Publications

Cyanide is a naturally occurring chemical, found in many plants, that has been used in conventional warfare and poisoning for 2 millennia. It is highly lethal, whether inhaled as a gas, ingested in solid form, or absorbed through topical exposure. Two notorious incidents in recent history—the Jonestown Massacre in 1978 and the Tylenol poisonings in 1982—highlight the lethality of this poison.

The Johns Hopkins Center for Health Security hosted a meeting, “National Strategy for Improving Indoor Air Quality,” in Washington, DC, on September 8, 2022. The meeting featured a keynote speaker and four expert panels focused on the importance of indoor air quality (IAQ), challenges to providing healthy indoor air across the United States, international perspectives and strategies for healthy air improvements, and catalyzing needed science and technology innovation in the IAQ field. Dr. Ashish Jha, White House COVID-19 Response Coordinator, opened the meeting by reiterating the importance of IAQ to the Biden-Harris Administration. 

A hallmark of the coronavirus disease 2019 (COVID-19) pandemic in its current stage is the ubiquity of home diagnostic testing for severe acute respiratory coronavirus virus 2 (SARS-CoV-2). These tests have been touted for their varied uses to facilitate navigating a world in which SARS-CoV-2 is an ever-present consideration. Apart from HIV at-home testing, COVID-19 is one of the only conditions that can be tested for at home with an almost immediate result. At-home infectious diseases testing has gained significant momentum during the COVID-19 pandemic given the myriad cascading positive benefits the technology offers. Currently, plans for home influenza and RSV tests are underway, as well as tests for sexually transmitted infections (STIs). These efforts began before the pandemic and have only accelerated as COVID-19 home tests have demonstrated their value. Here, I discuss how at-home infectious disease tests can be harnessed to optimize individual treatment outcomes and positively influence public health efforts. I have explored many of these themes in a prepandemic report,¹ and the ensuing years have concretized many of the theoretic benefits.

The Tianjin Biosecurity Guidelines for Codes of Conduct for Scientists are a set of ten principles designed to promote responsible science and strengthen biosecurity governance. They should be broadly adopted, including being endorsed by the Biological Weapons Convention at its 9th Review Conference in November 2022.

Despite projections of an oversupply of residency-trained emergency medicine physicians by 2030 and amidst intensifying national debate over Nurse Practitioner (NP) qualifications to practice independently and unsupervised, NPs are increasingly staffing Emergency Departments (EDs) as hospitals seek to contain costs while simultaneously expanding services. We sought to characterize NP practice in the ED by examining NP independent billing by level of severity of illness, and relationship to practice authority, State Medicaid expansion status, and rurality.

This report — a joint collaborative effort between the Infectious Diseases Society of America and the Johns Hopkins Center for Health Security — captures just how valuable infectious diseases professionals are to America’s health care system and society and sheds light on critical policies needed to ensure they are well positioned to help America for decades to come. We invite you to learn more.

The response by the biotech and pharmaceutical sectors to the COVID-19 pandemic has been historically unprecedented. Vaccines based in cutting-edge technologies, such as the mRNA platform, were invented, tested, and distributed to patients in less than a year. Yet politicians and activists argue that patents and other intellectual property (IP) have impeded the development and distribution of these vaccines. In explaining why this is profoundly mistaken, this essay first describes the medical and economic uncertainties inherent in the production of vaccines, especially those made in response to an emerging infectious disease like COVID-19. This makes clear the unprecedented achievement in the mass production and distribution of COVID-19 vaccines in less than 1 year after the start of the COVID-19 pandemic. It then describes the current manufacturing and licensing landscape, which was created on the basis of a market infrastructure built by reliable and effective patent rights. There is now a glut in the global supply of vaccine doses—and billions more doses are still being produced. The essay concludes by identifying the non-IP causes impeding global vaccine distribution, such as lack of infrastructure in the developing world, as well as regulatory restrictions and trade barriers. Those concerned with global vaccine equity should focus on policies to resolve these real-world problems.

The ability to diagnose and screen for infection is an important component of the US COVID-19 response and is facilitated by public health laboratories (PHLs). Anecdotal media reports and limited case studies have described some of the challenges faced by PHLs during the pandemic, particularly initial challenges related to developing and deploying tests to PHLs, but there has not been a systematic evaluation of the experience of PHLs during the pandemic.

The US nursing workforce crisis represents a danger to the quality and safety of patient care and an imminent threat to the nation's health security. The COVID-19 pandemic has exposed a range of perversities related to the nursing profession, including the inequitable financing and compensation of the nursing workforce, lack of workplace protections, and the perception that nursing is a subservient profession. It has also exacerbated workforce issues that predated the pandemic, leading to physical and mental exhaustion, lack of trust and perceptions of betrayal by hospital leaders, and moral injury and burnout. Nurses are critical to the sustainability of the US healthcare system, to the health of communities, and to the ability of the nation to respond to health security threats, including pandemics, natural disasters, and other large-scale emergencies. In the absence of an adequate labor supply of nurses, healthcare services are substantially degraded, hindering the country's ability to respond to emergencies and ultimately putting patients at risk.

