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)

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.

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.

To understand operational challenges involved with responding to US measles outbreaks in 2017–19 and identify applicable lessons in order to inform preparedness and response operations for future outbreaks, particularly with respect to specific operational barriers and recommendations for outbreak responses among insular communities.

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.

Candida auris infections continue to occur across the United States and abroad, and healthcare facilities that care for vulnerable populations must improve their readiness to respond to this emerging organism. We aimed to identify and better understand challenges faced and lessons learned by those healthcare facilities who have experienced C. auris cases and outbreaks to better prepare those who have yet to experience or respond to this pathogen.

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.

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 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 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.

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.

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.

Long-term care facilities, including skilled nursing facilities, nursing homes, and assisted living facilities, house some of the nation’s most at-risk populations for morbidity and mortality related to COVID-19 infection. Residents of these facilities require frequent interactions with staff such as for assistance with personal care (i.e. feeding, bathing, dressing), which increases the risk for transmission of COVID-19. Additionally, residents often have underlying medical conditions that put them at increased risk for severe complications if they become infected (1).

The global reach of infectious disease pandemics typically necessitates a similarly ubiquitous public health intervention: mass vaccination. The development and large-scale deployment of a vaccine requires substantial investment and a coalition of stakeholders to undertake research and development (including phase I to III clinical trials), manufacturing, and widespread administration. Recent efforts by national and international funders and researchers to advance the state of vaccinology for pandemics and other infectious disease emergencies have focused largely on expediting the R&D phase1. There has been comparatively less attention paid to modernizing, optimizing, and therefore accelerating other aspects of the vaccine enterprise—namely, manufacturing, distribution, and administration. The current COVID-19 pandemic plainly underscores the need to vastly accelerate mass vaccination in every phase.

Currently, there are approximately 2.3 million people detained behind bars in the U.S., including 21,142 people in Maryland state prisons and Baltimore city jails (1,2).

As evidenced by a surge of cases in jails and prisons across the country (for instance, Rikers Island Jail in NYC, Cook County Jail in Chicago, a federal prison in Louisiana, and others) and by prior infectious epidemics spreading in prisons and jails, institutions of incarceration are environments where COVID-19 is likely spread rapidly; furthermore, many incarcerated individuals have chronic health conditions and other risk factors that put them at risk for more severe disease. As of April 9, 57 COVID-19 cases have been reported by the Maryland Department of Public Safety and Correctional Services, a more than threefold increase in 5 days (3). These numbers-- which only reflect those in DPSCS custody (state prisoners and people in the Baltimore City jail system) but not local jails-- can be expected to increase as they have in other jurisdictions.

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

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).