Publications

Nursing is the largest health profession, with nearly 4 million providers practicing across acute, primary, and public health care settings. In response to the pandemic, nursing schools halted on-site course delivery and redesigned programs to attenuate risks to students and faculty. Key challenges faced by schools included financial cutbacks, rapid increases in online learning technology, maintaining student academic progression, disruption to clinical learning opportunities, and meeting accreditation standards, while addressing the stress and loss experienced by faculty, staff, and students. Despite challenges, nursing organizations provided guidance for decision making, new learning resources, and faculty development opportunities. Schools of nursing leveraged their resources to redesign nursing curricula, strengthen partnerships for student clinical experiences, and address needs of the community.

Nursing education will look different from its prepandemic profile in the future. Lessons learned during the pandemic point to gaps in nursing education, particularly related to disaster and public health preparedness, health equity, and technology. The American Association of Colleges of Nursing’s new Essentials—standards for professional nursing education—were finalized during the pandemic and reflect these lessons. The need for nurse scientists to conduct emergency response research was made evident. The importance of strong academic–practice partnerships was highlighted for rapid communication, flexibility, and responses to dynamic environments. For the future, nursing education and practice must collaborate to ensure that students and practicing nurses are prepared to address emergencies and pandemics, as well as the needs of vulnerable populations.

The COVID-19 pandemic has brought forth a number of biotechnological advances to enhance the public's health: new diagnostic tests, mRNA vaccines, and new antiviral medications. Biotechnology is also being used to address global challenges like climate change, food insecurity, and building the bioeconomy, which directly or indirectly improve public health. Gene drives are one such biotechnology. They are genetically engineered systems that can alter the inheritance patterns in a host species, such as a mosquito, so that a greater percentage of its progeny inherit a specific desired trait. Research and investments in biotechnology have been used to reduce arthropod-borne infectious diseases, such as malaria and Zika, and to manage or eliminate invasive species.² Funding thus far has been adequate. For example, Target Malaria, a global consortium of researchers developing a gene drive to decrease the burden of malaria, has an average of US$11.5 million per year in funding.³ Although no gene drive has been released into the environment yet, technologies with similar attributes have been released in field trials, notably by Oxitec in Florida.⁴

Monkeypox is a rare viral infection that is thought to typically spread from close person-to-person contact through large respiratory droplets, direct contact with skin lesions or bodily fluids, or indirect contact via contaminated clothing or linens. Symptoms include fever and chills, headache, muscle aches, swollen lymph nodes, and a rash similar to chickenpox that can spread throughout the body and notably on the palms of the hands.

Uganda has engaged in numerous capacity building activities related to outbreak preparedness over the last two decades and initiated additional just-in-time preparedness activities after the declaration of the 2018–2020 Ebola Virus Disease (EVD) outbreak in eastern Democratic Republic of Congo (DRC). When Uganda faced importation events related to the DRC outbreak in June—August 2019, the country’s ability to prevent sustained in-country transmission was attributed to these long-term investments in preparedness. In order to help prepare countries for similar future scenarios, this analysis reviewed evidence from Uganda’s response to the June—August 2019 importation events to identify preparedness activities and capacities that may have enabled Uganda to identify and isolate infected individuals or otherwise prevent further transmission. Content from 143 grey literature documents gathered via targeted and systematic searches from June 6, 2019 to October 29, 2019 and six interviews of key informants were utilized to inform a framework evaluation tool developed for this study. A conceptual framework of Uganda’s preparedness activities was developed and evaluated against timelines of Uganda’s response activities to the June—August 2019 EVD importation events based on the applicability of a preparedness activity to a response activity and the contribution of the said response activity to the prevention or interruption of transmission. Preparedness activities related to coordination, health facility preparation, case referral and management, laboratory testing and specimen transport, logistics and resource mobilization, and safe and dignified burials yielded consistent success across both importation events while point of entry screening was successful in one importation event but not another according to the framework evaluation tool. Countries facing similar threats should consider investing in these preparedness areas. Future analyses should validate and expand on the use of the framework evaluation tool.