Racial and ethnic minorities in the United States have been disproportionately affected by the COVID-19 pandemic, experiencing increased risk of infection, hospitalization, and death. In this study, we sought to examine race- and ethnicity-based differences in SARS-CoV-2 testing. We used publicly available US state dashboards to extract demographic data for COVID-19 cases and tests. Poisson regression models were used to model the effect of race and ethnicity on the number of SARS-CoV-2 tests performed per case. In total, just 8 states reported testing data by race and ethnicity. In regression models, race and ethnicity was a significant predictor of testing rate per case. In all states, Hispanic/Latino patients had a significantly lower testing rate than their non-Hispanic/Latino counterparts, with an incident rate ratio varying from 0.45 to 0.81, depending on the state and referent race category. These results suggest disparities in testing access among Hispanic/Latino individuals, who are already at a disproportionate risk for infection and severe outcomes.

This study examined the feasibility of creating a new nongovernmental health security research policy center in Asia, how such a center might benefit the advancement of policies promoting health security, and where such a center might be located. Health security policy encompasses numerous aspects of global health, including emerging infectious diseases, epidemics, medical and public health preparedness and response, deliberate and accidental biological threats, risk management related to advanced life science research and other biosecurity issues, and reduction of global catastrophic biological risks (GCBRs). GCBRs are those events in which biological agents—whether naturally emerging or reemerging, deliberately created and released, or laboratory engineered and escaped—could lead to sudden, extraordinary, widespread disaster beyond the collective capability of national and international governments and the private sector to control.¹ If unchecked, GCBRs could lead to great suffering, loss of life, and sustained damage to national governments, international relationships, economies, societal stability, or global security.

On April 8, 2022, the Johns Hopkins Center for Health Security at the Bloomberg School of Public Health convened a virtual, not-for-attribution meeting to solicit expert input on the US Department of Defense’s (DoD) first Biodefense Posture Review (BPR). US Secretary of Defense Lloyd J. Austin III called for a comprehensive BPR in a November 2021 memo concerning the DoD’s biodefense vision. In the memo, Secretary Austin points out the critical roles DoD played in the COVID-19 response, both within the Department and as part of the broader whole-of-government response. After-action reviews of these vital contributions highlighted areas for improvement in DoD’s preparedness and response. Therefore, Secretary Austin directed a whole-of-department review to efficiently and robustly assess the DoD’s capabilities and modernize its strategies for biodefense.

A radiological emergency such as the detonation of a radiological dispersal device would have catastrophic health, environmental, and economic consequences. Community assessments can provide useful information about radiological and other emergency preparedness at the household level. Tools such as logic models can be applied to link data collected in a community assessment to planned activities and targeted outcomes. This study sought to answer how public health departments can use the results of a community assessment to improve preparedness for radiological and other types of emergencies and to present a sample logic model demonstrating how questions asked in a community assessment can be used to drive intended outcomes.

Few clinicians practicing in the United States have ever seen a case of monkeypox infection. However, a new, unusual, multinational outbreak of monkeypox that is unfolding rapidly makes it important to know what a case might look like. This is critical not only to permitting rapid and proper medical and public health interventions but also to helping to understand the extent and spread of the outbreak. The current outbreak—which includes confirmed or suspected cases in the United States, the United Kingdom, Spain, Portugal, Italy, Belgium, Sweden, France, Canada, Australia, Germany, and the Netherlands—appears to have a pattern of spread that does not mirror past outbreaks outside of Africa, almost all of which have been related to importation via flights from Africa or exposure to infected exotic pets (1). This unusual monkeypox outbreak should prompt all clinicians to be attuned to the possibility of this infectious disease. Clinicians who suspect they may have a patient with monkeypox should contact their state or local health department immediately.

Nursing is the largest health profession, with nearly 4 million providers practicing across acute, primary, and public health care settings. In response to the pandemic, nursing schools halted on-site course delivery and redesigned programs to attenuate risks to students and faculty. Key challenges faced by schools included financial cutbacks, rapid increases in online learning technology, maintaining student academic progression, disruption to clinical learning opportunities, and meeting accreditation standards, while addressing the stress and loss experienced by faculty, staff, and students. Despite challenges, nursing organizations provided guidance for decision making, new learning resources, and faculty development opportunities. Schools of nursing leveraged their resources to redesign nursing curricula, strengthen partnerships for student clinical experiences, and address needs of the community.

Nursing education will look different from its prepandemic profile in the future. Lessons learned during the pandemic point to gaps in nursing education, particularly related to disaster and public health preparedness, health equity, and technology. The American Association of Colleges of Nursing’s new Essentials—standards for professional nursing education—were finalized during the pandemic and reflect these lessons. The need for nurse scientists to conduct emergency response research was made evident. The importance of strong academic–practice partnerships was highlighted for rapid communication, flexibility, and responses to dynamic environments. For the future, nursing education and practice must collaborate to ensure that students and practicing nurses are prepared to address emergencies and pandemics, as well as the needs of vulnerable populations.

