Understanding the Spread of Infectious Diseases

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 CONTENTS

Preface vii
Chapter 1 Coronaviruses: Understanding the Spread
of Infectious Diseases and Mobilizing
Innovative Solutions 1
Committee on Science, Space, and Technology
Chapter 2 Infectious Disease Modeling: Opportunities to
Improve Coordination and Ensure Reproducibility 165
United States Government Accountability Office
Index 255
 PREFACE

Outbreaks of infectious diseases—such as Ebola, Zika, and pandemic

viruses—have raised concerns from Congress about how federal agencies
use modeling to, among other things, predict disease distribution and
potential impacts. Chapter 1 discusses emerging infectious diseases, in
light of the recent coronavirus outbreak, and the modeling tools used to
detect, predict, and understand the spread of such diseases. Chapter 2
examines the extent to which HHS used models to inform policy, planning,
and resource allocation for public health decisions; the extent to which
HHS coordinated modeling efforts; steps HHS generally takes to assess
model development and performance; and the extent to which HHS has
addressed challenges related to modeling.
Chapter 1 - This is an edited, reformatted and augmented version of
Hearing before the Committee on Science, Space, and Technology, House
of Representatives One Hundred Sixteenth Congress Second Session,
Serial No. 116–71 dated March 5, 2020.
Chapter 2 - Outbreaks of infectious diseases—such as Ebola, Zika, and
pandemic influenza—have raised concerns from Congress about how
federal agencies use modeling to, among other things, predict disease
distribution and potential impacts. In general, a model is a representation
of reality expressed through mathematical or logical relationships. Models
of infectious diseases can help decision makers set policies for disease
viii Andrew J. Hinerman

control and may help to allocate resources. GAO was asked to review
federal modeling for selected infectious diseases. This chapter examines
(1) the extent to which HHS used models to inform policy, planning, and
resource allocation for public health decisions; (2) the extent to which
HHS coordinated modeling efforts; (3) steps HHS generally takes to assess
model development and performance; and (4) the extent to which HHS has
addressed challenges related to modeling. GAO reviewed documents and
interviewed HHS officials, state officials, and subject matter experts. GAO
identified practices commonly used to assess infectious disease model
performance and reviewed 10 selected modeling efforts to see if they
followed these practices.
In: Understanding the Spread … ISBN: 978-1-53618-892-9
Editor: Andrew J. Hinerman © 2021 Nova Science Publishers, Inc.

Chapter 1

CORONAVIRUSES: UNDERSTANDING THE

SPREAD OF INFECTIOUS DISEASES AND
MOBILIZING INNOVATIVE SOLUTIONS

Committee on Science, Space, and Technology

Thursday, March 5, 2020

House of Representatives,
Washington, D.C.

The Committee met, pursuant to notice, at 9:03 a.m., in room 2318 of

the Rayburn House Office Building, Hon. Ami Bera [Chairman of the
Committee] presiding.


This is an edited, reformatted and augmented version of Hearing before the Committee on
Science, Space, and Technology, House of Representatives One Hundred Sixteenth
Congress Second Session, Serial No. 116–71 dated March 5, 2020.
2 Committee on Science, Space, and Technology

COMMITTEE ON SCIENCE, SPACE, AND TECHNOLOGY,

U.S. HOUSE OF REPRESENTATIVES, HEARING CHARTER,
CORONAVIRUSES: UNDERSTANDING THE SPREAD OF
INFECTIOUS DISEASES AND MOBILIZING
INNOVATIVE SOLUTIONS

March 5, 2020; 9:00 a.m.; 2318 Rayburn House Office Building

Purpose

The purpose of the hearing is to discuss emerging infectious diseases,

in light of the recent coronavirus outbreak, and the modeling tools used to
detect, predict, and understand the spread of such diseases. The Committee
will discuss how some infectious agents spread from animals to humans
and how predictive modeling can help control and mitigate the effects of
emerging diseases. The Committee will also explore how investments in
U.S. research may help combat epidemics and pandemics.
Given that COVID-19 is an emerging, rapidly evolving situation,
please note that some information is subject to change.

