Publications

This report outlines a number of trends that are facilitating advances in different areas of the life sciences, including immunology, neuroscience, human genetics and reproductive science, agriculture and infectious disease. Research and development in these fields is overwhelmingly undertaken for peaceful purposes and potentially provides many benefits to society, the global economy, and future generations. However, the same areas of research raise a number of ethical, legal, safety and security concerns, including concerns that developments therein could feed into of new forms of biological weapons with different and potentially more damaging effects to those of the past.

The COVID-19 pandemic will continue for the foreseeable future, but widespread vaccination could hasten its end. At least 165 candidate vaccines for the SARS CoV-2 virus are in development around the world and there is hope that one or more of these candidates will soon be shown to be sufficiently safe and effective to achieve emergency use authorization in the United States. When a vaccine has been authorized for use, it will initially be in limited supply. During this period of scarcity, a plan is needed for how to allocate and distribute the limited supply—which groups should be prioritized to receive the vaccine first and which groups can wait until later. This difficult and potentially contentious topic is being actively discussed in the United States by the Advisory Committee on Immunization Practices (ACIP) of the US Centers for Disease Control and Prevention (CDC) and the National Academy of Medicine (NAM), as well as globally at the World Health Organization (WHO) and elsewhere. The purpose of this report is to offer an additional ethics framework for use in making decisions about allocation of SARS-CoV-2 vaccine during this initial period of scarcity in the United States and make related suggestions about vaccine distribution. Our approach takes into account considerations of medical risk, public health, ethics and equity, economic impact, and logistics. We note where our approach aligns or differs from the 2018 CDC guidance for vaccine allocation in a severe influenza pandemic, which is the most recent pandemic vaccine guidance from the US government.

On 21 January, California took a major step to increase biosecurity in commercial gene synthesis, introducing legislation that requires all scientists purchasing gene synthesis products to use companies that perform screening on customers and the sequences they order. If enacted, this legislation would make it a competitive advantage for companies to take biosecurity seriously. Here, we argue that the US federal government and other governments should emulate California’s actions.

Enterotoxigenic E. coli (ETEC) and Shigella are enteropathogens causing significant global morbidity and mortality, particularly in low-income countries. No licensed vaccine exists for either pathogen, but candidates are in development, with the most advanced candidates potentially approaching pivotal efficacy testing within the next few years.

To curb the spread of disease and open the economy, the U.S. must implement a national strategy to increase testingof both symptomatic and asymptomatic people while ensuring timely test results. For people with COVID-19 symptoms and people in close contact with known cases, highly accurate laboratory diagnostic tests (“PCR” tests) are required, with results turned around in 24-48 hours to allow effective contact tracing. Better support is also needed for people who face difficulties in isolating if they test positive. For people without symptoms, we also need broad availability of more rapid but sometimes less accuratescreening tests (involving a number of test platforms including pooled PCR, "antigen" tests, and other point-of-care tests) to detect outbreaks sooner and give people more confidence in their workplaces and schools. This is particularly important for high-risk populations such as nursing homes, essential workplaces, and hard-hit communities that currently have limited resources for testing. Financial support for test recipients is needed because screening tests are generally not covered by insurance. Guidance from regulators and public health authorities will also be required on how to use these tests effectively. These tools are needed to control transmission and facilitate safer reopening of schools and workplaces.

Recent infectious disease outbreaks, including the ongoing global COVID-19 pandemic and Ebola in the Democratic Republic of the Congo, have demonstrated the critical importance of resilient health systems in safeguarding global health security. Importantly, the human, economic and political tolls of these crises are being amplified by health systems’ inabilities to respond quickly and effectively. Improving resilience within health systems can build on pre-existing strengths to enhance the readiness of health system actors to respond to crises, while also maintaining core functions. Using data gathered from a scoping literature review, interviews with key informants and from stakeholders who attended a workshop held in Dhaka, Bangladesh, we developed a Health System Resilience Checklist (‘the checklist’). The aim of the checklist is to measure the specific capacities, capabilities and processes that health systems need in order to ensure resilience in the face of both infectious disease outbreaks and natural hazards. The checklist is intended to be adapted and used in a broad set of countries as a component of ongoing processes to ensure that health actors, institutions and populations can mount an effective response to infectious disease outbreaks and natural hazards while also maintaining core healthcare services. The checklist is an important first step in improving health system resilience to these threats, but additional research and resources will be necessary to further refine and prioritise the checklist items and to pilot the checklist with the frontline health facilities that would be using it. This will help ensure its feasibility and durability for the long-term within the health systems strengthening and health security fields.

