Task 9 - What has been published about ethical and social science considerations?

Articulate and translate existing ethical principles and standards to salient issues in COVID-2019

• Fill gaps in understanding of the natural history of infection to better define the period of infectiousness and transmissibility ; more accurately estimate the reproductive number in various outbreak settings and improve understanding the role of asymptomatic infection . • Comparative analysis of different quarantine strategies and contexts for their effectiveness and social acceptability • Enhance and develop an ethical framework for outbreak response that includes better equity for access to interventions for all countries • Promote the development of point - of - care diagnostic tests • Determine the best ways to apply knowledge about infection prevention and control in health - care settings in resource - constrained countries ( including identification of optimal personal protective equipment ) and in the broader community , specifically to understand behaviour among different vulnerable groups • Support standardised , best evidence - based approach for clinical management and better outcomes and implement randomised , controlled trials for therapeutics and vaccines as promising agents emerge • Validation of existing serological tests , including those that have been developed by commercial entities , and establishment of biobanks and serum panels of well characterised COVID - 19 sera to support such efforts • Complete work on animal models for vaccine and therapeutic research and development In September , 2019 , Alan Donnelly and Ilona Kickbusch called for a chief economist at WHO . 1 Such a position , they argued , would enable WHO to better advocate for greater recognition of , and thus action on , the interdependency of health and the economy . We support this proposal : recognition of the interdependence of health and the economy is vital for WHO to achieve its mandate : " the enjoyment of the highest attainable standard of health … without distinction of race , religion , political belief , economic or social condition " . 2 Given this mandate , WHO should be more ambitious than the appointment of one economist . A more strategic and enlightened approach , especially in the aftermath of the coronavirus disease 2019 ( COVID - 19 ) pandemic , 3 would be for WHO to embrace and articulate a feminist economic agenda .

however , the mechanism is unclear and existing theories cannot explain this phenomenon . Moreover , basic research efforts should be devoted to the molecular mechanisms and separation and / or purification . Another disturbing fact is that some unreasonable clinical trial schemes are consuming precious patient resources ; and some others have not even been approved by an ethics committee . Clinical trials must be undertaken actively , carefully and scientifically reflecting the basic principles of the Helsinki Declaration and its relevant laws and regulations . Despite the urgency generated by the emergence of a new coronavirus , the researchers should maintain rigorous evidence and follow the guidelines for clinical trial statistics and the basic principles including randomization , control and repetition . ' First , do no harm ' should still be the top priority .

The rapid emergence of clinical trials on COVID - 19 stimulated a wave of discussion in scientific community . We reviewed the characteristics of interventional trials from Chinese Clinical Trial Registration ( ChiCTR ) and ClinicalTrials . gov . A total of 171 COVID - 19 - related interventional trials were identified on Feb 22nd , 2020 . These trials are classified into 4 categories based on treatment modalities , including chemical drugs , biological therapies , traditional Chinese medicine treatments and other therapies . Our analysis focused on the issues of stage , design , randomization , blinding , primary endpoints definition and sample size of these trials . We found some studies with potential defects including unreasonable design , inappropriate primary endpoint definition , insufficient sample size and ethical issue . Clinical trials on COVID - 19 should be designed based on scientific rules , ethics and benefits for patients .

In The Lancet Respiratory Medicine , Kollengode Ramanathan and colleagues 1 provide excellent recommendations for the use of extracorporeal membrane oxygenation ( ECMO ) for patients with respiratory failure from acute respiratory distress syndrome ( ARDS ) secondary to coronavirus disease 2019 ( COVID - 19 ) . The authors describe pragmatic approaches to the challenges of delivering ECMO to patients with COVID - 19 , including training health - care personnel , resolving equipment and facilities issues , implementing systems for infection control and personal protection , providing overall support for health - care staff , and mitigating ethical issues . They also address some of the anticipated challenges with local and regional surges in COVID - 19 ARDS cases ; although there has been an increase in hospitals with the capacity to provide ECMO , the potential demand might exceed the available resources . Furthermore , some health - care systems offer advanced therapies such as ECMO but lack a coordinated local , regional , or national referral protocol .

