Six months have passed since the coronavirus pandemic reached Maryland, yet there is still so much to learn about the virus and how best to manage it, says Jacky Jennings, a social and infectious disease epidemiologist in the Department of Pediatrics. Here she discusses new research initiatives that aim to find some answers through a greater understanding of the experience of Baltimore City residents, among the hardest hit by the virus.

Tell us about the study.

It’s actually one of three initiatives I am involved in to better understand the burden of SARS-CoV-2/COVID-19 infection across the state of Maryland and in Baltimore City, including families with children. One initiative is an antibody surveillance study, which I am co-leading with Eili Klein from the Johns Hopkins University School of Medicine and Wilbur Chen from the University of Maryland, along with team members from the Maryland Department of Health, including Corey Carpenter and Mary Beth Tung, and the Maryland Public Health Laboratory. The initiative is in partnership with over 13 hospitals from selected regions in the state, including hospitals in the Johns Hopkins Health System. It aims to determine how many Marylanders have been exposed to SARS-CoV-2, in order to guide state and local policies. More than 6,000 people, including children, will be tested in the initial phase.

The other initiatives?

The second is a tri-school initiative including Shruti Mehta from the Bloomberg School of Public Health and Jason Farley from the school of nursing. The overarching goal is to facilitate and inform SARS-CoV-2/COVID-19 community-based research. The objectives are to develop assessment tools for use globally, use rapid pulse surveys to perform real-time symptom and physical distancing assessments in Maryland and other selected states, and conduct a population-representative study to determine the burden of infection including social, mental and economic impacts among more than 1,200 families across Baltimore City. Importantly, the latter will give us an in-depth understanding of the lived experiences of COVID-19 for families in Baltimore.

The third study, for which I am the principal investigator, is funded by the Centers for Disease Control and Prevention and is in partnership with the Baltimore City Health Department. We nested a SARS-CoV-2/COVID-19 study within an ongoing longitudinal study of gay, bisexual and other men who have sex with men (n=243) to better understand the lived experiences of COVID-19 among this subpopulation.

Your progress so far?

On the first initiative, the Maryland Department of Health brought us in to help inform a serology surveillance testing strategy. The state bought approximately 280,000 antibody tests and needed to figure out a strategy to best use the tests. In addition, they wanted results by the end of the summer to inform multiple policy decisions, including physical distancing policies. Using these parameters, we designed a strategy that included short- and long-term assessments and leveraged existing expertise infrastructure such as blood samples already being collected by hospitals across the state. As part of the process, we gathered a large group of experts from across the Johns Hopkins schools of medicine and public health, including the Center for Health Security, to inform our design. By mid-August, the Maryland Public Health Laboratory began to receive the first samples for antibody testing, and to date we have more than 13 hospitals on board. The reception by hospitals has been incredibly enthusiastic.

On the second initiative, we completed our assessment tool, disseminated it to over 100 investigators internal and external to Johns Hopkins, and submitted it to the National Institutes of Health (NIH) PhenX toolkit — a web-based catalog of high-priority measures related to complex diseases, phenotypic traits and environmental exposures. In addition, we launched our first real-time pulse survey and received supplemental funding from Johnson & Johnson to build out the tool and increase the reach of the survey.

And progress on the population research initiative?

Our population-representative, community-based study in the city has launched and enrolled its first Baltimore resident. As part of this work, we received supplemental funding from Formula One for a mobile testing van and submitted an NIH grant for additional funding. Finally, we completed our first COVID-19 assessment among gay, bisexual and other men who have sex with men. Preliminary data is deeply concerning; 14% of the men reported testing positive for SARS-CoV-2, 90% reported that they were laid off from full-time or part-time employment, and 75% reported that COVID-19 is highly impacting their day-to-day lives.

Why are these initiatives so important?

With COVID-19 we’ve seen glimmers of discovery, but there is still so much more to learn. Also, there are few studies that are population-representative household studies — most of the work is coming from patients in the hospital or clinic. Studies have largely shown the transmissions were within households when schools had already been closed, with adults rather than children bringing the infection into the household. Now we are starting to see more information about the big question: Are children getting infected? It’s pretty clear that children are getting infected and can transmit the virus, but they are experiencing less severity of infection. Beyond infection, our study will help to assess the impact on children and their families and how they are coping.

Is viral testing central to this work?

A big challenge across the landscape during this pandemic has been testing. The variability in testing and testing access has been tremendous. Early on in the epidemic, testing was severely limited by supply chain issues, including test kit and reagent shortages. While some of these aspects have improved, there is still great variability in access to testing and even more variability in obtaining results in a timely fashion. Receiving results six to 10 days later, which is what some people are experiencing, is really not helpful from a transmission perspective. Building trust through access to testing, timely results and quality clinical care is critical for eventual vaccine access, acceptance and uptake, particularly in our city where there are longstanding issues of medical distrust and mistrust.

How do we mitigate that?

We hope that the comprehensive effort of the population-representative sample will identify multifactorial drivers of testing disparities, health outcome disparities, and importantly, the behavioral, economic and mental health impacts on families, including families with children. We are following individuals from a baseline survey through antibody and viral PCR [polymerase chain reaction] testing. Next we are doing weekly and monthly pulses, or real-time rapid assessments, of all household members, then a 12-month follow-up. We are also conducting interim testing if anyone is symptomatic or a PUI [patient under investigation]. It’s a pretty comprehensive study that will yield a population-representative sample, rather than what we’ve seen in other studies that are using convenience sampling approaches. Very few places have done this type of massive undertaking — to not only understand prevalence and incidence but also the true burden of the impact.

The burden of impact?

The study will help us understand where the infection has been, where and what it is currently, and learn more about household transmission, including that of children, and lost jobs, lost family members, evictions and the medical effects of physical distancing. We will learn things about crowded living conditions, which are important for transmission. In Baltimore, where you can find up to 15 individuals living within a household, of course you are going to see a higher level of transmission. Physical distancing and wearing face masks in those conditions is incredibly important to minimize onward transmission. Understanding these impacts is critical for our city, where there are great racial and ethnic disparities in income and health outcomes, to enable social policy solutions and resources. Understanding these issues will also help directly inform public health practice, especially if we continue to experience second and third waves of COVID-19.

Are you optimistic these initiatives will effect change?

I believe firmly that we need evidence to drive policies and public health practice. I am optimistic in that Johns Hopkins was willing to invest in this work, which will help us develop a solid evidence base that will be incredibly informative to our public health practitioners who are on their own front line. So many of us are on the front line as we live and work during this pandemic. We expect that the work will also help to lay important groundwork for vaccine access, acceptance and uptake. Which are the most important populations to bring the vaccines to? Where might there be pockets of resistance? What does immunity and/or reinfection look like? We need answers to these kinds of questions in a population-based way. You need the evidence to argue for resources and policies.