Community resilience is a community’s ability to maintain functioning (ie, delivery of services) during and after a disaster event. The Composite of Post-Event Well-Being (COPEWELL) is a system dynamics model of community resilience that predicts a community’s disaster-specific functioning over time. We explored COPEWELL’s usefulness as a practice-based tool for understanding community resilience and to engage partners in identifying resilience-strengthening strategies. In 2014, along with academic partners, the New York City Department of Health and Mental Hygiene organized an interdisciplinary work group that used COPEWELL to advance cross-sector engagement, design approaches to understand and strengthen community resilience, and identify local data to explore COPEWELL implementation at neighborhood levels. The authors conducted participant interviews and collected shared experiences to capture information on lessons learned. The COPEWELL model led to an improved understanding of community resilience among agency members and community partners. Integration and enhanced alignment of efforts among preparedness, disaster resilience, and community development emerged. The work group identified strategies to strengthen resilience. Searches of neighborhood-level data sets and mapping helped prioritize communities that are vulnerable to disasters (eg, medically vulnerable, socially isolated, low income). These actions increased understanding of available data, identified data gaps, and generated ideas for future data collection. The COPEWELL model can be used to drive an understanding of resilience, identify key geographic areas at risk during and after a disaster, spur efforts to build on local metrics, and result in innovative interventions that integrate and align efforts among emergency preparedness, community development, and broader public health initiatives.

The impact of the COVID-19 pandemic in the United States has been profound. Despite initial declines in cases in May 2020 following implementation of stringent stay-at-home orders, cases are resurging in most states. The number of deaths has been rising in many states, with hospitalization rates for COVID-19 now again matching or exceeding numbers seen at the peak in New York City in March and April. Hospitals are under pressure or approaching a crisis in many places around the country. This resurgence is stressing many sectors of society, from businesses to education to health care. Unlike many countries in the world, the United States is not currently on course to get control of this epidemic. It’s time to reset.

This brief report describes concrete policy actions at the federal, state, and local levels that are needed to get control of the COVID-19 pandemic in the United States.

The Johns Hopkins Center for Health Security, a World Health Organization (WHO) Collaborating Centre on Global Health Security, has worked with WHO on the development of various tools and technical guidance for mass gatherings in the context of COVID-19. The primary aim of this partnership is to encourage stakeholders to use a risk-informed decision-making process when planning for mass gatherings and, specifically, to identify and mitigate the risk of spreading COVID-19 during the mass gathering. This process includes conducting risk assessments to determine the overall risk of disease spread connected to a mass gathering.

In view of the current COVID-19 pandemic, WHO, with the support of the Center and other members of the Novel Coronavirus-19 Mass Gatherings Expert Group, has developed a series of risk assessment tools and other resources for generic as well as sports- and religious-specific mass gatherings. These risk assessment tools include a risk evaluation, mitigation, and communication strategy to aid host countries and organizers of mass gatherings in assessing the specific risk of COVID-19 to their event. A training course has also been created that provides a brief overview of mass gathering planning during COVID-19 and walks users through the use of the risk assessment tools.

Resources for mass gathering planning in the context of COVID-19 can be found at the following link after selecting “COVID-19: Mass Gatherings” from the drop down menu.

Mass Gathering Risk Assessment Tools

1. WHO Mass Gathering COVID-19 Risk Assessment Tool – Generic Events (revised July 10, 2020). Link / Excel Tool
2. WHO Mass Gathering COVID-19 Risk Assessment Tool – Sports Events (revised July 10, 2020). Link / Excel Tool
3. WHO Mass Gathering COVID-19 Risk Assessment Tool – Religious Events (revised July 10, 2020). Link / Excel Tool

This report considers human factors in relation to future vaccines against the novel coronavirus (SARS-CoV-2), drawing on insights from design thinking and the social, behavioral, and communication sciences. It provides recommendations—directed to both US policymakers and practitioners, as well as nontraditional partners new to public health’s mission of vaccination—on how to advance public understanding of, access to, and acceptance of vaccines that protect against COVID-19.