The vital ethical issue is whether administration of chloroquine in the setting of COVID - 19 is experimental , and therefore requires ethical trial approval , or off - label ( i . e . ethically justifiable as the best available treatment ) . Additional information on chloroquine will soon be released in the context of the evolving outbreak . Timely release of this information can be of importance due to the growing number of infected patients , and the absence of licensed specific drugs . Meanwhile , the recommendations for " Clinical management of severe acute respiratory infection when novel coronavirus ( 2019 - nCoV ) infection is suspected " , published by the WHO , confirm that there is currently no evidence from RCTs to inform on specific drug treatment of COVID - 19 and that unlicensed treatments should be administered only in the context of ethically - approved clinical trials or the Monitored Emergency Use of Unregistered Interventions Framework ( MEURI ) , under strict monitoring [ 17 ] . The WHO therefore seems to view chloroquine as experimental . The authors tend to agree with this viewpoint . But even off - label use of chloroquine may be accompanied by several concerns ; the first is patient safety . Such use should be accompanied by close monitoring . An epidemic is hardly the ideal setting to do this . The ethical approach to off - label drug use also differs between countries , raising questions regarding equity . Finally , chloroquine remains a pivotal drug in the treatment of Malaria in many places in the world . Off label drug use can create major drug shortages [ 18 ] .

Embed ethics across all thematic areas, engage with novel ethical issues that arise and coordinate to minimize duplication of oversight

Support sustained education, access, and capacity building in the area of ethics

Establish a team at WHO that will be integrated within multidisciplinary research and operational platforms and that will connect with existing and expanded global networks of social sciences

Develop qualitative assessment frameworks to systematically collect information related to local barriers and enablers for the uptake and adherence to public health measures for prevention and control

The information and data from these exercises should be analysed to build and inform readiness and response plans for preventing and controlling health emergencies including the outbreak of COVID - 19 . The analyses of the operational readiness index have been used to support the development of a draft WHO strategic preparedness and response plan for COVID - 19 . 23 These findings must be triangulated with the latest risk assessments available for COVID - 19 and other assessments such as Joint External Evaluations , after - action reviews , simulation exercises , and others to understand the capacity level of countries and to implement priority actions at the national and subnational levels . 19 , 23 The WHO Secretariat is working on the development of a preparedness dashboard to provide real - time information that is based on these capacity assessments . Another limitation is related to the method being based on a deterministic approach ; therefore , proportionate or inverse interactions among variables could not be shown . 24 An effective way of managing airborne infections is applying evidence - based public health prevention strategies . 16 , 17 , 22 This method includes scaling up public awareness of behaviours such as hand hygiene and respiratory etiquette , communicating and engaging with local communities about the risks of the outbreak , and putting in place effective public health response measures . 17 , 25 , 26 National points of entry should also have the capacity to prevent , detect , and respond to potential threats in line with the IHR . Many countries have low capacities for preventing the occurrence and spread of outbreaks , such as measles , influenza , Ebola virus . 27 , 28 Therefore , enhancing national preparedness capacities in line with the gaps identified in this study should incorporate action to strengthen points of entry .

We need knowledge , attitude and practice studies in terms of acceptance and adherence to public health measures and other health initiatives for COVID - 19 . Accessing and addressing the physical health and psychosocial well - being of health care workers involved in care giving for COVID - 19 from time - to - time . Risk assessment and communication to address the public health needs and measures will help the general public to address their issues of anxiety , fear , and stigma associated with the COVID - 19 . There is also a need to understand the effect of restrictive public health measures used for management of COVID - 19 ( such as quarantine , isolation , lockdowns , etc . ) on the psychosocial and physical wellbeing of individuals . Socioeconomic status of the communities is also an important determinant for the compliance of sustainable public health measures . Public health information system must address pertinent issues based on dynamics of COVID - 19 and effectiveness of the control measures .