Witnesses

 Dr. Suzan Murray, Program Director, Smithsonian Global Health

Program, Smithsonian’s National Zoo & Conservation Biology
Institute.
 Dr. John Brownstein, Chief Innovation Officer, Boston Children’s
Hospital; Professor, Harvard Medical School.
 Dr. Peter Hotez, Professor and Dean, National School of Tropical
Medicine, Baylor College of Medicine; Co-Director, Texas
Children's Hospital Center for Vaccine Development.
 Coronaviruses 3

 Dr. Tara Kirk Sell, Senior Scholar, Johns Hopkins Center for
Health Security; Assistant Professor, Johns Hopkins Bloomberg
School of Public Health.

Key Questions

 What factors contribute to the emergence of new infectious

diseases, and how can we learn from past outbreaks to inform next
steps?
 How can we apply predictive modeling to anticipate present day
and future geographic distributions of infectious diseases?
 What are cutting-edge tools that can help decision-makers
understand and manage the effects of emerging infectious
diseases?
 How can investments in U.S. research contribute to global
preparedness and response to emerging infectious diseases?
 What steps can we take to mitigate harmful social stigmas
surrounding infectious diseases?

Background

Since 1980, outbreaks of emerging infectious diseases have been

occurring with greater frequency and have been causing higher numbers of
human infections.1 Nearly 75% of all emerging infectious diseases
identified in humans during the 21st century have been caused by zoonotic
pathogens,2 meaning the pathogen spreads from animals to humans, often

1
Katherine Smith et al., “Global Rise in Human Infectious Disease Outbreaks,” Journal of the
Royal Society Interface, volume 11 (August 2014); Stephen Morse et al., "Prediction and
Prevention of the Next Panemic Zoonosis," The Lancet, vol. 380 (December 1, 2012), pp.
1956-1965; and A. Marm Kilpatrick and Sarah Randolph, "Drivers, Dynamics, and Control
of Emerging Vector-Borne Zoonotic Diseases," The Lancet, vol. 380 (December 1, 2012),
pp. 1946-1955.
2
Smithsonian’s National Zoo & Conservation Biology Institute, Global Health Program.
4 Committee on Science, Space, and Technology

through a vector (e.g., a mosquito).3 Each year, zoonotic pathogens cause

an estimated one billion cases of human illness, including 15 million
deaths.4
An epidemic is an unusual, often sudden, increase in the number of
cases of a disease above what is normally expected. An outbreak carries
the same definition but is typically used for a more limited geographic
area. A pandemic refers to an epidemic that has spread over several
countries or continents, usually affecting many people. Changing
ecosystems, economic development and land use, climate and weather, and
international travel and commerce are all examples of ecological,
environmental, and social factors that will increase the emergence and
spread of infectious diseases in the future.5
Coronaviruses are a large family of zoonotic viruses that cause
respiratory illness ranging from the common cold to more severe diseases
like MERS (Middle East respiratory syndrome) and SARS (severe acute
respiratory syndrome).6 There are seven coronaviruses known to infect
humans, including the novel coronavirus (COVID-19) first identified in
Wuhan City, Hubei Province, China in December 2019.7 The most
common symptoms among confirmed COVID-19 patients include high
fever, cough, and shortness of breath.8

3
Katherine Smith et al., “Global Rise in Human Infectious Disease Outbreaks,” Journal of the
Royal Society Interface, volume 11 (August 2014); and Stephen Morse et al., "Prediction
and Prevention of the Next Pandemic Zoonosis," The Lancet, vol. 380 (December 1, 2012),
pp. 1956-1965.
4
William Karesh et al., "Ecology of Zoonoses: Natural and Unnatural Histories," The Lancet,
vol. 380 (December 1, 2012), pp. 1936-1945; Barbara Han et al., “Rodent Reservoirs of
Future Zoonotic Diseases,” Proceedings of the National Academy of Sciences of the United
States of America (PNAS), vol. 112, no. 22 (June 2, 2015), pp. 7039-7044; and Wu XiaoXu
et al., “Impact of Global Change on Transmission of Human Infectious Diseases,” Science
China, (April 19, 2013).
5
Institute of Medicine. 2014. The Influence of Global Environmental Change on Infectious
Disease Dynamics: Workshop Summary. Washington, DC: The National Academies Press.
6
Johns Hopkins Center for Health Security, Coronaviruses: SARS, MERS, and 2019-nCoV,
January 21, 2020.
7
Centers for Disease Control and Prevention. Human coronavirus types. January 10, 2020. The
virus has been named “SARS- CoV-2” and the disease it causes has been named
“coronavirus disease 2019” (abbreviated “COVID-19”).
8
Chaolin Huang, Yeming Wang, and Xingwang Li, et al., "Clinical features of patients infected
with 2019 novel coronavirus in Wuhan, China," The Lancet, January 24, 2020.
 Coronaviruses 5