The Kivu Ebola epidemic began on August 1, 2018, when four cases were confirmed in North Kivu Province in eastern Democratic Republic of the Congo (DRC). ¹ To date, the epidemic has led to over 3,400 confirmed and suspected cases in the DRC and over 2,200 deaths. Because there is frequent movement from North Kivu across the border into Uganda, including a regular influx of refugees, the Ugandan government and its partners put themselves on high alert and mobilized resources to prevent the importation of cases, detect imported disease quickly, contain the spread of imported disease, and treat sick people appropriately.

Exemplars in Global Health uses standardized methods to pinpoint countries that outperformed peers in key health outcomes, beyond what would be expected from their economic growth. Guided by global and in-country experts, we also consider geographic diversity, data availability, and research feasibility to select Exemplar candidates. We then conduct further research and analysis to validate our initial assessment. Learn more.

Before an infectious disease outbreak of any size can be addressed and before illness can be treated, it must be first be identified through the diagnosis of cases. Diagnostic testing is a mainstay of not only clinical medicine but also epidemiologic investigation. Limitations surrounding access to diagnostic testing have dominated much of the current response to COVID-19 and highlight the need to have more rapid, convenient, and equitable access to testing. Looking ahead, through the increasing diffusion of health technology to consumers and patients, it is becoming more feasible for diagnostic testing to be placed in the hands of the patient. Such tests when used to diagnose infectious disease, and coupled to information technology, could have a transformative benefit for future pandemic response.

The Johns Hopkins Center for Health Security conducted this study to develop an expert assessment of the promise and challenges posed by at home infectious diagnostic technologies. A major aim of this study is to inform pandemic preparedness activities that rely on diagnostic technologies and determine how at home approaches can integrate with and augment the existing diagnostic paradigm.

The lack of radiation knowledge among the general public continues to be a challenge for building communities prepared for radiological emergencies. This study applied a multi-criteria decision analysis (MCDA) to the results of an expert survey to identify priority risk reduction messages and challenges to increasing community radiological emergency preparedness.

This document describes the value of serosurveys (antibody studies) for SARS-CoV-2 infections, the different methods by which they can be performed, and the resources required to produce actionable information. It provides recommendations for the US government and states for performing these studies and deriving value from them.

Decision making under uncertainty can be paralyzing for any leader trying to choose the best way forward. In the COVID-19 pandemic, uncertainty is deep; while we learn more every day, information gaps—including those related to viral transmission dynamics, the human immune response, the effectiveness of public health interventions like social distancing, and the future trajectory of COVID-19 spread—continue to be barriers to leaders making evidence-based decisions about protective actions.

Continuing rapid advances in science and technology both pose potential risks and offer potential benefits for the effective implementation of the Biological Weapons Convention (BWC). The lack of commonly accepted methods for assessing relevant risks and benefits present significant challenges to building common understandings that could support policy choices. This article argues that qualitative frameworks can provide the basis to structure BWC discussions about potential risks and benefits, reveal areas of agreement and disagreement, and provide a basis for continuing dialogue. It draws on the results of a workshop held in Geneva during the 2019 BWC Meetings of Experts. A diverse group of international experts were given the opportunity to apply 2 qualitative frameworks developed specifically to assess potential biosecurity concerns arising from emerging science and technology to BWC-relevant case examples. Participants discussed how such frameworks might be adapted and put into action to help support the BWC. They also began a discussion of how a comparable framework to assess potential benefits could be developed.