Veterinary and animal care workers perform critical functions in biosecurity and public health, yet little has been done to understand the unique needs and barriers these workers face when responding during a pandemic crisis. In this article, we evaluated the perceived risks and roles of veterinary and animal care workers during the COVID-19 pandemic and explored barriers and facilitators in their readiness, ability, and willingness to respond during a pandemic. We deployed a survey targeting US veterinary medical personnel, animal shelter and control workers, zoo and wildlife workers, and other animal care workers. Data were collected on respondents' self-reported job and demographic factors, perceptions of risk and job efficacy, and readiness, ability, and willingness to respond during the pandemic. We found that leadership roles and older age had the strongest association with decreased perceived risk and improved job efficacy and confidence, and that increased reported contact level with others (both coworkers and the public) was associated with increased perceived risk. We determined that older age and serving in leadership positions were associated with improved readiness, willingness, and ability to respond. Veterinary and animal care workers' dedication to public health response, reflected in our findings, will be imperative if more zoonotic vectors of SARS-CoV-2 arise. Response preparedness in veterinary and animal care workers can be improved by targeting younger workers not in leadership roles through support programs that focus on improving job efficacy and confidence in safety protocols. These findings can be used to target intervention and training efforts to support the most vulnerable within this critical, yet often overlooked, workforce.

In October 2020, David Cutler and Lawrence H. Summers published a brief article in JAMA Viewpoint estimating that COVID-19 would cost the United States $16 trillion dollars, when combining economic damages and monetized health and life loss. This figure has been extensively cited and used in policy discussions. In this article, we update their estimate, using facts about the disease and its costs to society that have become known since their paper was published. 

We find that the total harms of COVID-19 to the U.S. are still about $16 trillion (with a range of $10 trillion and $22 trillion) but the components of harm are significantly different than those estimated by Cutler & Summers. The pandemic caused less economic damage than they projected, but more mental health damage.

On February 8 and 9, 2022, the Johns Hopkins Center for Health Security co-hosted a virtual dialogue session with the Regional Centre for Biotechnology of the Department of Biotechnology in the Indian Ministry of Science and Technology. The meeting focused on successes, challenges, opportunities, and lessons learned in the COVID-19 responses in India and the United States, and how COVID-19 responses can continue while also preparing for future health security crises.

The dialogue focused on COVID-19 developments that occurred since the last meeting in January 2021. Discussions centered around national response efforts, mass vaccination, surveillance approaches, causes and biosecurity implications of COVID-19 misinformation and disinformation, synthetic biological risks, global biosecurity governance, and the need for future collaboration among countries and within the scientific community.

The meeting convened senior thought leaders, scientists, public health practitioners, and medical experts from the United States and India. In accordance with the dialogue format, participants offered insights based on personal expertise and did not represent the government of either country in an official capacity.

On December 14 and 16, 2021, the Johns Hopkins Center for Health Security held a second virtual meeting of the Southeast Asia Strategic Multilateral Biosecurity Dialogue. The ongoing impacts of the COVID-19 pandemic, including health risks as well as quarantine requirements and other travel restrictions, necessitated hosting the meeting virtually. Additionally, many of our dialogue participants play important roles in their country’s COVID-19 response, which makes it difficult for them to take time away from work for travel. In order to maintain the relationships that are so critical to the success of this dialogue and to share lessons from national-level COVID-19 response activities, we held a second virtual meeting, which built on the topics and challenges discussed in our previous meeting in February 2021.¹

Ventilation is of primary concern for maintaining healthy indoor air quality and reducing the spread of airborne infectious disease, including COVID-19. In addition to building-level guidelines, increased attention is being placed on room-level ventilation. However, for many universities and schools, ventilation data on a room-by-room basis are not available for classrooms and other key spaces. We present an overview of approaches for measuring ventilation along with their advantages and disadvantages. We also present data from recent case studies for a variety of institutions across the United States, with various building ages, types, locations, and climates, highlighting their commonalities and differences, and examples of the use of this data to support decision making.

