Publications

A scoping literature review of learnings from the coronavirus disease 2019 (COVID-19) pandemic was commissioned by WHO to inform operational priorities for future respiratory pathogen pandemic preparedness. The learnings are grouped according to WHO’s subsystems for health emergency preparedness, response and resilience. Key takeaway messages include: 1) Preparedness works; 2) Health is everyone’s business; 3) No one is safe until everyone is safe; and 4) Response must be agile and adaptive. The review will support pandemic planners at all levels to develop and update preparedness and response plans.

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).

During the COVID-19 pandemic, countries often needed to divert their human, financial and material resources away from existing health programmes to mitigate the spread of COVID-19. There are numerous reports of global inequities in access to critical care and medical countermeasures exacerbated by the pandemic as a consequence of chronically underfunded and weakened public health systems.

Mass-gathering events are a public health challenge and have the potential to amplify the transmission of infectious diseases. During the COVID-19 pandemic, WHO and the Johns Hopkins Center for Health Security (Johns Hopkins University, Baltimore, MD, USA)—a WHO Collaborating Centre for Global Health Security—developed a global database of mass gatherings, which we continue to maintain. The purpose of this database is to monitor the planning and execution of mass-gathering events and to document the uptake of WHO-recommended policies by organisers; for example, the use of a risk-based approach.

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)

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

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 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

Serology (antibody) tests to detect previous SARS-CoV-2 infection have been in high demand from the beginning of the COVID-19 pandemic. The initial shortage of diagnostic tests coupled with asymptomatic infections led to a significant demand for serology tests to identify past infections. Despite serious limitations on the interpretation of a positive antibody test in terms of immunity to SARS-CoV-2, antibody testing was initially considered for release from social distancing, return to employment, and “immunity passports.” The regulatory approach to antibody tests was limited; manufacturers were encouraged to develop and market antibody tests without submitting validation data to the FDA. FDA guidance grew more stringent, but many poor-quality tests were already on the market—potentially inappropriately used for individual decision-making. This is a case study describing COVID-19 serology tests and the U.S. market and describes lessons learned for a future health security crisis.

Antibody tests for detecting past infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have many uses for public health decision making, but demand has largely come from individual consumers. This review focuses on the individual relevance of antibody tests: their accuracy in detecting prior infection, what past SARS-CoV-2 infection can currently infer about future immunity or possible medical sequelae, and the potential future importance of antibody tests for vaccine selection and medical screening. Given uncertainty about the antibody tests (quality, accuracy level, positive predictive value) and what those tests might indicate immunologically (durability of antibodies and necessity for protection from reinfection), seropositive test results should not be used to inform individual decision making, and antibody testing should remain a tool of public health at this time.

The Global Forum on Scientific Advances Important to the Biological Weapons Convention facilitates engagement between scientists performing cutting-edge research and States Parties delegations to the Biological Weapons Convention (BWC). The Global Forum helps the delegates become familiar with some of the rapid advances in the biological and related sciences that affect the treaty and its implementation, and it demonstrates to scientists the role of the BWC in shaping the governance of these technologies. Our efforts to inform BWC delegations on emerging and future biology and biotechnology capabilities supplement an existing portfolio of programs—including the BWC Meetings of Experts and regional science and technology workshops hosted by the InterAcademy Partnership—that work collectively to help States Parties identify and evaluate potential biological threats and develop mechanisms to allow the BWC to remain adaptive to these new capabilities. Additionally, the Global Forum supports efforts, such as model codes of conduct, to foster a culture of responsibility among the scientific community that enables researchers to pursue advanced and revolutionary capabilities while simultaneously encouraging them to account for potential risks and mitigate those effects.

This year, the Global Forum was cosponsored by the Johns Hopkins Center for Health Security and the United Nations Office for Disarmament Affairs (UNODA). The formal involvement of UNODA and the BWC Implementation Support Unit highlights the importance of addressing emerging science and technology in the context of the BWC and the commitment to facilitating engagement between scientists and policymakers to identify and understand emerging biological capabilities and risks.

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.

In the future, it may be possible for humans to manipulate entire ecosystems with little continuous input through the use of emerging biotechnologies. Gene drives are one such technology, themselves derived from nature, with the potential to make directed and highly specific modifications to the genetics of entire populations, with repercussions for whole ecosystems. While there has been extensive public analysis of the risks and benefits of gene drives for the control of malaria, which will likely be their first practical application, this report anticipates the world after that initial application.

Here we make recommendations for the responsible governance of gene drives as a used and normalized tool.

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.

Serology (antibody) tests for the SARS-CoV-2 virus have the potential to inform good public health decision making during the pandemic. This report describes potential uses of the tests, areas of uncertainty where additional research is needed, and examples from other countries now beginning to make use of these tests. The priority for the United States now is to make validated, accurate tests available to: (1) public health authorities, to conduct surveillance and to estimate the numbers of people previously infected. Should antibody tests be determined to correlate with immunity to the disease, they should then be made available to: (2) essential workers, with priority for healthcare workers and those who interact with vulnerable populations (eg, nursing home residents); and (3) individuals who may use them to assess their personal risk of becoming infected with SARS-CoV-2 (COVID-19 disease). These tests will be in high demand, and manufacturing should be scaled appropriately, but the first steps will be to ensure accuracy, validity, and comparability of available tests.

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

Since the inception of gene synthesis technologies, there have been concerns about possible misuse. Using gene synthesis, pathogens—particularly small viruses—may be assembled “from scratch” in the laboratory, evading the regulatory regimes many nations have in place to control unauthorized access to dangerous pathogens. Progress has been made to reduce these risks. In 2010, the US Department of Health and Human Services (HHS) published guidance for commercial gene synthesis providers that included sequence screening of the orders and customer screening. The industry-led International Gene Synthesis Consortium (IGSC) was formed in 2009 to share sequence and customer screening methods, and it now includes the major international gene synthesis providers among its members. Since the 2010 HHS Guidance was released, however, there have been changes in gene synthesis technologies and market conditions that have reduced the efficacy of these biosecurity protections, leading to questions about whether the 2010 HHS Guidance should be updated, what changes could make it more effective, and what other international governance efforts could be undertaken to reduce the risks of misuse of gene synthesis products. This article describes these conditions and recommends actions that governments should take to reduce these risks and engage other nations involved in gene synthesis research.

This year marks the 165th anniversary of the Broad Street cholera outbreak, which resulted in more than 500 deaths in the Soho neighborhood of London. This outbreak marked a critical turning point in both public and academic perception of disease transmission when it became known that cholera was being transmitted through a specific water pump. John Snow, a medical doctor, created a simple spot map to identify the Broad Street pump as the most likely source of the outbreak. Thus, spatial/temporal modeling became foundational in epidemiology and continues to be vital to modern outbreak investigations. Since 1854, mapping techniques and data imaging have greatly evolved in complexity, accessibility, and flexibility, such that they may be applied to a wide range of public health issues.

On December 3, 2018, the Johns Hopkins Center for Health Security convened the first annual Global Forum on Scientific Advances Important to the Biological and Toxin Weapons Convention, coinciding with the 2018 Meeting of States Parties to the Biological and Toxin Weapons Convention (BWC MSP) in Geneva, Switzerland. The forum had 2 purposes: (1) to inform States Parties’ delegations of cutting-edge biological capabilities, including the ability to engineer pathogens or more complex organisms, and (2) to build awareness of and support for international bioweapons nonproliferation norms among the scientific community. Advanced biology, engineered pathogens and other organisms, and accidental biological threats as sources of risk are of great concern to international biological nonproliferation regimes such as the BWC.