Publications

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

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.

As public health professionals around the world work tirelessly to respond to the COVID-19 pandemic, it is clear that traditional methods of contact tracing need to be augmented in order to help address a public health crisis of unprecedented scope. Innovators worldwide are racing to develop and implement novel public-facing technology solutions, including digital contact tracing technology. These technological products may aid public health surveillance and containment strategies for this pandemic and become part of the larger toolbox for future infectious outbreak prevention and control.

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.

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.

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.

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

In order to save lives, reduce COVID-19’s burden on our healthcare system, ease strict social distancing measures, and confidently make progress toward returning to work and school, the United States must implement a robust and comprehensive system to identify all COVID-19 cases and trace all close contacts of each identified case. It is estimated that each infected person can, on average, infect 2 to 3 others. This means that if 1 person spreads the virus to 3 others, that first positive case can turn into more than 59,000 cases in 10 rounds of infections.

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).

The coronavirus disease 2019 (COVID-19) pandemicpresents countries with major political, scientific, and public health challenges. Pandemic preparedness and reducing risk of global spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are key concerns. Mass gathering (MG) eventspose considerable public health challenges to health authorities and governments. Historically, sporting, religious, music, and other MGs have been the source of infectious diseases that have spread globally. However, the scale of the problem has declined over the years as better public health measures have been implemented at MGs in response to the World Health Assembly's endorsement on Dec 22, 2011, of the 130th Executive Board Decision “Global mass gatherings: implications and opportunities for global health security” that encompassed joint planning, enhancement of health infrastructures, and taking proper pre-emptive and preventive measures to control infectious diseases on an international scale. Since then, many MGs have been held safely and successfully without any major communicable disease issues arising, even for MG events held during three WHO declared Public Health Emergencies of International Concern: the Vancouver 2010 Winter Olympics and the 2010 FIFA World Cup in South Africa during the H1N1 influenza pandemic; the 2015 Africa Cup of Nations Football tournament in Equatorial Guinea during the outbreak of Ebola virus disease; and the Rio 2016 Olympics during the Zika virus outbreak.

Clade X was a day-long pandemic tabletop exercise conducted by the Johns Hopkins Center for Health Security on May 15, 2018, in Washington, DC. In this report, we briefly describe the exercise development process and focus principally on the findings and recommendations that arose from this project.

Clade X was a day-long pandemic tabletop exercise conducted by the Johns Hopkins Center for Health Security on May 15, 2018, in Washington, DC. Many details of the exercise are available online, including videos, background documents, and fact sheets.In this report, we briefly describe the exercise development process and focus principally on the findings and recommendations that arose from this project.

Vaccines are the cornerstone of the management of an infectious disease outbreak and are the surest means to defuse pandemic and epidemic risk. The faster a vaccine can be deployed, the faster an outbreak can be extinguished. To date, however, the pharmaceutical response to emerging infectious diseases and bioterrorism has been characterized by a “one bug, one drug” approach, in which specific medical countermeasures—effective vaccines and therapeutics—are developed, manufactured, and deployed. This is a process that is often measured in decades.

On July 26, 2019, the workshop “Biosafety and Biosecurity in the Era of Synthetic Biology: Meeting the Challenges in China and the U.S.”, co-hosted by Johns Hopkins Center for Health Security and Tianjin University Centre for Biosafety Research & Strategy, was held in Washington, D.C. of the United States. The goal of this workshop was to bring technical and policy experts from China and the U.S., as well as experts from Europe, together to develop a mutual understanding of each country’s current governance structures and to begin a dialogue on what is required to promote global biosafety and biosecurity.

From April 29 to May 1, 2019, the Johns Hopkins Center for Health Security and the Thailand Ministry of Public Health’s Department of Disease Control co-hosted a meeting of the Southeast Asia Strategic Multilateral Biosecurity Dialogue in Phuket, Thailand. This dialogue began in 2014 as a bilateral Track II dialogue between Singapore and the United States and expanded the following year to include Indonesia and Malaysia. The Philippines and Thailand were added as observers in 2017, and they became full participants starting with this year’s meeting. The purpose of this dialogue is to examine biological risks facing the United States and the Southeast Asia region—including natural, accidental, and deliberate. This dialogue aims to facilitate cross-border and regional engagement and collaboration and identify novel solutions and share best practices in combatting priority threats.

This report examines the current state of preparedness for pandemics caused by “high-impact respiratory pathogens”—that is, pathogens with the potential for widespread transmission and high observed mortality. Were a high-impact respiratory pathogen to emerge, either naturally or as the result of accidental or deliberate release, it would likely have significant public health, economic, social, and political consequences. Novel high-impact respiratory pathogens have a combination of qualities that contribute to their potential to initiate a pandemic. The combined possibilities of short incubation periods and asymptomatic spread can result in very small windows for interrupting transmission, making such an outbreak difficult to contain. The potential for high-impact respiratory pathogens to affect many countries at once will likely require international approaches different from those that have typically occurred in geographically limited events, such as the ongoing Ebola crisis in Democratic Republic of the Congo (DRC).

On July 26, 2019, researchers, policymakers, and other stakeholders gathered at the St. Regis Hotel in Washington, DC, for a day-long dialogue on safety and security in an era of synthetic biology. The meeting, co-sponsored by the Johns Hopkins Center for Health Security and Tianjin University Centre for Biosafety Research and Strategy, drew more than 100 attendees and featured speakers from China, Europe, and the United States.

The United States and China are at the forefront of research and investment in synthetic biology. As leading countries in this rapidly evolving field, they have a responsibility to work together to promote safety and security. The goal of this meeting was to bring representatives from China and the United States together to develop a mutual understanding of each country’s current governance structures and to begin a dialogue on what is required to promote global safety and security. This report recounts the meeting’s activities and shares several key themes derived from the presentations and conversations of the day.

Predicting which pathogen will confer the highest global catastrophic biological risk (GCBR) of a pandemic is a difficult task. Many approaches are retrospective and premised on prior pandemics; however, such an approach may fail to appreciate novel threats that do not have exact historical precedent. In this paper, based on a study and project we undertook, a new paradigm for pandemic preparedness is presented. This paradigm seeks to root pandemic risk in actual attributes possessed by specific classes of microbial organisms and leads to specific recommendations to augment preparedness activities.

On July 16, the Johns Hopkins Center for Health Security and Ginkgo Bioworks convened a meeting in Washington, DC, to solicit stakeholder input on specific ways that national policy can strengthen the US bioeconomy. For the purposes of this meeting, the bioeconomy was defined broadly as the economy built on biotechnology. There currently is no consensus on a definition of bioeconomy, but most accept that it encompasses parts of the energy, agriculture, medical, industrial, and defense sectors. The aims of the meeting were to consider the benefits to the US if its bioeconomy were to be expanded; examine the current health of the US bioeconomy; discuss existing US government programs, policies, and initiatives related to the bioeconomy; and identify priorities for strengthening the US bioeconomy.

In February 2019, the Johns Hopkins Center for Health Security (“the Center”) hosted a dialogue on biosecurity between senior experts and leaders from the United States and the Republic of India. The purposes of this dialogue are to increase knowledge of prevention and response efforts for natural, deliberate, and accidental biological threats in India and the United States; to look for new synergies and share best practices and innovations; to examine opportunities for partnership and collaboration; to develop and deepen relationships between dialogue participants; and to identify issues that may warrant being brought to the attention of the Indian or US government.