Global Effects of COVID-19

The size of the COVID-19 outbreak has created a public health crisis
with significant international dimensions. As of March 2, 2020, COVID-19
has been detected in 60 locations internationally, including in the United
States.9 While the overwhelming number of cases and deaths have
occurred in China, significant outbreaks are now arising in other countries
such as South Korea, Italy, and Iran. The global spread of the COVID-19
virus prompted the World Health Organization (WHO) to take action by
declaring a “public health emergency of international concern” on January
30, 2020, only the sixth time in the organization’s history that it has
declared a public health emergency since it gained the authority to do so in
2005.10 The WHO’s declaration is advisory in nature and cannot compel
any nation to undertake any specific policy or action. Nevertheless, it is
viewed as an important signal of severe concern from the world’s leading
international public health organization, and it may galvanize further
responses to the outbreak at the national and sub-national level.

Figure 1.

9
Centers for Disease Control and Prevention, “Coronavirus Disease 2019 (COVID-19),”
COVID-19 Situation Summary.
10
Sui-Lee Wee, Donald G. McNeil Jr., and Javier C. Hernandez, “W.H.O. Declares Global
Emergency as Wuhan Coronavirus Spreads,” New York Times, January 30, 2020.
6 Committee on Science, Space, and Technology

The impacts of COVID-19 will extend broadly throughout the U.S.

and global economies. Depending on the size of the eventual outbreak and
the length of time that it persists, the U.S. economy could suffer significant
disruption due to a decline in tourism from China and elsewhere, decreased
demand for American exports, the disruption of global supply chains for
American companies, and disruptions to daily life in the United States.11
The financial sector has taken note of these concerns, as the S&P 500
index experienced its worst week since the 2008 financial crisis last week,
although it rebounded somewhat on March 2, 2020.12 The technology and
automotive sectors could be particularly vulnerable due to the potential for
shortages to occur among critical parts for their production lines.13
The U.S. international public health response to COVID-19 has
centered around the goal of overseas containment through the imposition
of severe travel restrictions on foreign nationals from China and Iran, the
issuance of heightened warnings for U.S. citizens traveling to South Korea
and Italy, and the use of mandatory quarantines for American citizens
returning from some affected areas.14 The United States has also sent two
public health experts to China as part of a WHO team of international
disease experts deployed to assist the Chinese government’s response.15
Finally, the United States has offered an additional $100 million in support
of the WHO’s international response efforts to study the virus and contain
the outbreak.16 Due to the outbreak of the virus within the country, the
United States is increasingly shifting its focus to confronting the effects of
COVID-19 domestically.
On February 26, 2020, President Trump named Vice President Pence
to coordinate the government’s response to COVID-19. The White House

11
Paul Davidson, “How is the coronavirus in China casting a widening shadow across the US
economy,” USA Today, February 20, 2020.
12
New York Times, “Asian Markets Seesaw, Bonds Rise as Coronavirus Fears Linger,” March
1, 2020.
13
Id.
14
Rob Stein, “U.S. Coronavirus Quarantine and Travel Limits: Needed Protection or
Overreaction?” NPR, February 3, 2020.
15
Steven Lee Myers and Edward Wong, “Coronavirus Worsens U.S.-China Ties and Bolsters
Hawks in Washington,” New York Times, February 19, 2020.
16
Reuters, “U.S. announces aid for China, other countries impacted by coronavirus,” February 7,
2020.
 Coronaviruses 7

submitted a $2.5 billion plan to Congress to address the outbreak. Senate

Minority Leader Chuck Schumer proposed to increase the President’s
emergency request substantially, to $8.5 billion in new funds, including $3
billion for a public health emergency fund, $1.5 billion for the Centers for
Disease Control and Prevention (CDC), $1 billion for vaccine
development, and $2 billion for reimbursing states and cities for efforts
they have so far made to monitor and prepare for potential cases of the
virus.17

