Publications

Decision making under uncertainty can be paralyzing for any leader trying to choose the best way forward. In the COVID-19 pandemic, uncertainty is deep; while we learn more every day, information gaps—including those related to viral transmission dynamics, the human immune response, the effectiveness of public health interventions like social distancing, and the future trajectory of COVID-19 spread—continue to be barriers to leaders making evidence-based decisions about protective actions.

Continuing rapid advances in science and technology both pose potential risks and offer potential benefits for the effective implementation of the Biological Weapons Convention (BWC). The lack of commonly accepted methods for assessing relevant risks and benefits present significant challenges to building common understandings that could support policy choices. This article argues that qualitative frameworks can provide the basis to structure BWC discussions about potential risks and benefits, reveal areas of agreement and disagreement, and provide a basis for continuing dialogue. It draws on the results of a workshop held in Geneva during the 2019 BWC Meetings of Experts. A diverse group of international experts were given the opportunity to apply 2 qualitative frameworks developed specifically to assess potential biosecurity concerns arising from emerging science and technology to BWC-relevant case examples. Participants discussed how such frameworks might be adapted and put into action to help support the BWC. They also began a discussion of how a comparable framework to assess potential benefits could be developed.

The 2014-2016 West African Ebola epidemic was devastating in many respects, not least of which was the impact on healthcare systems and their health workforce. Healthcare workers—including physicians, clinical officers, nurses, midwives, and community health workers—serve on the front lines of efforts to detect, control, and stop the spread of disease. Risk mitigation strategies, including infection prevention and control (IPC) practices, are meant to keep healthcare workers safe from occupational exposure to disease and to protect patients from healthcare-associated infections. Despite ongoing IPC efforts, steady rates of both healthcare-associated and healthcare worker infections signal that these mitigation measures have been inadequate at all levels and present a potential critical point of failure in efforts to limit and control the spread of outbreaks. The fact that healthcare workers continue to be infected or are a source of infection during public health emergencies reveals a weakness in global preparedness efforts. Identification of key points of failure—both within the health system and during emergencies—is the first step to mitigating risk of exposure. A 2-pronged solution is proposed to address long-term gaps in the health system that impact infection control and emergency response: prioritization of IPC for epidemic preparedness at a global level and development and use of rapid risk assessments to prioritize risk mitigation strategies for IPC. Without global support, evidence, and systems in place to support the lives of healthcare workers, the lives of their patients and the health system in general are also at risk.

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

Globally, institutions of higher education are facing unprecedented challenges related to Coronavirus Disease (COVID-19). The resulting academic, financial, ethical, and operational questions are complex and high-stakes. The COVID-19 pandemic may represent an inflection point, fundamentally altering how we work, socialize, and learn. The authors of this toolkit collectively believe that our institutions need near-term tools to ensure continuity through this pandemic as well as methods for rethinking the basic assumptions and values of their institutions.

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.

The COVID-19 pandemic has shown the devastating potential impact of new infectious diseases on the United States and the world. More than 104,000 Americans have already died, communities are shut down, and huge economic losses are occurring here and around the world. The profound effects of this pandemic should galvanize the US Congress to do everything in its power to prevent this from happening again. There are an average of 200 epidemics requiring international response each year, and the next fast-moving, novel infectious disease pandemic—“Virus 201”—could be right around the corner.

Editor's Note, May 7, 2021: The proposed Virus 201 Program has been renamed the Disease X Medical Countermeasure Program.

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.

Plague is an infectious disease that has haunted the human species for millennia. The Justinian Plague in the 6th century and the Black Death beginning in the 14th century were civilization-shattering events, the effects of which were felt long after plague had dissipated [3]. What conferred this capacity on plague was its virulence, its transmission characteristics, and a lack of effective countermeasures, which did not appear until the 20th century.

Plague, caused by the bacterium Yersinia pestis, continues to cause disruptive and deadly outbreaks, especially in resource-limited areas. Recent outbreaks in Madagascar and Uganda have triggered domestic turmoil, large-scale antimicrobial prophylaxis of case contacts and health-care workers, and concern for international spread [4, 5].

In the future, it may be possible for humans to manipulate entire ecosystems with little continuous input through the use of emerging biotechnologies. Gene drives are one such technology, themselves derived from nature, with the potential to make directed and highly specific modifications to the genetics of entire populations, with repercussions for whole ecosystems. While there has been extensive public analysis of the risks and benefits of gene drives for the control of malaria, which will likely be their first practical application, this report anticipates the world after that initial application.

Here we make recommendations for the responsible governance of gene drives as a used and normalized tool.

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.

While many aspects of the response to the pandemic were wanting, the extraordinary global mobilisation of the scientific community is a source of hope.

The Ebola communication crisis of 2014 generated widespread fear and attention among Western news media, social media users, and members of the United States (US) public. Health communicators need more information on misinformation and the social media environment during a fear-inducing disease outbreak to improve communication practices. The purpose of this study was to describe the content of Ebola-related tweets with a specific focus on misinformation, political content, health related content, risk framing, and rumors.

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.

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?

In 2015 and 2016, outbreaks of the Zika virus began occurring in the Americas and the Caribbean. Following the introduction of this new threat, the United States’ Centers for Disease Control and Prevention (CDC) issued testing guidance for the nation’s state public health laboratories. We collected and analyzed testing guidance for all fifty states and the District of Columbia for both 2017 and 2018. In both years, state testing guidance was consistent for men and non-pregnant women, but there was notable variation in guidance for pregnant women. In addition, there were changes between the two years as testing algorithms shifted toward guidance that recommended testing in more limited circumstances. States adopted large, or complete, portions of CDC testing guidance, but were not required to conform completely, 33% of states had identical guidance in 2017 and 49% in 2018. Some of these trends, such as specifying that testing be contingent on travel, or sexual contact with an individual who has recently traveled, to an area where the Zika virus was circulating, presents a potential deficiency in the United States surveillance capacity. Understanding variations in state testing guidance enables public health professionals to better understand ongoing surveillance. This analysis provides insight into the testing practices for the various states across the country. Better understanding of how states approach Zika testing, and how that testing changes over time, will increase the public health community’s ability to interpret future Zika case counts.

Coronavirus disease 2019 (COVID-19) is a respiratory infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), first detected in early December 2019 in Wuhan, China. It has since spread throughout the world.

One measure of viral spread is the R0, the expected number of secondary infectious cases produced by a primary infectious case. This calculation is used to determine the potential for epidemic spread in a susceptible population. The effective reproduction number, Rt, determines the potential for epidemic spread at a specific time t under the control measures in place (Figure 1). To evaluate the effectiveness of public health interventions, the Rt should be quantified in different settings, ideally at regular and frequent intervals (eg, weekly).

Epidemic readiness and response command the disproportionate attention of health security decision-makers, planners, and practitioners, overshadowing recovery. How patients and their families, health organizations, community sectors, and entire societies recuperate from major outbreaks requires more systematic study and better translation into policy and guidance. To help remedy this neglected aspect of health emergency management, we offer a working definition for epidemic recovery and a preliminary model of post-epidemic recovery. Guiding this framework’s development are insights gleaned from the more mature study of post-disaster reconstruction and rehabilitation as well as recognition that post-outbreak recovery – which involves infectious disease, a biological hazard – presents challenges and opportunities distinct from events involving geological or meteorological hazards. Future work includes developing a consensus around characteristics of successful epidemic recovery, applying these metrics to support pre-incident planning for post-epidemic recovery, and using such a scheme to track and inform actual recovery from an epidemic.