People who inject drugs often have a higher prevalence of risk factors associated with coronavirus disease 2019 (COVID-19) infection and associated morbidity and mortality, compounded by challenges in health care access. This increased vulnerability underscores the critical need to prioritize people who inject drug in ongoing COVID-19 vaccination efforts. Co-location of syringe services, COVID-19 vaccination services, and other communicable disease testing has proved an effective model to provide necessary interventions without creating additional barriers. Here, we describe a partnership between the Baltimore City Health Department, Johns Hopkins Mobile Vaccine Unit, and the Center for Infectious Disease and Nursing Innovation at the Johns Hopkins School of Nursing to provide COVID-19 vaccination, HIV and sexually transmitted infection testing, wound care, and linkage to care services co-located with a long-running syringe services program. We describe the services offered by each partner and lessons learned from this community-based co-location of services initiative.

Scientists have explored gene drive technologies with the aim of controlling vector-borne diseases, including malaria, which killed an estimated 386,000 people in 2019.¹ Gene drives are genetic modifications that can be used to create populations where a particular gene is passed from a parent organism to its offspring at a higher rate than would be expected under natural inheritance conditions.² For example, mosquitoes that transmit malaria may be modified with a gene drive so that surviving offspring inherit and spread a gene that inhibits or alters the mosquitoes' infection potential. The drive would spread over subsequent generations, resulting in limited malaria transmission. Other gene drive strategies are designed to dramatically reduce the population of the carrying organism, such as a mosquito. Due to the broad-acting and potentially irreversible nature of these tools, current regulations may not be sufficient to mitigate the unique risks posed by gene drive technologies.³

On December 31, 2019, the World Health Organization (WHO) Country Office in China reported novel “viral pneumonias of unknown cause” in Wuhan, but China did not confirm case clusters until January 3, 2020. Two years later, more than 285 million cases and 5.4 million deaths have been reported. As of December 2021, more than 800 000 COVID-19 deaths have occurred in the US, surpassing the 675 446 total deaths that occurred during the great influenza pandemic of 1918. The COVID-19 pandemic reduced global economic growth by an estimated 3.2% in 2020, with trade declining by 5.3%; an estimated 75 million people entered extreme poverty, with 80 million more undernourished compared with prepandemic levels.¹ Although the COVID-19 and 1918 influenza pandemics stand alone in morbidity and mortality, evidence suggests the frequency of infectious disease emergencies will increase. What lessons does COVID-19 teach to advance preparedness, detection, and response?

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.

The Global Health Security Index benchmarks countries’ capacities to carry out the functions necessary to prevent, detect and respond to biological threats. The COVID-19 pandemic served as an opportunity to evaluate whether the Index contained the correct array of variables that influence countries’ abilities to respond to these threats; assess additional variables that may influence preparedness; and examine how the impact of preparedness components change during public health crises.

The 2021 Global Health Security (GHS) Index finds that despite significant steps taken by countries to respond to the COVID-19 pandemic, all countries remain dangerously unprepared to meet future epidemic and pandemic threats. Importantly, countries now have a more acute understanding of what this lack of preparedness means for their health and prosperity. This understanding presents an opportunity to convert high levels of political awareness about pandemics to long-term gains in preparedness by sustaining newly developed tools and building out additional capacities to better protect lives and livelihoods against the next pandemic.

Much is at stake. Countries continue to suffer harm from the COVID-19 pandemic as a result of insufficient health security capacity. This lack of capacity comes at a time when political and security risks have increased in nearly all countries, and enduring financial investment necessary to sustain capacities has yet to be demonstrated. Such weaknesses leave a world acutely vulnerable to future health emergencies, including those potentially more devastating than COVID-19.