COVID-19: A Rapidly Evolving Situation

In an effort to contextualize COVID-19 as the outbreak is rapidly

evolving, attempts have been made to explain the threat through
comparisons to other well-known outbreaks, like the seasonal flu, SARS,
and H1N1. For example, the CDC has confirmed two COVID-19-related
deaths as of March 2, 2020,18 while this year’s seasonal flu has killed more
than 18,000.19 However, it is important to note that such comparisons are
complicated while the virus continues to spread. Not all those who have
contracted the virus have been diagnosed, and most of those who have
been diagnosed have neither died nor recovered yet. When the H1N1
influenza pandemic broke out in the spring of 2009, the mortality rate
appeared to be 10%. However, as time progressed, it became clear that
there were many cases of people whose infections were so mild that they
didn’t seek medical help. Ultimately, the death rate of H1N1 was below
0.1%.20
Like with any other outbreak, outcomes of COVID-19 cases will vary
based on the resources available to the impacted communities. H1N1, for

17
Jordain Carney, “Schumer requesting $8.5 billion in emergency funding on coronavirus,”
February 26, 2020.
18
“Coronavirus Disease 2019 (COVID-19),” Centers for Disease Control and Prevention, March
2, 2020.
19
“Weekly U.S. Influenza Surveillance Report (FluView),” Centers for Disease Control and
Prevention, February 15, 2020.
20
Emily Baumgaertner, “How deadly is the new coronavirus? Scientists race to find the answer,”
LA Times, February 12, 2020.
8 Committee on Science, Space, and Technology

example, had a death rate over four times higher for American Indians and
Alaska Natives than for all other racial and ethnic groups combined.
Reasons for this include a high prevalence of chronic health conditions,
poverty, and delayed access to healthcare.21 In the Hubei province, medical
resources are stretched very thin, exacerbated by a lockdown that is
slowing the delivery of protective wear for hospital staff.22
Over 3,000 medical workers have now been infected with COVID-19
in China, largely in the Hubei province.23 Meanwhile, according to the
CDC, there have been 43 cases of COVID-19 confirmed in the United
States as of March 2, 2020 including 26 cases of transmission to people
who had not recently been to China or had known contact with someone
who had. There have been 48 confirmed cases among individuals
repatriated to the United States from Asia, including three from Wuhan and
45 from the Diamond Princess, a cruise ship on which 695 people were
infected.24
Epidemiologists believe that, despite the Chinese government’s
lockdown of areas surrounding Wuhan, COVID-19 will infect more people
in the United States and around the world.25 Like SARS and MERS, it will
be more dangerous for elderly patients and those with existing
cardiovascular disorders.26 Beyond that, it is difficult at the moment to
make predictions about how contagious or deadly COVID-19 will be
outside China.

21
“Deaths Related to 2009 Pandemic Influenza A (H1N1) Among American Indian/Alaska
Natives – 12 States, 2009,” Center for Disease Control MMWR Weekly, December 11, 2009.
22
Chris Buckley, Sui-Lee Wee, Amy Qin, “China’s Doctors, Fighting the Coronavirus, Beg for
Masks,” New York Times, February 14, 2020.
23
“China says more than 3,000 medical staff infected by COVID-19,” Channel News Asia,
February 24, 2020.
24
Coronavirus Disease 2019 (COVID-19), Centers for Disease Control and Prevention.
25
James Hamblin, “You’re Likely to Get the Coronavirus,” The Atlantic, February 24, 2020.
26
Katarina Zimmer, “Why Some COVID-19 Cases Are Worse than Others,” The Scientist,
February 24, 2020.
 Coronaviruses 9