Summary Background Public health measures to prevent , detect , and respond to events are essential to control public health risks , including infectious disease outbreaks , as highlighted in the International Health Regulations ( IHR ) . In light of the outbreak of 2019 novel coronavirus disease ( COVID - 19 ) , we aimed to review existing health security capacities against public health risks and events . Methods We used 18 indicators from the IHR State Party Annual Reporting ( SPAR ) tool and associated data from national SPAR reports to develop five indices : ( 1 ) prevent , ( 2 ) detect , ( 3 ) respond , ( 4 ) enabling function , and ( 5 ) operational readiness . We used SPAR 2018 data for all of the indicators and categorised countries into five levels across the indices , in which level 1 indicated the lowest level of national capacity and level 5 the highest . We also analysed data at the regional level ( using the six geographical WHO regions ) . Findings Of 182 countries , 52 ( 28 % ) had prevent capacities at levels 1 or 2 , and 60 ( 33 % ) had response capacities at levels 1 or 2 . 81 ( 45 % ) countries had prevent capacities and 78 ( 43 % ) had response capacities at levels 4 or 5 , indicating that these countries were operationally ready . 138 ( 76 % ) countries scored more highly in the detect index than in the other indices . 44 ( 24 % ) countries did not have an effective enabling function for public health risks and events , including infectious disease outbreaks ( 7 [ 4 % ] at level 1 and 37 [ 20 % ] at level 2 ) . 102 ( 56 % ) countries had level 4 or level 5 enabling function capacities in place . 32 ( 18 % ) countries had low readiness ( 2 [ 1 % ] at level 1 and 30 [ 17 % ] at level 2 ) , and 104 ( 57 % ) countries were operationally ready to prevent , detect , and control an outbreak of a novel infectious disease ( 66 [ 36 % ] at level 4 and 38 [ 21 % ] at level 5 ) . Interpretation Countries vary widely in terms of their capacity to prevent , detect , and respond to outbreaks . Half of all countries analysed have strong operational readiness capacities in place , which suggests that an effective response to potential health emergencies could be enabled , including to COVID - 19 . Findings from local risk assessments are needed to fully understand national readiness capacities in relation to COVID - 19 . Capacity building and collaboration between countries are needed to strengthen global readiness for outbreak control . Funding None .

Risk Assessment 1 and 2 are based on a situation with no reported cases in Korea and reporting of the disease outside Korea . The main public health measures are early detection of possible imported cases and isolation of the case to prevent further transmission in Korea . Communication of infection risks through the media provides information of the disease and upcoming public health measures , enabling public health authorities to lead community engagement for the forthcoming situation . The authorities can use all available formats including social media , homepages , and press - releases . The ECDC evaluated the situation based on the Chinese report , initially indicating a “ low ” likelihood of importation to Europe [ 6 ] . The WHO indicated that the imported case in Thailand did not prove human - to - human transmission as further information was required [ 7 ] .

Risk Assessment 6 was conducted in a situation where the number of imported cases and local transmission were identified . At this stage , the public health measures aimed to contain , if applicable , or mitigate transmission . This strategy will help to gain time for development and supply of personal protective equipment ( PPE ) and antivirals . It helps to reduce the burden of national health systems , and to increase the number of laboratory testing kits and increase capacity in the healthcare system . Communication of risk at this stage informs the stakeholders of public health measures , including case isolation , contact tracing , and PPE use . ECDC evaluations of the likelihood of importation to Europe were escalated from “ low ” to “ moderate , ” and likelihood of importation to neighboring Asian countries as “ high . ” Infection contracted in hospital was considered a “ low ” risk when appropriate infection prevention and control measures were in place [ 9 ] . The WHO evaluates risk in China as “ very high ” and the Asia region ’ s risk as “ high . ” The WHO proposed that super - spread events may occur with human - to - human transmission among family members , and healthcare workers [ 10 ] .

How the burden of responding to the outbreak and implementing public health measures affects the physical and psychological health of those providing care for Covid-19 patients?