The COVID-19 pandemic has brought forth a number of biotechnological advances to enhance the public's health: new diagnostic tests, mRNA vaccines, and new antiviral medications. Biotechnology is also being used to address global challenges like climate change, food insecurity, and building the bioeconomy, which directly or indirectly improve public health. Gene drives are one such biotechnology. They are genetically engineered systems that can alter the inheritance patterns in a host species, such as a mosquito, so that a greater percentage of its progeny inherit a specific desired trait. Research and investments in biotechnology have been used to reduce arthropod-borne infectious diseases, such as malaria and Zika, and to manage or eliminate invasive species.² Funding thus far has been adequate. For example, Target Malaria, a global consortium of researchers developing a gene drive to decrease the burden of malaria, has an average of US$11.5 million per year in funding.³ Although no gene drive has been released into the environment yet, technologies with similar attributes have been released in field trials, notably by Oxitec in Florida.⁴

Monkeypox is a rare viral infection that is thought to typically spread from close person-to-person contact through large respiratory droplets, direct contact with skin lesions or bodily fluids, or indirect contact via contaminated clothing or linens. Symptoms include fever and chills, headache, muscle aches, swollen lymph nodes, and a rash similar to chickenpox that can spread throughout the body and notably on the palms of the hands.

Uganda has engaged in numerous capacity building activities related to outbreak preparedness over the last two decades and initiated additional just-in-time preparedness activities after the declaration of the 2018–2020 Ebola Virus Disease (EVD) outbreak in eastern Democratic Republic of Congo (DRC). When Uganda faced importation events related to the DRC outbreak in June—August 2019, the country’s ability to prevent sustained in-country transmission was attributed to these long-term investments in preparedness. In order to help prepare countries for similar future scenarios, this analysis reviewed evidence from Uganda’s response to the June—August 2019 importation events to identify preparedness activities and capacities that may have enabled Uganda to identify and isolate infected individuals or otherwise prevent further transmission. Content from 143 grey literature documents gathered via targeted and systematic searches from June 6, 2019 to October 29, 2019 and six interviews of key informants were utilized to inform a framework evaluation tool developed for this study. A conceptual framework of Uganda’s preparedness activities was developed and evaluated against timelines of Uganda’s response activities to the June—August 2019 EVD importation events based on the applicability of a preparedness activity to a response activity and the contribution of the said response activity to the prevention or interruption of transmission. Preparedness activities related to coordination, health facility preparation, case referral and management, laboratory testing and specimen transport, logistics and resource mobilization, and safe and dignified burials yielded consistent success across both importation events while point of entry screening was successful in one importation event but not another according to the framework evaluation tool. Countries facing similar threats should consider investing in these preparedness areas. Future analyses should validate and expand on the use of the framework evaluation tool.

Veterinary and animal care workers perform critical functions in biosecurity and public health, yet little has been done to understand the unique needs and barriers these workers face when responding during a pandemic crisis. In this article, we evaluated the perceived risks and roles of veterinary and animal care workers during the COVID-19 pandemic and explored barriers and facilitators in their readiness, ability, and willingness to respond during a pandemic. We deployed a survey targeting US veterinary medical personnel, animal shelter and control workers, zoo and wildlife workers, and other animal care workers. Data were collected on respondents' self-reported job and demographic factors, perceptions of risk and job efficacy, and readiness, ability, and willingness to respond during the pandemic. We found that leadership roles and older age had the strongest association with decreased perceived risk and improved job efficacy and confidence, and that increased reported contact level with others (both coworkers and the public) was associated with increased perceived risk. We determined that older age and serving in leadership positions were associated with improved readiness, willingness, and ability to respond. Veterinary and animal care workers' dedication to public health response, reflected in our findings, will be imperative if more zoonotic vectors of SARS-CoV-2 arise. Response preparedness in veterinary and animal care workers can be improved by targeting younger workers not in leadership roles through support programs that focus on improving job efficacy and confidence in safety protocols. These findings can be used to target intervention and training efforts to support the most vulnerable within this critical, yet often overlooked, workforce.

In October 2020, David Cutler and Lawrence H. Summers published a brief article in JAMA Viewpoint estimating that COVID-19 would cost the United States $16 trillion dollars, when combining economic damages and monetized health and life loss. This figure has been extensively cited and used in policy discussions. In this article, we update their estimate, using facts about the disease and its costs to society that have become known since their paper was published. 

We find that the total harms of COVID-19 to the U.S. are still about $16 trillion (with a range of $10 trillion and $22 trillion) but the components of harm are significantly different than those estimated by Cutler & Summers. The pandemic caused less economic damage than they projected, but more mental health damage.