Publications

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 postepidemic recovery. Guiding this framework’s development are insights gleaned from the more mature study of postdisaster reconstruction and rehabilitation as well as recognition that postoutbreak 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 preincident planning for postepidemic recovery, and using such a scheme to track and inform actual recovery from an epidemic.

Long-term care facilities, including skilled nursing facilities, nursing homes, and assisted living facilities, house some of the nation’s most at-risk populations for morbidity and mortality related to COVID-19 infection. Residents of these facilities require frequent interactions with staff such as for assistance with personal care (i.e. feeding, bathing, dressing), which increases the risk for transmission of COVID-19. Additionally, residents often have underlying medical conditions that put them at increased risk for severe complications if they become infected (1).

Serology (antibody) tests for the SARS-CoV-2 virus have the potential to inform good public health decision making during the pandemic. This report describes potential uses of the tests, areas of uncertainty where additional research is needed, and examples from other countries now beginning to make use of these tests. The priority for the United States now is to make validated, accurate tests available to: (1) public health authorities, to conduct surveillance and to estimate the numbers of people previously infected. Should antibody tests be determined to correlate with immunity to the disease, they should then be made available to: (2) essential workers, with priority for healthcare workers and those who interact with vulnerable populations (eg, nursing home residents); and (3) individuals who may use them to assess their personal risk of becoming infected with SARS-CoV-2 (COVID-19 disease). These tests will be in high demand, and manufacturing should be scaled appropriately, but the first steps will be to ensure accuracy, validity, and comparability of available tests.

Recent experiences during a variety of disease outbreaks, ranging from Ebola to influenza, have underscored the potential for epidemics to have an impact on daily life, even for those who are not themselves infected.^1,2 In severe situations, epidemics or pandemics can even affect overall community functioning. For example, a rapidly expanding pandemic can result in shuttered schools, cancelled events, food insecurity, and social distrust in communities.

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.

Currently, there are approximately 2.3 million people detained behind bars in the U.S., including 21,142 people in Maryland state prisons and Baltimore city jails (1,2).

As evidenced by a surge of cases in jails and prisons across the country (for instance, Rikers Island Jail in NYC, Cook County Jail in Chicago, a federal prison in Louisiana, and others) and by prior infectious epidemics spreading in prisons and jails, institutions of incarceration are environments where COVID-19 is likely spread rapidly; furthermore, many incarcerated individuals have chronic health conditions and other risk factors that put them at risk for more severe disease. As of April 9, 57 COVID-19 cases have been reported by the Maryland Department of Public Safety and Correctional Services, a more than threefold increase in 5 days (3). These numbers-- which only reflect those in DPSCS custody (state prisoners and people in the Baltimore City jail system) but not local jails-- can be expected to increase as they have in other jurisdictions.

This article describes implementation considerations for Ebola-related monitoring and movement restriction policies in the United States during the 2013–2016 West Africa Ebola epidemic.

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

While health-care providers have used incentives in an attempt to motivate patients to obtain vaccinations, their effect on vaccination rates has not been systematically evaluated on a large scale. In this study, we examined whether mobile applications may improve population vaccination rates through enhanced communication and incentives education. Our study is the first randomized controlled trial assessing the effect of large-scale messaging combined with individualized incentives on influenza-vaccination rates. In this trial, we delivered messages regarding influenza vaccinations to 50,286 adults, aged 18 through 65, then compared the subsequent vaccination rate, the effectiveness of the message content and the timing. Multiple rounds of messaging occurred over a seven-week period during the 2016 flu season, after which vaccination rates were observed for one week. Participants were randomly assigned to one of three messaging approaches: conspicuous (highlighting the amount of rewards to be received for obtaining a flu shot); generic (promoting vaccinations with no mention of rewards); or no-message. Evidence of vaccination obtainment was indicated by medical and pharmacy claims, augmented by patients self-reporting through the mobile wellness app during the study period. Of the people assigned to receive messaging, 23.2% obtained influenza vaccination, compared to 22.0% of people who obtained vaccination in the no-messaging control arm. This difference was statistically significant (p < 0.01). The research revealed that messaging effectiveness decreased after each successive batch sent, suggesting that most participants responsive to messaging would become activated immediately after receiving one alert. Interestingly, in this large-scale study, there were no significant differences between conspicuous incentives and generic messaging, suggesting an important area for future research.

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 immediate priorities of our national efforts to address the COVID-19 epidemic are appropriately aimed at suppressing chains of transmission through community-wide measures like stay-in-place orders and at surging hospital capacity to expand our ability to care for the rising number of sick patients. At the same time that we confront the current crisis, we must plan for the future by putting in place tools to enhance our ability to conduct effective surveillance, containment, and case management. As incidence of COVID-19 declines, case-based interventions will again become an option. Building those capabilities now will enable us to move beyond the extreme and disruptive physical isolation measures in place across the United States.

This report provides a road map for navigating through the current COVID-19 pandemic in the United States. It outlines specific directions for adapting our public-health strategy as we limit the epidemic spread of COVID-19 and are able to transition to new tools and approaches to prevent further spread of the disease. We outline the steps that can be taken as epidemic transmission is brought under control in different regions. These steps can transition to tools and approaches that target those with infection rather than mitigation tactics that target entire populations in regions where transmission is widespread and not controlled. We suggest measurable milestones for identifying when we can make these transitions and start reopening America for businesses and families.

This strategy aims to slow transmission of the novel coronavirus and interrupt its spread. In metropolitan areas where cases are increasing, this strategy should delay and reduce the peak number of cases. In metropolitan areas where case numbers may be stable or declining, this strategy should accelerate the decline, creating more opportunities for decisions to relax social distancing policies.

The recommendations will require significant resources for implementation. Metropolitan areas should consider establishing public-private partnerships to coordinate and support this work.

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.

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.

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.

Effective communication about medical countermeasures—including drugs, devices and biologics—is often critical in emergency situations. Such communication, however, does not just happen. It must be planned and prepared for. One mechanism to develop communication strategies is through the use of prospective scenarios, which allow readers the opportunity to rehearse responses while also weighing the implications of their actions. This article describes the development of such a scenario: The SPARS Pandemic 2025-2028. Steps in this process included deciding on a timeframe, identifying likely critical uncertainties, and then using this framework to construct a storyline covering both the response and recovery phases of a fictional emergency event. Lessons learned from the scenario development and how the scenario can be used to improve communication are also discussed.