Publications

At the onset of the COVID-19 pandemic, and to this day, US state, tribal, local, and territorial health departments lacked comprehensive case investigation and contact tracing (CI/CT) guidelines that clearly define the capabilities and capacities of CI/CT programs and how to scale up these programs to respond to outbreaks. This research aims to identify the capabilities and capacities of CI/CT programs and to develop a conceptual framework that represents the relationships between these program components.

The COVID-19 pandemic illuminated the lack of resources available to US state and local public health agencies to respond to large-scale health events. Two response activities that were notably underresourced are case investigation and contact tracing (CI/CT), which health agencies routinely employ to control and prevent the transmission of infectious diseases. However, the scale of contact tracing required during the COVID-19 pandemic exceeded available resources, even in high-capacity public health agencies

Prior to 2020, most pandemic preparedness efforts centered on influenza. Some countries, such as Aotearoa (New Zealand)¹, were able to successfully adapt national pandemic influenza plans to the response to COVID-19, and global influenza surveillance systems were harnessed for SARS-CoV-2 (ref. ²). It is now critical that nations and the international community implement lessons learned from COVID-19 back into influenza preparedness³. This task is particularly urgent given both the emergence of a number of influenza spillover threats and exhausted and depleted public health systems globally.

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.

High quality epidemic forecasting and prediction are critical to support response to local, regional and global infectious disease threats. Other fields of biomedical research use consensus reporting guidelines to ensure standardization and quality of research practice among researchers, and to provide a framework for end-users to interpret the validity of study results. The purpose of this study was to determine whether guidelines exist specifically for epidemic forecast and prediction publications.

In response to the protracted Ebola virus outbreak in the Democratic Republic of Congo, the international public health community called for increased attention, coordination, and resources to support the response. The use of real-time modeling and analytics to support public health decision-making (also known as “outbreak science”) has been an important capability that has grown during previous outbreaks [1–3]. Despite the informative role that infectious disease models played in the recent DRC outbreak [4–7], cross-talk within the infectious disease modeling community and between infectious disease modelers and model stakeholders, such as health agencies, may be limited. Lack of communication can reduce the potential use of modeling capability to inform outbreak prevention and mitigation strategies. For example, mathematical modelers may not be aware of questions that would be particularly useful for guiding the response, such as the location and staffing of Ebola treatment units. On the other end, public health teams may not be aware of outbreak features that may signal improvement or worsening of incidence or increased potential for spatial spread.

The human and social toll of the coronavirus disease 2019 (COVID-19) pandemic has already spurred several major public health “lessons learned,” and the theme of effective and responsible scientific communication is among them. We propose that Twitter has played a fundamental—but often precarious—role in permitting real-time global communication between scientists during the COVID-19 epidemic, on a scale not seen before. Here, we discuss 3 key facets to Twitter-enabled scientific exchange during public health emergencies, including some major drawbacks. This discussion also serves as a succinct primer on some of the pivotal epidemiological analyses (and their communication) during the early phases of the COVID-19 outbreak, as seen through the lens of a Twitter feed.

As of February 2021, 3 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants of concern with worrisome characteristics have emerged, each on a different continent. The B.1.1.7 variant, first identified in the United Kingdom, is substantially more transmissible than previously circulating variants. The B.1.351 and P.1 variants, first identified in South Africa and Brazil, respectively, both exhibit some degree of immune escape. Each of these variants has precipitated resurgences in the communities where they have become dominant. All 3 have already been identified at low levels in the United States. If they gain a foothold, the same resurgences can be expected here.

For many children in the United States, the 2020 school year is beginning online, presenting a difficult set of challenges to keep kids learning. The importance of schools goes far beyond the academic benefits of in-person instruction. Schools provide meals, access to health services, and a safe space for students to develop social and emotional skills. Prolonged school closures can jeopardize access to these resources, particularly for the most vulnerable students. School closures also affect parents and guardians. More than 41 million adults were a care provider for a child under the age of 18 in the United States in 2018. During the Covid-19 pandemic, the care of children for many of these adults has collided with work. A survey of working parents in May and June by Northeastern University reported that 13% of the 2,557 participants had to reduce their working hours or leave work entirely to compensate for the loss of childcare availability due to school and childcare closures. Those still working reported an average of eight working hours of the week lost to childcare needs.

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.

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.

Most elementary schools, middle schools, and high schools across the United States have been closed since March in an effort to reduce the spread of COVID-19. Schools that are able to do so have replaced classroom education with remote learning, using a range of tools and approaches. As of the publication of this report, governors from most US states have recommended or ordered that schools remain closed for the remainder of this academic year, affecting more than 50 million public school students. While a few schools may reopen before the end of the current school year, most schools, students, and their families in the United States are now facing uncertainty about whether or how schools will resume for in-class learning in the fall.

This operational toolkit has been developed to help business owners who are considering reopening or expanding their operations to determine their establishments’ risk of transmission of COVID-19 and how to reduce it.

As displayed in the figure below, the Operational Toolkit consists of 3 parts: an instruction manual; a business risk worksheet; and an assessment calculator.

As some governments begin to lift strict public health measures and move into the next phase of their outbreaks of COVID-19, local, state, and federal authorities are planning for the gradual reopening of businesses and resumption of economic activity. While planning for a staged approach to business resumption must be coordinated by local, state, and federal authorities, individual organizations should start planning for how they will restart or expand their operations so that modification and mitigation measures will already be in place when work can resume and the new ”business as usual” can commence.

