vaccines and medicines. Yet the potential remains for a lethal strain of influenza or other contagious pathogen to overwhelm global health care systems by spreading at a rate that outpaces our ability to respond. In such a calamitous scenario, neither the United States nor other countries would be well enough equipped to contain it, increasing the potential for a true national or global catastrophe.

Last week, Houston-area hospitals displayed great resiliency as they faced catastrophic flooding from Hurricane Harvey's relentless rains over several days. However, some vital hospital services—understandably—experienced significant disruptions. Health systems nationwide can learn vital lessons from Texas' planning and response to further strengthen their own preparedness and "harden" their facilities to all hazards.

The Johns Hopkins Center for Health Security is working to analyze and deepen scientific dialogue regarding potential global catastrophic biological risks (GCBRs), in a continuation of its mission to reduce the consequences of epidemics and disasters. Because GCBRs constitute an emerging policy concern and area of practice, we have developed a framework to guide our work. We invited experts from a variety of disciplines to engage with our underlying concepts and assumptions to refine collective thinking on GCBRs and thus advance protections against them.

Policy-makers and practitioners have a need to assess community resilience in disasters. Prior efforts conflated resilience with community functioning, combined resistance and recovery (the components of resilience), and relied on a static model for what is inherently a dynamic process. We sought to develop linked conceptual and computational models of community functioning and resilience after a disaster.

Due to increasing rates of antimicrobial-resistant infections and the current inadequacy of the antibiotic pipeline, there is increasing interest in nontraditional approaches to antibacterial therapies. We define “traditional” agents as small-molecule agents that directly target bacterial components to exert a bacteriostatic or bactericidal effect, and “nontraditional approaches” as antimicrobial therapeutics that work through other means (ie, not a small molecule and/or utilizes a nontraditional target). Due to their atypical features, such therapies may be less susceptible to the emergence of resistance than traditional antibiotics. They include approaches such as monoclonal antibodies, virulence disruptors, immunomodulators, phage therapies, microbiome-based therapies, antibiotic potentiators, and antisense approaches. This article discusses both the developmental and regulatory advantages and challenges associated with each of these technologies. By identifying existing regulatory and developmental gaps, we hope to provide a sense of where focusing resources may provide the greatest impact on successful product development.

A scientific understanding of the threat posed by biological weapons is critical to determine biodefense priorities, set preparedness and response policies, and implement prevention and mitigation measures. The United States is committed to upholding the Biological and Toxin Weapons Convention (BWC)[1] and 18 U.S. Code 175,[2] which make it a crime to knowingly possess a biological agent, toxin, or delivery system for use as a weapon or if the material is not intended for peaceful purposes. For the purposes of defense, the U.S. government (USG) has deemed it necessary to conduct risk assessments and characterize the threat posed by biological weapons use to the U.S. homeland. Yet, the data required to develop risk assessments are largely insufficient; there are large gaps in our knowledge and understanding regarding biological weapons.[3] We often have limited data on the biology of many potential biological threat agents (e.g., their dose–response profile, behavior under different conditions, and environmental persistence), and rather limited understanding of the intentions of adversaries who possess or seek to possess biological weapons. This uncertainty about both the biology of a threat agent as well as its likelihood of use makes effective decision making about biodefense resource prioritization difficult.

A severe influenza pandemic could overwhelm hospitals but planning guidance that accounts for the dynamic interrelationships between planning elements is lacking. We developed a methodology to calculate pandemic supply needs based on operational considerations in hospitals and then tested the methodology at Mayo Clinic in Rochester, MN.

The Ebola epidemic of 2014–2016 was a fast-moving, multidimensional emergency that presented unprecedented challenges for the multi -lateral system. In response to the outbreak, which was spreading exponentially in Guinea, Liberia, and Sierra Leone, Secretary-General Ban Ki-moon established the UN’s first-ever emergency health mission, the UN Mission for Ebola Emergency Response (UNMEER). UNMEER was mandated by the UN General Assembly in September 2014 to scale up and coordinate the activities of the UN presence on the ground working to stop the outbreak, which eventually claimed over 11,000 lives.

This report asks: Was UNMEER needed? Was it properly structured? Did it deliver? And what broader lessons can be learned from the experience of UNMEER for UN crisis response?

Despite increasing and significant global risks from emerging infectious diseases (eg, SARS in 2003, H1N1 in 2009, MERS and Ebola in 2014), federal powers to conduct accurate surveillance and nontherapeutic countermeasures are antiquated and, at times, ineffectual. After several prior attempts to modernize its rules over the past decade,¹ the US Centers for Disease Control and Prevention (CDC) issued a notice of proposed rulemaking (NPRM)² on August 15, 2016, to modernize its powers to control communicable diseases pursuant to the Public Health Service Act (PHSA).³ Through October 14, CDC has received more than 15,000 public comments on its NPRM.

This is a checklist of actions for healthcare, public health, nongovernmental organizations, and private entities to use to strengthen the resilience of their community's health sector to disasters. It is informed by the experience of Hurricane Sandy in New York and New Jersey and analyzed in the context of findings from other recent natural disasters in the United States. The health sector is defined very broadly, including—in addition to hospitals, emergency medical services (EMS), and public health agencies—healthcare providers, outpatient clinics, long-term care facilities, home health providers, behavioral health providers, and correctional health services. It also includes community-based organizations that support these entities and represent patients. We define health sector resilience very broadly, including all factors that preserve public health and healthcare delivery under extreme stress and contribute to the rapid restoration of normal or improved health sector functioning after a disaster. We present the key findings organized into 8 themes. We then describe a conceptual map of health sector resilience that ties these themes together. Lastly, we provide a series of recommended actions for improving health sector resilience at the local level. The recommended actions emphasize those items that individuals who experienced Hurricane Sandy deemed to be most important. The recommendations are presented as a checklist that can be used by a variety of interested parties who have some role to play in disaster preparedness, response, and recovery in their own communities. Following a general checklist are supplemental checklists that apply to specific parts of the larger health sector.

Blood products are critical to the success of both routine healthcare delivery and emergency response efforts. Ensuring the safety and availability of blood products presents nations with considerable collection, screening, and distribution challenges that are often exacerbated by public health crises, particularly mass-casualty events involving traumatic injuries. However, recent outbreaks of Ebola and Zika virus disease have also illustrated the importance of securing blood product supplies during ongoing infectious disease emergencies. The United States and other nations should consider enhancing existing mechanisms for sharing medical countermeasures by creating formal agreements for sharing blood products during public health emergencies.

Events in the United States and internationally have shown the kinds of great stakes and consequences that often follow epidemics and disasters. Consider the series of health security shocks since 2001: National fear during the anthrax letters events, with impact on all 3 branches of the US government. The respiratory transmissible SARS and MERS viruses spreading via airplanes and hospitals, sometimes by super-spreading individual patients. Human cases of H5N1 bird flu with a case fatality rate of 50%. The sudden emergence and global spread of 2009 H1N1. The congenital malformations following Zika infections—the first mosquito-borne illness to cause such malformations. The terrible mortality and wide spread of Ebola across multiple countries in West Africa, with imposition of large-scale quarantines and costly economic disruptions to trade and travel. The widespread disabling of the healthcare system during major US hurricanes. The use of chemical weapons in war in the Middle East, breaking years of international taboo against it. Discovery of smallpox in an insecure box in a US government lab. The radiation risks and uncertainties over large areas following the Fukushima tsunami and nuclear power plant accident. High-containment laboratory accidents involving important live pathogens.