Publications

COVID-19 has revealed what many public health practitioners have known for some time: our nation's disjointed and underfunded public health system lacks the ability to mount a coordinated response against novel epidemic threats. Our failure to invest in our nation's state and local governmental public health infrastructure, as well as key federal programs, risks a large loss of life from future infectious disease threats, and during crises, jeopardizes the economy and the normal functioning of society.

Among the most pressing issues in preparing for the global response to a pandemic are the design, development, manufacture, and dissemination of vaccines. In 2018 and 2019, we conducted 48 interviews with prominent leaders in public health, pandemic preparedness, vaccine design, and vaccine manufacturing about how they would respond to a sudden, urgent need to manufacture 2 billion or more doses of vaccine. Little did we know that this scenario would become a dire global challenge a few months later with the onset of COVID-19. The response to this pandemic has shown that when leading vaccine manufacturers are fully engaged in a global response, it might be possible for them to manufacture substantial doses of vaccine on timelines faster than previously envisioned. It is now hoped that hundreds of millions of doses of vaccine will start to be produced sometime in the end of 2020 or the start of 2021, and that billions of doses of vaccine could be produced in the months that follow. Whether these timelines can be met or not, it is crucial now, while the world is fully attuned to the terrible consequences of pandemics, to begin preparing the system of global manufacturing for future pandemics. The following insights and recommendations are taken from our interviews with leading experts and our own analysis.

Effective communication during epidemics and outbreaks is a critical component of a public health response. Even more than usual, people need accurate information so that they can adapt their behavior and protect themselves, their families, and their communities against infection, onward transmission, and death. However, during an epidemic or pandemic, the communication environment can be complicated by an “infodemic,” which is the rapid, large-scale spread of health information and misinformation through a variety of media and informational channels.¹ This overabundance of information—some accurate and some not—makes it difficult for people to differentiate between false and true information, and has been particularly challenging to address during the ongoing coronavirus disease 2019 (COVID-19) pandemic. Addressing infodemics is a new and centrally important challenge to responding to acute health events. Given its global scale and rapid spread, the current COVID-19 infodemic is an important opportunity to find and adapt new preparedness and response tools to manage the information ecosystem in which we live.

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 coronavirus disease 2019 (COVID-19) pandemic has had tragic and disproportionate adverse effects on Black, Indigenous, and People of Color (BIPOC) communities across the United States. The number of cases, hospitalizations, and deaths related to this disease is significantly higher in these groups. Additionally, members of BIPOC communities are among those hit the hardest by the economic and social upheavals caused by the pandemic.

This article examines the current state of the life sciences in the Russian Federation, which has potential health-security and biosecurity implications. Research involving advanced biotechnologies present opportunities for public-health advancement, but their dual-use capabilities raise biosecurity concerns that carry global economic and security implications. While experts have raised such concerns about possible Russian misuse of biotechnologies, Russia is not a top-tier nation for life sciences research, by many metrics. A better understanding of the current landscape of biotechnology and life-science research and investment in the Russian Federation will help to identify potential areas of concern and opportunities for international scientific engagement. This work builds on the substantial legacy of Raymond A. Zilinskas in his work to describe and analyze biodefense and biosecurity concerns in the Russian Federation and the Soviet Union.

The US/EU collaboration on health and health security issues has been steadily productive for years. Whether it was working together to support the World Health Organization, standing up the Global Health Security Agenda (GHSA) in 2014, or responding to the Ebola crisis in West Africa in 2014, health security problems have been in existence long before the COVID-19 pandemic, and fruitful cooperation between the US and EU has helped minimize threats and advance health. In the last four years, however, the US has stepped away from international cooperation on health security issues with the EU as well as other partners.

Recent advances have allowed the genomes of the severe acute respiratory syndrome coronavirus2 (SARS-CoV-2) – the causative agent of COVID-19 – to be sequenced within hours or days of a case being identified. As a result, for the first time, genomic sequencing in real time has been able to inform the public health response to a pandemic. Metagenomic sequencing was fundamental to the detection and characterization of the novel pathogen. Early sharing of SARS-CoV-2 genome sequences allowed molecular diagnostic assays to be developed rapidly, which improved global preparedness, and contributed to the design of countermeasures. Rapid, large-scale virus genome sequencing is contributing to understanding the dynamics of viral epidemics and to evaluating the efficacy of control measures. Increased recognition that viral genome sequencing can contribute to improving public health is driving more laboratories to invest in this area. However, the cost and work involved in gene sequencing are substantial, and laboratories need to have a clear idea of the expected public health returns on this investment. This document provides guidance for laboratories on maximizing the impact of SARS-CoV-2 sequencing activities now and in the future.