This operational toolkit allows business leaders to work through a 4-stage process to obtain an overall risk score for their business and to identify considerations for reducing both operational and individual level risks posed by COVID-19. The overall score represents the inherent risk of exposure to COVID-19 that may occur in a business and possible changes to daily operations and policies that can lower the inherent risk of exposure. This toolkit is intended to provide businesses with a starting point in their planning to reopen or expand their operations by identifying their risk levels for contributing to the spread of COVID-19 and providing them with a list of mitigation measures to implement that will increase the safety of their employees, clients, customers, and community. 

The 3 parts of the Operational Toolkit include:

1. An Instruction Manual (PDF)
   Instructions that explain how to complete the 4-stage Business Risk Worksheet and Assessment Calculator.
    
2. A Business Risk Worksheet (PDF)
   A 4-stage step-by-step worksheet for you to report and understand your business’s overall risk of spreading COVID-19 and how your business operations can be made safer.
    
3. An Assessment Calculator (XLSX)
   An Excel spreadsheet you will fill out to receive a calculated risk score and a modification score.

In the 2 months after the first report of 4 cases of atypical pneumonia in Wuhan, China, on December 27, 2019,¹ the cumulative number of confirmed cases of coronavirus disease 2019 (COVID-19) in the city rose to 49 122, with 2195 deaths by the end of February 2020.² On January 23, Wuhan city shut down in response to the quickly evolving epidemic. All public transportation within, to, and from the city was suspended, and residents were barred from leaving. An estimated 9 million people remained in the city after the lockdown.³ Strict social distancing measures were also implemented, including the compulsory wearing of face masks in public.

Recent experiences during a variety of disease outbreaks, ranging from Ebola to influenza, have underscored the potential for epidemics to have an impact on daily life, even for those who are not themselves infected.^1,2 In severe situations, epidemics or pandemics can even affect overall community functioning. For example, a rapidly expanding pandemic can result in shuttered schools, cancelled events, food insecurity, and social distrust in communities.

As the COVID-19 pandemic continues to progress, most jurisdictions have implemented physical distancing measures to reduce further transmission, which have contributed to reductions in numbers of new cases. As chains of transmission begin to decline, along with new COVID-19 cases, there will need to be decisions at the state level about how to transition out of strict physical distancing measures and into a phased reopening

While health-care providers have used incentives in an attempt to motivate patients to obtain vaccinations, their effect on vaccination rates has not been systematically evaluated on a large scale. In this study, we examined whether mobile applications may improve population vaccination rates through enhanced communication and incentives education. Our study is the first randomized controlled trial assessing the effect of large-scale messaging combined with individualized incentives on influenza-vaccination rates. In this trial, we delivered messages regarding influenza vaccinations to 50,286 adults, aged 18 through 65, then compared the subsequent vaccination rate, the effectiveness of the message content and the timing. Multiple rounds of messaging occurred over a seven-week period during the 2016 flu season, after which vaccination rates were observed for one week. Participants were randomly assigned to one of three messaging approaches: conspicuous (highlighting the amount of rewards to be received for obtaining a flu shot); generic (promoting vaccinations with no mention of rewards); or no-message. Evidence of vaccination obtainment was indicated by medical and pharmacy claims, augmented by patients self-reporting through the mobile wellness app during the study period. Of the people assigned to receive messaging, 23.2% obtained influenza vaccination, compared to 22.0% of people who obtained vaccination in the no-messaging control arm. This difference was statistically significant (p < 0.01). The research revealed that messaging effectiveness decreased after each successive batch sent, suggesting that most participants responsive to messaging would become activated immediately after receiving one alert. Interestingly, in this large-scale study, there were no significant differences between conspicuous incentives and generic messaging, suggesting an important area for future research.

The immediate priorities of our national efforts to address the COVID-19 epidemic are appropriately aimed at suppressing chains of transmission through community-wide measures like stay-in-place orders and at surging hospital capacity to expand our ability to care for the rising number of sick patients. At the same time that we confront the current crisis, we must plan for the future by putting in place tools to enhance our ability to conduct effective surveillance, containment, and case management. As incidence of COVID-19 declines, case-based interventions will again become an option. Building those capabilities now will enable us to move beyond the extreme and disruptive physical isolation measures in place across the United States.

This report provides a road map for navigating through the current COVID-19 pandemic in the United States. It outlines specific directions for adapting our public-health strategy as we limit the epidemic spread of COVID-19 and are able to transition to new tools and approaches to prevent further spread of the disease. We outline the steps that can be taken as epidemic transmission is brought under control in different regions. These steps can transition to tools and approaches that target those with infection rather than mitigation tactics that target entire populations in regions where transmission is widespread and not controlled. We suggest measurable milestones for identifying when we can make these transitions and start reopening America for businesses and families.

The use of infectious disease modeling to support public health decision making, referred to in this report as “outbreak science,” has increased in prominence in the past decade. It has been used in the responses to several major outbreaks, from severe acute respiratory syndrome (SARS) in 2003, to H1N1 influenza in 2009, to the 2 most recent Ebola outbreaks in West Africa (2014-2016) and the Democratic Republic of the Congo (2018-current).