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).

Integrated vaccine delivery – the linkage of routine vaccination with provision of other essential health services – is a hallmark of robust primary care systems that has been linked to equitable improvements in population health outcomes.

Large-scale epidemics in resource-constrained settings disrupt delivery of core health services, such as routine immunization. Rebuilding and strengthening routine immunization programs following epidemics is an essential step toward improving vaccine equity and averting future outbreaks. We performed a comparative case study analysis of routine immunization program recovery in Liberia and Haiti following the 2014-16 West Africa Ebola epidemic and 2010s cholera epidemic, respectively.

Following the 2001 end to negotiations on a legally binding protocol, states parties to the 1972 Biological and Toxin Weapons Convention (BWC) developed entrenched positions about the necessity of treaty verification, hindering progress on treaty aims. The study described in this article was designed to facilitate dialogue on verification-related issues outside the context of those positions, using the term “assurance” to represent the degree of certainty that states parties are meeting their treaty obligations. From August 2020 to July 2021, the researchers conducted 36 interviews—16 with state-party delegations and 20 with independent experts, representing 20 countries. They performed mixed-methods analysis on the interviews, including quantitative metrics on qualitative interview content. Interviewees’ views on verification, compliance, and related concepts varied widely. Future efforts by states parties to achieve common understanding on these topics could facilitate concrete progress. While no single mechanism is sufficient to achieve verification or assess compliance, packages of mechanisms could increase assurance. Interviewees expressed general support for implementing assurance mechanisms, even in the absence of a comprehensive, legally binding protocol or verification regime, even among states parties for which that is the primary goal. Avenues to increase assurance among BWC stakeholders merit further discussion in the current intersessional program.

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.

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On October 4 and 6, 2022, the Johns Hopkins Center for Health Security, in collaboration with the Center for Health and Economic Resilience Research at Texas State University, convened a virtual symposium to consider how to operationalize the process of holistic recovery from the COVID-19 pandemic. The purpose of the event was to advise leaders in local and state government on what strategies they might adopt and/or support to facilitate recovery of the whole person from COVID-19, reverse the societal determinants of uneven impacts, and develop resilience to future public health emergencies.

Participant discussions produced a set of strategic actions that government authorities and partners can implement now and moving forward to effect necessary repair and change when the impulse to forget and move on is strong. Speakers represented a broad range of stakeholders, including local elected officials, recovery/resilience officers, planners, public health practitioners, disaster managers, financial investors, mental health professionals, healthcare administrators, religious leaders, housing advocates, community health providers, rural health experts, food security providers, social service administrators, academic researchers, restorative justice experts, equity strategists, artists, writers, and journalists.

The ability to diagnose and screen for infection is an important component of the US COVID-19 response and is facilitated by public health laboratories (PHLs). Anecdotal media reports and limited case studies have described some of the challenges faced by PHLs during the pandemic, particularly initial challenges related to developing and deploying tests to PHLs, but there has not been a systematic evaluation of the experience of PHLs during the pandemic.

Uganda has engaged in numerous capacity building activities related to outbreak preparedness over the last two decades and initiated additional just-in-time preparedness activities after the declaration of the 2018–2020 Ebola Virus Disease (EVD) outbreak in eastern Democratic Republic of Congo (DRC). When Uganda faced importation events related to the DRC outbreak in June—August 2019, the country’s ability to prevent sustained in-country transmission was attributed to these long-term investments in preparedness. In order to help prepare countries for similar future scenarios, this analysis reviewed evidence from Uganda’s response to the June—August 2019 importation events to identify preparedness activities and capacities that may have enabled Uganda to identify and isolate infected individuals or otherwise prevent further transmission. Content from 143 grey literature documents gathered via targeted and systematic searches from June 6, 2019 to October 29, 2019 and six interviews of key informants were utilized to inform a framework evaluation tool developed for this study. A conceptual framework of Uganda’s preparedness activities was developed and evaluated against timelines of Uganda’s response activities to the June—August 2019 EVD importation events based on the applicability of a preparedness activity to a response activity and the contribution of the said response activity to the prevention or interruption of transmission. Preparedness activities related to coordination, health facility preparation, case referral and management, laboratory testing and specimen transport, logistics and resource mobilization, and safe and dignified burials yielded consistent success across both importation events while point of entry screening was successful in one importation event but not another according to the framework evaluation tool. Countries facing similar threats should consider investing in these preparedness areas. Future analyses should validate and expand on the use of the framework evaluation tool.

Many kindergarten through 12th grade (K-12) schools in the United States do not have good ventilation. This is a longstanding problem with demonstrably negative effects on student learning. We can and should act to fix this to ensure good indoor air quality for all students, educators, and school staff. During the COVID-19 pandemic, it is even more important that ventilation problems in K-12 schools be addressed now. Along with other mitigation measures, improvements in ventilation in K-12 schools can decrease the risk of SARS-CoV-2 spread.

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.

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 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.

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

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.

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