Publications

On February 8 and 9, 2022, the Johns Hopkins Center for Health Security co-hosted a virtual dialogue session with the Regional Centre for Biotechnology of the Department of Biotechnology in the Indian Ministry of Science and Technology. The meeting focused on successes, challenges, opportunities, and lessons learned in the COVID-19 responses in India and the United States, and how COVID-19 responses can continue while also preparing for future health security crises.

The dialogue focused on COVID-19 developments that occurred since the last meeting in January 2021. Discussions centered around national response efforts, mass vaccination, surveillance approaches, causes and biosecurity implications of COVID-19 misinformation and disinformation, synthetic biological risks, global biosecurity governance, and the need for future collaboration among countries and within the scientific community.

The meeting convened senior thought leaders, scientists, public health practitioners, and medical experts from the United States and India. In accordance with the dialogue format, participants offered insights based on personal expertise and did not represent the government of either country in an official capacity.

On December 14 and 16, 2021, the Johns Hopkins Center for Health Security held a second virtual meeting of the Southeast Asia Strategic Multilateral Biosecurity Dialogue. The ongoing impacts of the COVID-19 pandemic, including health risks as well as quarantine requirements and other travel restrictions, necessitated hosting the meeting virtually. Additionally, many of our dialogue participants play important roles in their country’s COVID-19 response, which makes it difficult for them to take time away from work for travel. In order to maintain the relationships that are so critical to the success of this dialogue and to share lessons from national-level COVID-19 response activities, we held a second virtual meeting, which built on the topics and challenges discussed in our previous meeting in February 2021.¹

Ventilation is of primary concern for maintaining healthy indoor air quality and reducing the spread of airborne infectious disease, including COVID-19. In addition to building-level guidelines, increased attention is being placed on room-level ventilation. However, for many universities and schools, ventilation data on a room-by-room basis are not available for classrooms and other key spaces. We present an overview of approaches for measuring ventilation along with their advantages and disadvantages. We also present data from recent case studies for a variety of institutions across the United States, with various building ages, types, locations, and climates, highlighting their commonalities and differences, and examples of the use of this data to support decision making.

People who inject drugs often have a higher prevalence of risk factors associated with coronavirus disease 2019 (COVID-19) infection and associated morbidity and mortality, compounded by challenges in health care access. This increased vulnerability underscores the critical need to prioritize people who inject drug in ongoing COVID-19 vaccination efforts. Co-location of syringe services, COVID-19 vaccination services, and other communicable disease testing has proved an effective model to provide necessary interventions without creating additional barriers. Here, we describe a partnership between the Baltimore City Health Department, Johns Hopkins Mobile Vaccine Unit, and the Center for Infectious Disease and Nursing Innovation at the Johns Hopkins School of Nursing to provide COVID-19 vaccination, HIV and sexually transmitted infection testing, wound care, and linkage to care services co-located with a long-running syringe services program. We describe the services offered by each partner and lessons learned from this community-based co-location of services initiative.

Scientists have explored gene drive technologies with the aim of controlling vector-borne diseases, including malaria, which killed an estimated 386,000 people in 2019.¹ Gene drives are genetic modifications that can be used to create populations where a particular gene is passed from a parent organism to its offspring at a higher rate than would be expected under natural inheritance conditions.² For example, mosquitoes that transmit malaria may be modified with a gene drive so that surviving offspring inherit and spread a gene that inhibits or alters the mosquitoes' infection potential. The drive would spread over subsequent generations, resulting in limited malaria transmission. Other gene drive strategies are designed to dramatically reduce the population of the carrying organism, such as a mosquito. Due to the broad-acting and potentially irreversible nature of these tools, current regulations may not be sufficient to mitigate the unique risks posed by gene drive technologies.³

On December 31, 2019, the World Health Organization (WHO) Country Office in China reported novel “viral pneumonias of unknown cause” in Wuhan, but China did not confirm case clusters until January 3, 2020. Two years later, more than 285 million cases and 5.4 million deaths have been reported. As of December 2021, more than 800 000 COVID-19 deaths have occurred in the US, surpassing the 675 446 total deaths that occurred during the great influenza pandemic of 1918. The COVID-19 pandemic reduced global economic growth by an estimated 3.2% in 2020, with trade declining by 5.3%; an estimated 75 million people entered extreme poverty, with 80 million more undernourished compared with prepandemic levels.¹ Although the COVID-19 and 1918 influenza pandemics stand alone in morbidity and mortality, evidence suggests the frequency of infectious disease emergencies will increase. What lessons does COVID-19 teach to advance preparedness, detection, and response?