These are sobering conclusions revealed by the 2021 GHS Index. With data captured during a period when countries wrestled with COVID-19,¹ researchers used a revised framework and updated data collection to glean hard truths about pandemic preparedness while assessing and benchmarking health security capacities across 195 countries.²

Xie et al. recently described ‘a reverse genetic system that enables rapid synthesis of wild-type, mutant and reporter SARS-CoV-2 [severe acute respiratory syndrome coronavirus 2] strains’¹. Their goal was to enable researchers to assess the functional properties of sequence variants, including their susceptibility to countermeasures such as vaccine-induced immune responses. We agree that the rapid development of medical countermeasures is of utmost importance, especially during an ongoing pandemic. However, we believe that public dissemination of this protocol in its current form poses risks that outweigh the benefits. In providing detailed, step-by-step instructions, it enables anyone skilled in the art anywhere in the world to create novel variants of SARS-CoV-2 more quickly, including variants that have even more worrisome properties than those that have occurred naturally. Sometimes research should be slowed, not hastened, to ensure a proper discussion of goals and a full and public vetting of proposed plans. Detailed protocols pose special risks under certain circumstances like this one and should undergo special prepublication scrutiny.

This article describes what is known about the origin of SARS-CoV-2, with implications for policy, biological research and public-health surveillance. Theories about the origin include a natural emergence; a laboratory accident with a naturally harvested strain; an accident with a naturally harvested strain modified in a laboratory; and the deliberate creation of a biological weapon. While available scientific evidence points to a natural zoonotic event as the origin of SARS-CoV-2, this paper recommends specific steps governments and scientific institutions should take to address uncertainties about the origin of the COVID-19 pandemic, as well as to make all potential causes for a pandemic less likely to produce one in the future. Immediate steps include promoting international scientific collaboration, addressing scientific misinformation and disinformation, fully implementing ‘One Health’ and reining in the illegal wildlife trade.

This CommuniVax Coalition report represents a waypoint in the COVID-19 pandemic: an opportunity to pause to mark the distance traveled, alter the course if necessary, and set out on the next part of the journey. It describes progress made toward greater equity in the COVID-19 vaccination campaign and proposes steps to advance even further. CommuniVax is a national rapid research coalition of social scientists, public health experts, healthcare providers, and community advocates, and a part of the larger community of practice that has observed and participated in the COVID-19 vaccine rollout through an equity lens.

Nursing is the largest health profession, with nearly 4 million providers practicing across acute, primary, and public health care settings. In response to the pandemic, nursing schools halted onsite course delivery and redesigned programs to attenuate risks to students and faculty. Key challenges faced by schools included financial cutbacks, rapid increases in online learning technology, maintaining student academic progression, disruption to clinical learning opportunities, and meeting accreditation standards, while addressing the stress and loss experienced by faculty, staff, and students. Despite challenges, nursing organizations provided guidance for decision making, new learning resources, and faculty development opportunities. Schools of nursing leveraged their resources to redesign nursing curricula, strengthen partnerships for student clinical experiences, and address needs of the community.

Since the emergence of the SARS-CoV-2 virus in late 2019, the world has been in a state of high alert and reactivity. Once the acute stage of the infectious disease crisis does abate, however, few if any communities will have a detailed roadmap to guide recovery – that is, the process of becoming whole again and working to reduce similar, future risk. In both research and policy contexts where data are absent or difficult to obtain, expert judgment can help fill the void. Between November 2019 and February 2020, we conducted an expert elicitation process, asking fourteen key informants – with specializations in infectious diseases, disaster recovery, community resilience, public health, emergency management, and policymaking – to identify the design principles, priority issues, and field experiences that should inform development of an epidemic recovery model. Participants argued that recovery from epidemics is distinct from natural disasters due to epidemics’ potential to produce effects over large areas for extended periods of time and ability to generate high levels of fear, anticipatory anxiety, and antisocial behavior. Furthermore, epidemic recovery is a complex, nonlinear process involving many domains – political, economic, sociocultural, infrastructural, and human health. As such, an adequate model of post-epidemic recovery should extend beyond strictly medical matters, specify units of interest (e.g., individual, family, institution, sector, community), capture differing trajectories of recovery given social determinants of health, and be fit for use depending upon user group (e.g., policymakers, responders, researchers). This formative study commences a longer-term effort to generate indicators for a holistic, transformative epidemic recovery at the community level.