The 2014-2016 West African Ebola epidemic was devastating in many respects, not least of which was the impact on healthcare systems and their health workforce. Healthcare workers—including physicians, clinical officers, nurses, midwives, and community health workers—serve on the front lines of efforts to detect, control, and stop the spread of disease. Risk mitigation strategies, including infection prevention and control (IPC) practices, are meant to keep healthcare workers safe from occupational exposure to disease and to protect patients from healthcare-associated infections. Despite ongoing IPC efforts, steady rates of both healthcare-associated and healthcare worker infections signal that these mitigation measures have been inadequate at all levels and present a potential critical point of failure in efforts to limit and control the spread of outbreaks. The fact that healthcare workers continue to be infected or are a source of infection during public health emergencies reveals a weakness in global preparedness efforts. Identification of key points of failure—both within the health system and during emergencies—is the first step to mitigating risk of exposure. A 2-pronged solution is proposed to address long-term gaps in the health system that impact infection control and emergency response: prioritization of IPC for epidemic preparedness at a global level and development and use of rapid risk assessments to prioritize risk mitigation strategies for IPC. Without global support, evidence, and systems in place to support the lives of healthcare workers, the lives of their patients and the health system in general are also at risk.

In the aftermath of severe acute respiratory syndrome (SARS) outbreak, the WHO fundamentally revised the International Health Regulations (IHR), which entered into force in 2007. The 196 States Parties to the IHR recognised that certain public health events pose a significant risk to the global community and should be designated as a Public Health Emergency of International Concern (PHEIC). Under Article I of the IHR, a PHEIC is defined by three criteria: an extraordinary event which ‘constitute[s] a public health risk to other States through international spread of disease and…potentially require[s] a coordinated international response.’ The IHR (Annex 2) provides a ‘decision instrument’ that guides States Parties as to which health events have the potential to become PHEICs, thus requiring reporting to WHO. [Annex 2 of the IHR provides a decision instrument for States Parties to assess which events detected by national surveillance systems would require notification to the WHO. This includes a single case of smallpox, poliomyelitis due to wild-type poliovirus, human influenza caused by a new subtype and SARS. Other health events that have the potential to cause international public health concerns or serious impact trigger an algorithm to determine if notification to WHO is required. Criteria for this algorithm include determining if the event is serious, unusual or unexpected, has a significant risk of international spread, or poses a significant risk of international travel or trade restrictions. If two of the criteria are true, then notification to WHO is required under the IHR]. The IHR also empowers the WHO Director-General (DG) to convene an Emergency Committee (EC) which consists of international experts brought together on an ad-hoc basis. The EC provides their advice on whether the current situation should be considered a PHEIC, and what Temporary Recommendations should be given to Member States to bolster the response and control the outbreak. Ultimately, however, the WHO DG has sole authority to declare a PHEIC and make Temporary Recommendations for Member States to follow.¹

Globally, institutions of higher education are facing unprecedented challenges related to Coronavirus Disease (COVID-19). The resulting academic, financial, ethical, and operational questions are complex and high-stakes. The COVID-19 pandemic may represent an inflection point, fundamentally altering how we work, socialize, and learn. The authors of this toolkit collectively believe that our institutions need near-term tools to ensure continuity through this pandemic as well as methods for rethinking the basic assumptions and values of their institutions.

The rapid evolution and spread of the COVID-19 pandemic have revealed insufficiencies in the US health system to respond to a public health emergency, resulting in healthcare worker infections and deaths.¹ Nurses have played and will continue to play a pivotal role in the response, yet compelling evidence from nurses in the field reveals a lack of access to personal protective equipment; inadequate knowledge and skills related to pandemic response; a lack of decision rights as they relate to workflow redesign, staffing decisions, and allocation of scarce resources; and a fundamental disconnect between frontline nurses and nurse executives and hospital administrators. These issues were brought to light in a recent survey conducted by the American Nurses Association, which found that 87% of nurses fear going to work, 36% have cared for an infectious patient without having adequate personal protective equipment (PPE), and only 11% felt well-prepared to care for a COVID-19 patient.² The efforts put forth by frontline nurses in caring for patients and ensuring the sustainability of health system operations during the COVID-19 pandemic, despite these challenges, is inspiring. However, there is a critical and compelling need to identify and understand the gaps and inadequacies in the US health system that have contributed to a lack of pandemic readiness, both within and outside of the nursing workforce, including in emergency planning and the procurement and allocation of resources such as PPE and ventilators.