As of September 2021, mortality in the United States due to the SARS-CoV-2 virus had exceeded the death toll from the 1918 influenza pandemic. COVID-19 was the ultimate test of healthcare and public health capacity and capability across the United States. From its acute onset and throughout its extended duration, the COVID-19 pandemic has overwhelmed hospitals, disrupted businesses, and caused lasting economic harm. It has also illuminated and exploited major vulnerabilities within the US healthcare and public health systems. The impact of the pandemic on hospitals, and to a lesser extent on public health departments, has been explored elsewhere, but relatively little has been written about the impact on primary care services. Operating largely in silos and chronically underfunded disciplines, primary care providers and public health practitioners in the United States have struggled to respond to the numerous waves of the pandemic, which have caused high levels of morbidity and mortality and jeopardized health systems in communities across the country, especially those that are most vulnerable. It is crucial that the lessons learned from the COVID-19 pandemic must be shared.

The Global Health Security Index benchmarks countries’ capacities to carry out the functions necessary to prevent, detect and respond to biological threats. The COVID-19 pandemic served as an opportunity to evaluate whether the Index contained the correct array of variables that influence countries’ abilities to respond to these threats; assess additional variables that may influence preparedness; and examine how the impact of preparedness components change during public health crises.

The 2021 Global Health Security (GHS) Index finds that despite significant steps taken by countries to respond to the COVID-19 pandemic, all countries remain dangerously unprepared to meet future epidemic and pandemic threats. Importantly, countries now have a more acute understanding of what this lack of preparedness means for their health and prosperity. This understanding presents an opportunity to convert high levels of political awareness about pandemics to long-term gains in preparedness by sustaining newly developed tools and building out additional capacities to better protect lives and livelihoods against the next pandemic.

Much is at stake. Countries continue to suffer harm from the COVID-19 pandemic as a result of insufficient health security capacity. This lack of capacity comes at a time when political and security risks have increased in nearly all countries, and enduring financial investment necessary to sustain capacities has yet to be demonstrated. Such weaknesses leave a world acutely vulnerable to future health emergencies, including those potentially more devastating than COVID-19.

These are sobering conclusions revealed by the 2021 GHS Index. With data captured during a period when countries wrestled with COVID-19,¹ researchers used a revised framework and updated data collection to glean hard truths about pandemic preparedness while assessing and benchmarking health security capacities across 195 countries.²

Xie et al. recently described ‘a reverse genetic system that enables rapid synthesis of wild-type, mutant and reporter SARS-CoV-2 [severe acute respiratory syndrome coronavirus 2] strains’¹. Their goal was to enable researchers to assess the functional properties of sequence variants, including their susceptibility to countermeasures such as vaccine-induced immune responses. We agree that the rapid development of medical countermeasures is of utmost importance, especially during an ongoing pandemic. However, we believe that public dissemination of this protocol in its current form poses risks that outweigh the benefits. In providing detailed, step-by-step instructions, it enables anyone skilled in the art anywhere in the world to create novel variants of SARS-CoV-2 more quickly, including variants that have even more worrisome properties than those that have occurred naturally. Sometimes research should be slowed, not hastened, to ensure a proper discussion of goals and a full and public vetting of proposed plans. Detailed protocols pose special risks under certain circumstances like this one and should undergo special prepublication scrutiny.

This article describes what is known about the origin of SARS-CoV-2, with implications for policy, biological research and public-health surveillance. Theories about the origin include a natural emergence; a laboratory accident with a naturally harvested strain; an accident with a naturally harvested strain modified in a laboratory; and the deliberate creation of a biological weapon. While available scientific evidence points to a natural zoonotic event as the origin of SARS-CoV-2, this paper recommends specific steps governments and scientific institutions should take to address uncertainties about the origin of the COVID-19 pandemic, as well as to make all potential causes for a pandemic less likely to produce one in the future. Immediate steps include promoting international scientific collaboration, addressing scientific misinformation and disinformation, fully implementing ‘One Health’ and reining in the illegal wildlife trade.

This CommuniVax Coalition report represents a waypoint in the COVID-19 pandemic: an opportunity to pause to mark the distance traveled, alter the course if necessary, and set out on the next part of the journey. It describes progress made toward greater equity in the COVID-19 vaccination campaign and proposes steps to advance even further. CommuniVax is a national rapid research coalition of social scientists, public health experts, healthcare providers, and community advocates, and a part of the larger community of practice that has observed and participated in the COVID-19 vaccine rollout through an equity lens.

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 onsite 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.