While there is consensus for the use of personal protective equipment and other measures for the prevention of transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in high-risk situations, such as aerosol-generating medical procedures, there is a divergence of opinion and enthusiasm for measures such as social distancing, cloth masks, and other recommendations in low-risk situations. The insights of epidemiologist Geoffrey Rose¹ on sick and high-risk populations may be helpful. In its simplest form, his concept can be explained as follows: the high-risk subpopulation—such as elderly people with preexisting cardiac or pulmonary conditions—may contribute a lesser share to the outcome (eg, infection, death) than a low-risk subpopulation would. This is simply because of the sheer larger number of persons in the low-risk subpopulation. Consider, for example, a population of 1,000 persons, with 100 in a high-risk subpopulation and 900 in a low-risk subpopulation, and a rate of infection 4 times as high in the high-risk subpopulation as in the low-risk subpopulation; their rates of infection are 20% and 5%, respectively. In this hypothetical scenario, the high-risk subpopulation contributes 20 cases to the outcome compared to 45 cases from the low-risk subpopulation.

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, in the words of Tedros Adhanom Ghebreyesus, the director general of the World Health Organization (WHO), “is a once-in-a-century health crisis.” Indeed, the last public health emergency to wreak such havoc was the great influenza pandemic that began in 1918, which sickened about a third of the world’s population and killed at least 50 million people. But because global conditions are becoming increasingly hospitable to viral spread, the current pandemic is unlikely to be the last one the world faces this century. It may not even be the worst.

Biology can be misused, and the risk of this causing widespread harm increases in step with the rapid march of technological progress. A key security challenge involves attribution: determining, in the wake of a human-caused biological event, who was responsible. Recent scientific developments have demonstrated a capability for detecting whether an organism involved in such an event has been genetically modified and, if modified, to infer from its genetic sequence its likely lab of origin. We believe this technique could be developed into powerful forensic tools to aid the attribution of outbreaks caused by genetically engineered pathogens, and thus protect against the potential misuse of synthetic biology.

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.

In 2019, the US Centers for Disease Control and Prevention (CDC) reported the largest number of measles cases since 1992. Thirty-one states reported a total of 1282 cases.1 Rising measles incidence increases the likelihood that state and local health departments across the US will have to respond to an outbreak of this disease in the future.

Given the social and economic upheavals caused by the COVID-19 pandemic, political leaders, health officials, and members of the public are eager for solutions. One of the most promising, if they can be successfully developed, is vaccines. While the technological development of such countermeasures is currently underway, a key social gap remains. Past experience in routine and crisis contexts demonstrates that uptake of vaccines is more complicated than simply making the technology available. Vaccine uptake, and especially the widespread acceptance of vaccines, is a social endeavor that requires consideration of human factors. To provide a starting place for this critical component of a future COVID-19 vaccination campaign in the United States, the 23-person Working Group on Readying Populations for COVID-19 Vaccines was formed. One outcome of this group is a synthesis of the major challenges and opportunities associated with a future COVID-19 vaccination campaign and empirically-informed recommendations to advance public understanding of, access to, and acceptance of vaccines that protect against SARS-CoV-2. While not inclusive of all possible steps than could or should be done to facilitate COVID-19 vaccination, the working group believes that the recommendations provided are essential for a successful vaccination program.

Since its recognition as a pandemic in early 2020, novel coronavirus disease 2019 (COVID-19) has touched nearly every corner of US society. However, some populations and environments have been affected far more severely than others. Vulnerable populations—especially those subject to structural racism, discrimination due to disability, and financial insecurity—tend also to be particularly susceptible to the economic consequences of and severe disease and death from COVID-19. In addition, the institutions, industries, and systems that are fundamentally important to our lives and our democracy have, in some cases, become places where severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spreads readily if allowed to gain a foothold. In these places, it can be difficult to prevent the introduction of the virus or control the spread of SARS-CoV-2 once it is introduced.

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.

Infectious disease outbreaks pose major threats to human health and security. Countries with robust capacities for preventing, detecting and responding to outbreaks can avert many of the social, political, economic and health system costs of such crises. The Global Health Security Index (GHS Index)—the first comprehensive assessment and benchmarking of health security and related capabilities across 195 countries—recently found that no country is sufficiently prepared for epidemics or pandemics. The GHS Index can help health security stakeholders identify areas of weakness, as well as opportunities to collaborate across sectors, collectively strengthen health systems and achieve shared public health goals. Some scholars have recently offered constructive critiques of the GHS Index’s approach to scoring and ranking countries; its weighting of select indicators; its emphasis on transparency; its focus on biosecurity and biosafety capacities; and divergence between select country scores and corresponding COVID-19-associated caseloads, morbidity, and mortality. Here, we (1) describe the practical value of the GHS Index; (2) present potential use cases to help policymakers and practitioners maximise the utility of the tool; (3) discuss the importance of scoring and ranking; (4) describe the robust methodology underpinning country scores and ranks; (5) highlight the GHS Index’s emphasis on transparency and (6) articulate caveats for users wishing to use GHS Index data in health security research, policymaking and practice.

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.