Publications

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.

We conducted semistructured interviews with health officials from 9 city or county health departments to collect the firsthand experience of public health responders. We collected data from January to October 2018 via teleconference. Key informants, whom we purposefully sampled, were senior public health officials who were directly involved in outbreak response or in preparing for potential hepatitis A outbreaks in their communities.

The use of PrEP has revolutionized the response to HIV. If this success can be replicated for other STIs — which are on a major upswing — it would be a major win in the battle against these infections. Although the evidence base is not strong, there is an important positive signal that needs to be studied more systematically to demonstrate benefit and assess the risk of antimicrobial resistance with widespread use of antibiotic-based therapies. However, it may be a feasible strategy in high-risk populations if coupled to surveillance for resistance among targeted infections. STIs such as gonorrhea, chlamydia, and syphilis have slipped out of control and having an effective pharmaceutical preventive measure could significantly diminish the force of infection and reverse the worrying trend currently occurring.

Present capacity to develop, evaluate, manufacture, distribute and administer effective medical countermeasures (e.g., vaccines, diagnostics, therapeutics) is inadequate to meet the burden of both recurrent and emerging outbreaks of infectious diseases. When such interventions are unavailable, public health measures (e.g., contact tracing, outbreak investigations, social distancing) and supportive clinical care remain the only feasible tools to slow an emerging outbreak. Decision-making under such circumstances can be greatly improved by the use of appropriate data and advanced analytics such as infectious disease modeling or machine learning. Furthermore, these analyses can guide decision-making when medical countermeasures become available, allowing them to be used in more effective ways. Data analyses already underpin public health actions such as anticipating resource requirements, refining situational awareness and monitoring control efforts^2,3,4,5. New applications of data science and statistical analyses to disease outbreaks could provide support to decision-makers during public health crises.

Advances in biotechnology in the twenty-first century, fueled in large part by the field of synthetic biology, have greatly accelerated capabilities to manipulate and re-program bacteria, viruses, and other organisms. These genetic engineering capabilities are driving innovation and progress in drug manufacturing, bioremediation, and tissue engineering, as well as biosecurity preparedness. However, biotechnology is largely dual use, holding the potential of misuse for deliberate harm along with positive applications; defenses against those threats need to be anticipated and prepared. This chapter describes the challenges of managing dual-use capabilities enabled by modern biotechnology and synthetic biology and highlights a framework tool developed by a National Academies committee to aid analysis of the security effects of new scientific discoveries and prioritization of concerns. The positive aspects of synthetic biology in preparedness are also detailed, and policy directions are highlighted for taking advantage of the positive aspects of these emerging technologies while minimizing risks.

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.

This year marks the 165th anniversary of the Broad Street cholera outbreak, which resulted in more than 500 deaths in the Soho neighborhood of London. This outbreak marked a critical turning point in both public and academic perception of disease transmission when it became known that cholera was being transmitted through a specific water pump. John Snow, a medical doctor, created a simple spot map to identify the Broad Street pump as the most likely source of the outbreak. Thus, spatial/temporal modeling became foundational in epidemiology and continues to be vital to modern outbreak investigations. Since 1854, mapping techniques and data imaging have greatly evolved in complexity, accessibility, and flexibility, such that they may be applied to a wide range of public health issues.

Research with animals presents a wide array of hazards, some of which overlap those in the in vitro research laboratory. The challenge for environmental health and safety professionals when making their recommendations and performing the risk assessment is to balance worker safety with animal safety/welfare. The care and husbandry of animals require procedures and tasks that create aerosols and involve metabolized chemicals and a variety of physical hazards that must be assessed in addition to the research related risks, all while balancing the biosecurity of the facility and NIH animal care requirements. Detailed communication between health and safety, research, and animal care teams is essential to understand how to mitigate the risks that are present and if modifications need to be made as the experiments and processes progress and change over time. Additionally, the backgrounds and education levels of the persons involved in animal research and husbandry can be quite broad; the training programs created need to reflect this. Active learning and hands-on training are extremely beneficial for all staff involved in this field. Certain areas of research, such as infectious disease research in high- and maximum-containment (biosafety level 3 and 4) facilities, present challenges that are not seen in lower containment or chemical exposure experiments. This paper reviews potential hazards and mitigation strategies and discusses unique challenges for safety at all biosafety levels.

Testing of 14 patients with acute flaccid myelitis, or AFM, showed they had antibodies against enteroviruses, especially EV-D68, in their cerebrospinal fluid at a significantly higher rate than controls, supporting “the plausibility of a link” between enterovirus infection and AFM, researchers reported in mBio.

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.