Since the emergence of the SARS-CoV-2 virus in late 2019, the world has been in a state of high alert and reactivity. Once the acute stage of the infectious disease crisis does abate, however, few if any communities will have a detailed roadmap to guide recovery – that is, the process of becoming whole again and working to reduce similar, future risk. In both research and policy contexts where data are absent or difficult to obtain, expert judgment can help fill the void. Between November 2019 and February 2020, we conducted an expert elicitation process, asking fourteen key informants – with specializations in infectious diseases, disaster recovery, community resilience, public health, emergency management, and policymaking – to identify the design principles, priority issues, and field experiences that should inform development of an epidemic recovery model. Participants argued that recovery from epidemics is distinct from natural disasters due to epidemics’ potential to produce effects over large areas for extended periods of time and ability to generate high levels of fear, anticipatory anxiety, and antisocial behavior. Furthermore, epidemic recovery is a complex, nonlinear process involving many domains – political, economic, sociocultural, infrastructural, and human health. As such, an adequate model of post-epidemic recovery should extend beyond strictly medical matters, specify units of interest (e.g., individual, family, institution, sector, community), capture differing trajectories of recovery given social determinants of health, and be fit for use depending upon user group (e.g., policymakers, responders, researchers). This formative study commences a longer-term effort to generate indicators for a holistic, transformative epidemic recovery at the community level.

The US Food and Drug Administration (FDA) granted Emergency Use Authorization for Pfizer-BioNTech’s mRNA COVID-19 vaccine (BNT162b2) for children 5 to 11 years of age on October 29, 2021. The Centers for Disease Control and Prevention recommended use of the vaccine among children in this age group on November 2, 2021. Approximately 28 million children are now eligible for vaccination, with only those younger than 5 years remaining excluded from vaccine eligibility. The benefits of pediatric COVID-19 vaccines are clear. Vaccinations protect children, decrease spread to families and communities, and ensure educational continuity. What do parents, practitioners, and policy makers need to know about pediatric COVID-19 vaccines?

The COVID-19 pandemic has revealed that a true, end-to-end research and development (R&D) and response ecosystem—meaning, one that develops, produces, and delivers needed vaccines to global populations in a rapid and equitable fashion—remains an elusive goal. Most low- and middle-income countries (LMICs) have been unable to acquire and administer a sufficient supply of COVID-19 vaccines, and the dearth of vaccines and limited capacity to deliver them are prolonging the pandemic and contributing to destabilizing economies and societies around the world. Multilateral initiatives, bilateral aid, and vaccine donations, though useful, have been slow to arrive and insufficient to provide adequate vaccine coverage for LMIC populations. The consequences of this deeply inequitable global response extend beyond the COVID-19 pandemic. Global initiatives to prepare for and respond to future pandemic threats cannot succeed if LMIC governments believe they will be the last to benefit from vaccines produced as a result of improvements in global disease surveillance, increased sample sharing, or expedited vaccine R&D.

The 20th anniversary of the terrorist attacks on September 11, 2001, resulted in deep national reflection. Less remembered are the events that began to unfold 7 days later as anonymous letters laced with deadly anthrax (Bacillus anthracis) spores began arriving at postal facilities, media companies, and congressional offices. The first death from inhaled anthrax exposure occurred on October 5, with an additional 4 deaths and 17 infections over the ensuing months.¹ The anthrax attacks exposed a health system ill-equipped to respond to acute emergencies.

The COVID-19 pandemic has shown that false or misleading health-related information can dangerously undermine the response to a public health crisis. These messages include the  inadvertent spread of erroneous information (misinformation) or deliberately created and propagated false or misleading information (disinformation). Misinformation and disinformation have contributed to reduced trust in medical professionals and public health responders, increased belief in false medical cures, politicized public health countermeasures aimed at curbing transmission of the disease, and increased loss of life.

The importance of infectious disease epidemic forecasting and prediction research is underscored by decades of communicable disease outbreaks, including COVID-19. Unlike other fields of medical research, such as clinical trials and systematic reviews, no reporting guidelines exist for reporting epidemic forecasting and prediction research despite their utility. We therefore developed the EPIFORGE checklist, a guideline for standardized reporting of epidemic forecasting research.

For the US, COVID-19 testing is here to stay. The White House’s “Path out of the Pandemic” announcement on September 10, 2021 calls for increased access to COVID-19 testing and testing programs, including for schools and for employees of businesses larger than 100 people who are not vaccinated.(1) To increase the availability of tests, the Defense Production Act has been invoked by the Administration to increase manufacturing, free pharmacy testing has been expanded, and home rapid antigen tests will be sold at reduced prices by major retailers. This plan is a welcomed ramp-up of testing capacity which will help address current shortages of tests and long delays in getting test results. It will be important, however, for the US government to not only address the current demands for testing but to anticipate what testing needs are likely for the future, and plan for them. Testing needs are increasing and will change—though not disappear—when cases of COVID-19 eventually decline.