Using Technology to Detect, Predict, and

Understand the Spread of Infectious Diseases

During outbreaks of novel viruses—especially ones with pandemic

potential—public health leaders use epidemiological models to detect,
predict, and control the spread and impact of disease.27 These models can
assist in answering critical questions, such as: ‘When will the disease reach
its peak?’ or ‘How transmissible is the disease?’ or ‘Who in the population
should be prioritized for vaccination or treatment?’.28 The researchers
using such models require quality data but are limited by time; as time
passes and the outbreak progresses, more data become available to
analyze.29
Traditional models or techniques that track outbreaks often use
manually coded data, like confirmed infections and hospitalizations.
However, it can take a long time to collect and verify this data. For
example, a physician might identify a cluster of patients with a new set of
similar symptoms and contact the CDC for further follow-up and testing.
The CDC (or one of its designated laboratories) would then analyze and
verify patient specimens before making recommendations and issuing an
official alert. While necessary, this process can delay critical policies and
interventions during the early stages of an outbreak.
One of the key differences between the SARS outbreak in 2003 and
COVID-19 is the greater availability and amount of non-traditional data
like social media posts, Google Search queries, and online news reports.
Researchers are now using artificial intelligence (AI) applications to
identify and track outbreaks faster and more precisely. HealthMap, for

27
Manoj Gambhir, et al., “Infectious Disease Modeling Methods as Tools for Informing
Response to Novel Influenza Viruses of Unknown Pandemic Potential,” Clinical Infectious
Diseases, 2015;60(S1):S11-9.
28
Typically, descriptive modeling tries to estimate what probably occurred or is occurring now,
while predictive modeling predicts cases in the future. Government Accountability Office,
“Emerging Infectious Diseases: Actions Needed to Address the Challenges of Responding
to Zika Virus Disease Outbreaks,” May 23, 2017.
29
Manoj Gambhir, et al., “Infectious Disease Modeling Methods as Tools for Informing
Response to Novel Influenza Viruses of Unknown Pandemic Potential,” Clinical Infectious
Diseases, 2015;60(S1):S11-9.
10 Committee on Science, Space, and Technology

example, is a tool that collects and analyzes online informal sources to

generate visualizations that show how and where communicable diseases
like COVID-19 are spreading.30 The WHO uses HealthMap as part of its
Epidemic Intelligence from Open Sources initiative, facilitating early
detection of global public health threats.31
While advancements in AI could help predict infectious disease
outbreaks before they happen, these methods are considered a supplement
to, and not a replacement for, traditional surveillance and diagnostic
processes. Decision-makers could use a hybrid approach to allocate
resources faster and contain the spread of an outbreak more effectively.

Halting the Spread of Misinformation around

Infectious Disease Outbreaks

Researchers generally define misinformation as information that is

false or misleading but promulgated with sincerity by a person who
believes it is true. Disinformation, on the other hand, is shared with the
deliberate intent to deceive. The Subcommittee on Investigations &
Oversight of the House Committee on Science, Space, and Technology
held a hearing on this important topic on September 26, 2019, particularly
focusing on the tools needed to combat these threats.32
The outbreak of global viruses is often followed by the spread of
misinformation about the virus, such as its origins, causes, and government
response. The WHO has even labeled this outbreak an “infodemic,”
meaning there is “an over-abundance of information – some accurate and
some not – that makes it hard for people to find trustworthy sources and
reliable guidance when they need it.”33 There have been multiple reports

30
Will Knight, “How AI is Tracking the Coronavirus Outbreak,” WIRED, February 8, 2020.
31
Alejandro De La Garza, “Coronavirus Researchers Are Using High-Tech Methods to Predict
Where the Virus Might Go Next,” TIME, February 11, 2020.
32
“Online Imposters and Disinformation,” hearing before the Subcommittee on Investigations
and Oversight, H. Comm. On Sci., Space, and Tech. (September 26, 2019).
33
World Health Organization, “Novel Coronavirus (2019-nCoV) Situation Report -13,” February
2, 2020.