Background : The 2019 coronavirus disease ( COVID - 19 ) epidemic is a public health emergency of international concern and poses a challenge to psychological resilience . Research data are needed to develop evidence - driven strategies to reduce adverse psychological impacts and psychiatric symptoms during the epidemic . The aim of this study was to survey the general public in China to better understand their levels of psychological impact , anxiety , depression , and stress during the initial stage of the COVID - 19 outbreak . The data will be used for future reference . Methods : From 31 January to 2 February 2020 , we conducted an online survey using snowball sampling techniques . The online survey collected information on demographic data , physical symptoms in the past 14 days , contact history with COVID - 19 , knowledge and concerns about COVID - 19 , precautionary measures against COVID - 19 , and additional information required with respect to COVID - 19 . Psychological impact was assessed by the Impact of Event Scale - Revised ( IES - R ) , and mental health status was assessed by the Depression , Anxiety and Stress Scale ( DASS - 21 ) . Results : This study included 1210 respondents from 194 cities in China . In total , 53 . 8 % of respondents rated the psychological impact of the outbreak as moderate or severe ; 16 . 5 % reported moderate to severe depressive symptoms ; 28 . 8 % reported moderate to severe anxiety symptoms ; and 8 . 1 % reported moderate to severe stress levels . Most respondents spent 20 – 24 h per day at home ( 84 . 7 % ) ; were worried about their family members contracting COVID - 19 ( 75 . 2 % ) ; and were satisfied with the amount of health information available ( 75 . 1 % ) . Female gender , student status , specific physical symptoms ( e . g . , myalgia , dizziness , coryza ) , and poor self - rated health status were significantly associated with a greater psychological impact of the outbreak and higher levels of stress , anxiety , and depression ( p < 0 . 05 ) . Specific up - to - date and accurate health information ( e . g . , treatment , local outbreak situation ) and particular precautionary measures ( e . g . , hand hygiene , wearing a mask ) were associated with a lower psychological impact of the outbreak and lower levels of stress , anxiety , and depression ( p < 0 . 05 ) . Conclusions : During the initial phase of the COVID - 19 outbreak in China , more than half of the respondents rated the psychological impact as moderate - to - severe , and about one - third reported moderate - to - severe anxiety . Our findings identify factors associated with a lower level of psychological impact and better mental health status that can be used to formulate psychological interventions to improve the mental health of vulnerable groups during the COVID - 19 epidemic .

Our findings suggest that with respect to the initial psychological responses of the general public from 31 January to 2 February 2020 , just two weeks into the country ’ s outbreak of COVID - 19 and one day after WHO declared public health emergency of international concern , 53 . 8 % of respondents rated the psychological impact of outbreak as moderate or severe ; 16 . 5 % of respondents reported moderate to severe depressive symptoms ; 28 . 8 % of respondents reported moderate to severe anxiety symptoms ; and 8 . 1 % reported moderate to severe stress levels . The prevalence of moderate or severe psychological impact as measured by IES - R was higher than the prevalence of depression , anxiety , and stress as measured by the DASS - 21 . The difference between IES - R and DASS - 21 is due to the fact that the IES - R assesses the psychological impact after an event . In this study , respondents might refer the COVID - 19 outbreak as the event while the DASS - 21 did not specify any such event .

In this survey study of physicians and nurses in hospitals with fever clinics or wards for patients with COVID - 19 in China , health care workers responding to the spread of COVID - 19 reported high rates of symptoms of depression , anxiety , insomnia , and distress . Protecting health care workers is an important component of public health measures for addressing the COVID - 19 epidemic . Special interventions to promote mental well - being in health care workers exposed to COVID - 19 need to be immediately implemented , with women , nurses , and frontline workers requiring particular attention .

