Publications

This report calls out the urgent need to strengthen and build resilience in primary care (PC) whilst building cross-sector collaboration between public health (PH) and community-based organizations (CBOs).

The uniquely fragmented healthcare system of the United States is currently unable to adequately respond in a national emergency. Lessons From the COVID War: An Investigative Report documents how the US “met the 21st century COVID pandemic with structures mainly built for 19th century problems,” acknowledging that a new national health security enterprise is urgently needed. These findings are consistent with an earlier report, Integrating Primary Care and Public Health to Save Lives and Improve Practice During Public Health Crises: Lessons from COVID-19, in which the Johns Hopkins Center for Health Security at the Bloomberg School of Public Health (CHS) detailed the challenges encountered during the pandemic and presented potential pathways for effectively addressing them. Experts and frontline workers interviewed for the report indicated that better integration of primary care (PC), public health (PH), and community-based organizations (CBOs) could have eased the burden on overstretched PH personnel and significantly leveraged PC’s trusted position and reach to amplify PH messaging, including information to support ill individuals and bolster testing and vaccination campaigns. If these coordinated activities had been effectively prepared for and implemented, they would have saved lives and reduced the pandemic’s health, economic, and societal impacts in the US.

View the report (PDF)

The home healthcare worker is a unique, under-represented subgroup in healthcare research. Based on labor statistics, 87% are female and 39% lack affordable housing. Just over 50% receive some kind of public assistance and most do not have a college degree. Home healthcare workers are racially diverse and earn relatively low wages.¹ This population has high levels of vaccine hesitancy, yet close interaction with potentially at-risk individuals.^{2, 3}

A constellation of factors related to confidence, complacency, and convenience affect vaccine hesitancy.⁴ Innovative countermeasures that engage, educate, and empower diverse populations with varied beliefs, life circumstances, and means of engaging with media are needed.⁵ Personalized persuasion has proven to be effective means of motivating behavioral change,⁶ but requires a thorough understanding of sub-populations. Political discord and social divides heighten the need for highly tailored communications.⁷

We aimed to understand underlying motivations and/or behavioral inhibitions of the home healthcare population to support proactive public health outreach campaigns, and aid responses in future health crises. This study was conducted in accordance with Johns Hopkins University's Institutional Review Board.

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.

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.

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.

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.

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.

Masks and respirators have played an essential role in the response to the COVID-19 pandemic for both healthcare workers and the public. However, the masks and respirators that both healthcare workers and the public have needed to rely upon leave much to be desired. Despite drawbacks in terms of comfort and fit, the ubiquitous disposable masks and disposable N95 respirators used by the vast majority of healthcare workers have not appreciably improved since the mid-1990s. During the COVID-19 pandemic, the public has been advised to wear masks as well. Masks have long been known to be effective means of “source control” (ie, reducing transmission of respiratory droplets from the wearer to others). More recently evidence has accumulated that properly constructed and worn masks as well as respirators afford a limited but not inconsequential degree of protection to the wearer as well. Existing masks and respirators run the gamut in terms of effectiveness and wearability. In a future large-scale outbreak or pandemic, it is possible to increase the protection of healthcare workers and the public from infection through more efficient, well-fitting, and comfortable masks. The design and manufacture of better masks and respirators are possible by harnessing emerging technologies, the innovative research and development spirit evidenced since the early days of the COVID-19 pandemic, and the availability of resources to support technological innovation.

Healthcare and hospital workers providing care and support to infected patients during a pandemic are at increased risk for mental distress. Factors impacting their mental health include high risk of exposure and infection, financial insecurity due to furloughs, separation from and worries about loved ones, a stressful work environment due to surge conditions with scarce supplies, traumatic experiences due to witnessing the deaths of patients and colleagues, and other acute stressors. Finding ways for institutions to support the mental wellbeing of healthcare and hospital workers in an acute pandemic-related crisis situation is of critical importance. The factors affecting mental health are deeply connected to work-related motivation and attendance. Willingness to come to work is multifactorial and is dependent upon an individual’s self-perception of risk, as well as having the skills and resources necessary to perform work tasks given the nature of the public health emergency. Social and material support for healthcare workers in a variety of high-stress and high-risk settings is important for supporting workers’ mental health and in maintaining their commitment in challenging conditions.

National debate persists surrounding the expanded use of nurse practitioners in the emergency department. Current understanding of the alignment of nurse practitioner educational preparation and practice parameters in United States emergency departments is inchoate. The objective of this review was to seek evidence to support that nurse practitioner education and training align with current practices in the emergency department.

Seven months into the COVID-19 vaccination campaign in the United States, nearly 50% of the American population has been vaccinated. While this is a monumental accomplishment, there is still much work to do.

In the coming months, the country will face a series of vaccination challenges including serving groups with persistently low vaccine uptake (due to, for example, low/no access, vaccine hesitancy, or a combination of factors), expanding COVID-19 vaccination to children (particularly those whose parents may be less willing to vaccinate their children than to get vaccinated themselves), and orchestrating a potential booster dose campaign (with its own hesitancy issues). As the COVID-19 vaccination campaign continues, lessons from the vaccine rollout to date can help provide direction moving forward.

One of the lessons learned from the COVID-19 pandemic is the utility of an early, flexible and rapidly deployable disease screening and detection response. The largely uncontrolled spread of the pandemic in the United States exposed a range of planning and implementation shortcomings, which if they had been in place before the pandemic emerged, may have changed the trajectory. Disease screening by detection dogs show great promise as a non-invasive, efficient, and cost-effective screening method for COVID-19 infection. We explore evidence of their use in infectious and chronic diseases, the training, oversight, resources required for implementation, and potential uses in various settings. Disease detection dogs may contribute to the current and future public health pandemics; however, further research is needed to extend our knowledge and measurement of their effectiveness and feasibility as a public health intervention tool and efforts are needed ensure public and political support.

The coronavirus disease 2019 (COVID-19) pandemic has had tragic and disproportionate adverse effects on Black, Indigenous, and People of Color (BIPOC) communities across the United States. The number of cases, hospitalizations, and deaths related to this disease is significantly higher in these groups. Additionally, members of BIPOC communities are among those hit the hardest by the economic and social upheavals caused by the pandemic.

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.

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.

The COVID-19 (COVID) pandemic has led to unprecedented action and innovation in the US healthcare system; at the same time, it has presented extraordinary challenges and risks. Through dramatic augmentation of surge capacity, deferral of other services, and implementation of crisis standards of care, hospitals in many locations have been able to absorb the blow of the first peak of COVID cases and continue to provide lifesaving care to both COVID patients and others with life-threatening emergencies. But many communities are just beginning to experience the full force of the pandemic, and in every location, the healthcare response to COVID has come at a very dear price. Healthcare facilities have sustained huge financial losses, and healthcare workers’ health and well-being have been put at high risk. New standard operating procedures and work processes have been improvised, and many old lessons have had to be relearned.