This paper considers approaches to risk and benefit assessment that could be applied to advances in the life sciences with possible “dual-use” implications for bioweapons development. The paper describes the components of scientific risk assessment and outlines existing risk assessment tools of particular relevance to the Biological Weapons Convention, including those developed by the U.S. National Science Advisory Board for Biosecurity (NSABB), Jonathan B. Tucker, and the U.S. National Academy of Sciences. Finally, it highlights additional risk management tools and discusses approaches to weighing benefits.

Since the 2014–2016 West Africa Ebola epidemic, the concept of measuring health security capacity has become increasingly important within the broader context of health systems-strengthening, enhancing responses to public health emergencies, and reducing global catastrophic biological risks. Efforts to regularly and sustainably track the evolution of health security capabilities and capacities over time – while also accounting for political, social, and environmental risks – could help countries progress toward eliminating sources of health insecurity. We sought to aggregate evidence-based principles that capture a country’s baseline public health and healthcare capabilities, its health security system performance before and during infectious disease crises, and its broader social, political, security, and ecological risk environments.

Infectious disease modeling has played a prominent role in recent outbreaks, yet integrating these analyses into public health decision-making has been challenging. We recommend establishing ‘outbreak science’ as an inter-disciplinary field to improve applied epidemic modeling.

Infectious diseases (ID) physicians play a crucial role in public health in a variety of settings. Unfortunately, much of this work is undercompensated despite the proven efficacy of public health interventions such has hospital acquired infection (HAI) prevention, antimicrobial stewardship, disease surveillance, and outbreak response. The lack of compensation makes it difficult to attract the best and the brightest to the field of infectious diseases, threatening the future of the ID workforce. This paper examines compensation data for ID physicians compared to their value in population and public health settings and suggests policy recommendations to address the pay disparities between cognitive and procedural specialties which prevents more medical students and residents from entering the field. All ID physicians should take an active role in promoting the value of the subspecialty to policymakers and influencers as well as trainees.

Measurement is a community endeavor that can enhance the ability to anticipate, withstand, and recover from a disaster, as well as foster learning and adaptation. This project’s purpose was to develop a self-assessment toolkit—manifesting a bottom-up, participatory approach—that enables people to envision community resilience as a concrete, desirable, and obtainable goal; organize a cross-sector effort to evaluate and enhance factors that influence resilience; and spur adoption of interventions that, in a disaster, would lessen impacts, preserve community functioning, and prompt a more rapid recovery. In 2016–2018, we engaged in a process of literature review, instrument development, stakeholder engagement, and local field-testing, to produce a self-assessment toolkit (or “rubric”) built on the Composite of Post-Event Well-being (COPEWELL) model that predicts post-disaster community functioning and resilience. Co-developing the rubric with community-based users, we generated self-assessment instruments and process guides that localities can more readily absorb and adapt. Applied in three field tests, the Social Capital and Cohesion materials equip users to assess this domain at different geo-scales. Chronicling the rubric’s implementation, this account sheds further light on tensions between community resilience assessment research and practice, and potential reasons why few of the many current measurement systems have been applied

Among the myriad infectious disease threats humans face from bacteria, prions, parasites, protozoa, fungi, ectoparasites, and viruses, it is viral infections that arguably constitute the biggest pandemic threat in the modern era. The replication rates and transmissibility of viruses are two major factors that underlie this threat. However, at least one additional factor plays an essential role: the lack of ‘broad-spectrum’ antiviral agents. Indeed, while bacteria can still cause substantial epidemics in parts of the world where access to clean water and/or antimicrobials is limited, the pandemic threats posed by bacteria, such as from the plague-causing Yersinia pestis, has been substantially diminished in the antibiotic era [1]. For viruses that pose epidemic risks, on the other hand, current therapeutic options are more limited.

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.

The life sciences now interface broadly with information technology (IT) and cybersecurity. This convergence is a key driver in the explosion of biotechnology research and its industrial applications in health care, agriculture, manufacturing, automation, artificial intelligence, and synthetic biology. As the information and handling mechanisms for biological materials have become increasingly digitized, many market sectors are now vulnerable to threats at the digital interface. This growing landscape will be addressed by cyberbiosecurity, the emerging field at the convergence of both the life sciences and IT disciplines. This manuscript summarizes the current cyberbiosecurity landscape, identifies existing vulnerabilities, and calls for formalized collaboration across a swath of disciplines to develop frameworks for early response systems to anticipate, identify, and mitigate threats in this emerging domain.

A mass drug administration, or MDA, of azithromycin remained effective at reducing child mortality in the 3rd year of its implementation in Niger, according to a cluster-randomized trial published in The New England Journal of Medicine.