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 COVID-19 pandemic may serve as a prime example of a 21st century public health emergency, an event accelerated and amplified by global interconnectedness, systemic fragility, and public misinformation. However, the United States continues to address this and other threats with distinctly 20th century information tools. This must change. Health emergency preparedness for modern threats requires rapid situational awareness, achieved only through common data elements, enforced information standards, investment in innovation, expert data analysis, and private sector engagement. To protect the health and safety of Americans, we must confront these challenges now and change the narrative of our future responses.

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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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.

Masks and respirators have played an essential role in the response to the COVID-19 pandemic for both healthcare workers and the public. However, the masks and respirators that both healthcare workers and the public have needed to rely upon leave much to be desired. Despite drawbacks in terms of comfort and fit, the ubiquitous disposable masks and disposable N95 respirators used by the vast majority of healthcare workers have not appreciably improved since the mid-1990s. During the COVID-19 pandemic, the public has been advised to wear masks as well. Masks have long been known to be effective means of “source control” (ie, reducing transmission of respiratory droplets from the wearer to others). More recently evidence has accumulated that properly constructed and worn masks as well as respirators afford a limited but not inconsequential degree of protection to the wearer as well. Existing masks and respirators run the gamut in terms of effectiveness and wearability. In a future large-scale outbreak or pandemic, it is possible to increase the protection of healthcare workers and the public from infection through more efficient, well-fitting, and comfortable masks. The design and manufacture of better masks and respirators are possible by harnessing emerging technologies, the innovative research and development spirit evidenced since the early days of the COVID-19 pandemic, and the availability of resources to support technological innovation.

COVID-19 has fundamentally challenged the delivery of health care services across the world, forcing difficult choices on health professionals and laying bare many preexisting health, medical, and public health sector frailties. Extreme shortages of key resources and worries that patients would not receive the care they needed were frequent features of the response beginning in the spring of 2020 and were recurrent during subsequent regional and national peaks.

The coronavirus disease 2019 pandemic may require rationing of various medical resources if demand exceeds supply. Theoretical frameworks for resource allocation have provided much needed ethical guidance, but hospitals still need to address objective practicalities and legal vetting to operationalize scarce resource allocation schemata. To develop operational scarce resource allocation processes for public health catastrophes, including the coronavirus disease 2019 pandemic, five health systems in Maryland formed a consortium—with diverse expertise and representation—representing more than half of all hospitals in the state. Our efforts built on a prior statewide community engagement process that determined the values and moral reference points of citizens and health-care professionals regarding the allocation of ventilators during a public health catastrophe. Through a partnership of health systems, we developed a scarce resource allocation framework informed by citizens’ values and by general expert consensus. Allocation schema for mechanical ventilators, ICU resources, blood components, novel therapeutics, extracorporeal membrane oxygenation, and renal replacement therapies were developed. Creating operational algorithms for each resource posed unique challenges; each resource’s varying nature and underlying data on benefit prevented any single algorithm from being universally applicable. The development of scarce resource allocation processes must be iterative, legally vetted, and tested. We offer our processes to assist other regions that may be faced with the challenge of rationing health-care resources during public health catastrophes.

Hospitals across the United States must take immediate action to save lives and fairly allocate limited resources by implementing crisis standards of care (CSC).

Hospitals are experiencing large surges in COVID-19 patients, and intensive care units are already over capacity in many areas. In response, hospitals are canceling admissions and procedures, augmenting staffing, transferring patients, even establishing and operating alternate care sites. But these actions may not be enough. There will come a point in the crisis when these adaptations cannot compensate for the overwhelming caseload. At this point, hospitals must shift to crisis standards of care. This means making unprecedented and agonizing decisions under great uncertainty in order to do the most good possible with limited resources. The tools and publications on this page are intended to help health care providers and public officials plan for the implementation of CSC.

This document was authored by Dan Hanfling, John Hick, Rick Hunt, and Eric Toner, drawing on evidence-based reports from the Institute of Medicine (now National Academy of Medicine).

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.

Recent infectious disease outbreaks, including the ongoing global COVID-19 pandemic and Ebola in the Democratic Republic of the Congo, have demonstrated the critical importance of resilient health systems in safeguarding global health security. Importantly, the human, economic and political tolls of these crises are being amplified by health systems’ inabilities to respond quickly and effectively. Improving resilience within health systems can build on pre-existing strengths to enhance the readiness of health system actors to respond to crises, while also maintaining core functions. Using data gathered from a scoping literature review, interviews with key informants and from stakeholders who attended a workshop held in Dhaka, Bangladesh, we developed a Health System Resilience Checklist (‘the checklist’). The aim of the checklist is to measure the specific capacities, capabilities and processes that health systems need in order to ensure resilience in the face of both infectious disease outbreaks and natural hazards. The checklist is intended to be adapted and used in a broad set of countries as a component of ongoing processes to ensure that health actors, institutions and populations can mount an effective response to infectious disease outbreaks and natural hazards while also maintaining core healthcare services. The checklist is an important first step in improving health system resilience to these threats, but additional research and resources will be necessary to further refine and prioritise the checklist items and to pilot the checklist with the frontline health facilities that would be using it. This will help ensure its feasibility and durability for the long-term within the health systems strengthening and health security fields.

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.

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.

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.

Coronavirus disease 2019 (COVID-19) is on the verge of being declared a pandemic. As of 7 March 2020, a total of 423 cases and 19 deaths, including several non–travel-related cases, areas of sustained community transmission, and a nursing home outbreak, have been reported (). Best-case estimates suggest that COVID-19 will stress bed capacity, equipment, and health care personnel in U.S. hospitals in ways not previously experienced (). How can health systems prepare to care for a large influx of patients with this disease?

Stark gaps exist between projected health needs in a pandemic situation and the current capacity of health care and medical countermeasure systems. Existing pandemic ethics discussions have advocated to engage the public in scarcity dilemmas and attend the local contexts and cultural perspectives that shape responses to a global health threat. This public engagement study thus considers the role of community and culture in the ethical apportionment of scarce health resources, specifically ventilators, during an influenza pandemic. It builds upon a previous exploration of the values and preferences of Maryland residents regarding how a finite supply of mechanical ventilators ought to be allocated during a severe global outbreak of influenza. An important finding of this earlier research was that local history and place within the state engendered different ways of thinking about scarcity.

Sustained spread of SARS-CoV-2 has happened in major US cities. Capacity needs in Chinese cities could inform the planning of local healthcare resources.

In late December 2019, a cluster of unexplained cases of viral pneumonia occurred in Wuhan, China.1 This initial cluster of patients with what soon became known as coronavirus disease 2019 (COVID-19) heralded the arrival of a new pandemic caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). To date, close to 90 000 cases have occurred in more than 60 countries with approximately 3000 deaths. The World Health Organization (WHO) has declared these events a Public Health Emergency of International Concern.

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.

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.