7 . Future directions to control the spread of the disease Extensive measures to reduce person - to - person transmission of COVID - 19 are required to control the current outbreak . Special attention and efforts to protect or reduce transmission should be applied in susceptible populations including children , health care providers , and elderly people . A guideline was published for the medical staff , healthcare providers , and , public health individuals and researchers who are interested in the 2019 - nCoV [ 29 ] . The early death cases of COVID - 19 outbreak occurred primarily in elderly people , possibly due to a weak immune system that permits faster progression of viral infection [ 8 , 12 ] . The public services and facilities should provide decontaminating reagents for cleaning hands on a routine basis . Physical contact with wet and contaminated objects should be considered in dealing with the virus , especially agents such as faecal and urine samples that can potentially serve as an alternative route of transmission [ 15 , 16 ] . China and other countries including the US have implemented major prevention and control measures including travel screenings to control further spread of the virus [ 13 ] . Epidemiological changes in COVID - 19 infection should be monitored taking into account potential routes of transmission and subclinical infections , in addition to the adaptation , evolution , and virus spread among humans and possible intermediate animals and reservoirs . There remains a considerable number of questions that need to be addressed . These include , but are not limited to , details about who and how many have been tested , what proportion of these turned positive and whether this rate remains constant or variable . Very few paediatric cases have so far been reported ; is this due to lack of testing or a true lack of infection / susceptibility ? Of the ones that have so far been tested , how many have developed severe disease and how many were tested positive but showed no clinical sign of disease ? There are some basic questions that would provide a framework for which more specific and detailed public health measures can be implemented .

This study has several limitations . Given the limited resources available and time - sensitivity of the COVID - 19 outbreak , we adopted the snowball sampling strategy . The snowballing sampling strategy was not based on a random selection of the sample , and the study population did not reflect the actual pattern of the general population . Furthermore , it would be ideal to conduct a prospective study on the same group of participants after a period . Due to ethical requirements on anonymity and confidentiality , we were not allowed to collect contact details and personal information from the respondents . As a result , we could not conduct a prospective study that would provide a concrete finding to support the need for a focused public health initiative . There was an oversampling of a particular network of peers ( e . g . , students ) , leading to selection bias . As a result , the conclusion was less generalizable to the entire population , particularly less educated people . Another limitation is that self - reported levels of psychological impact , anxiety , depression and stress may not always be aligned with assessment by mental health professionals . Similarly , respondents might have provided socially desirable responses in terms of the satisfaction with the health information received and precautionary measures . Lastly , the number of respondents with contact history and who had sought medical consultations was very small . Our findings could not be generalized to confirmed or suspected cases of COVID - 19 . Notwithstanding the above limitations , this study provides invaluable information on the initial psychological responses 2 weeks after the outbreak of COVID - 19 from respondents across 194 cities in China . Our results could be used as a historical reference . Most importantly , our findings directly inform the development of psychological interventions that can minimize psychological impact , anxiety , depression , and stress during the outbreak of COVID - 19 and provide a baseline for evaluating prevention , control , and treatment efforts throughout the remainder of the COVID - 19 epidemic , which is still ongoing at the time of preparing this manuscript .

Identify the underlying drivers of fear, anxiety and stigma that fuel misinformation and rumor, particularly through social media

The sudden escalation of the control and the spread of the number of infected and deaths , however , ignited strong emotional responses of fear and panic among people in Wuhan . The negative emotional responses soon spread from Wuhan to other parts of China , and further to the world via almost all communication channels , particularly social media . The highly emotional responses of the public were fueled by ( 1 ) sudden increases in the number of detected new cases after the massive intervention measures to identify the infected ;

As COVID19 is a new disease and is having the most devastating effects globally , its emergence and spread , causes confusion , anxiety and fear among the general public . Fear is the breeding ground for hatred and stigma . Social stigma has arisen as certain populations ( Indian north - east people ) are targeted as being the reason for this outbreak ( WHO , 2020c ) . It is vital to avoid this stigma as it can make people hide their illness and not seek health care immediately . WHO is providing expert guidance and answers to public questions , to help people manage fear , stigma , and discrimination during COVID - 19 ( WHO , 2020c ) . As research into COVID - 19 continues , a lot of the facts keep on changing and many myths are also prevalent in the general population regarding the prevention and management of the infection . In the time of widespread use of social media , these myths along with fake news around corona are also spreading rapidly . These are sometimes very disturbing for certain individuals . Several sites including WHO are thus providing myth busters and authentic information ( WHO , 2020c ) . Governments are also urging people to not sharing these messages without checking their authenticity .

When anxiety affects a larger population , it may result in panic buying , leading to exhaustion of resources . It also can lead to limitations in daily activities , avoidance behavior causing limited socialization , self - medication . Because of anxiety , people adopt various unwanted lifestyle and dietary modifications under the influence of rumors . These may affect mental health adversely . Hence , it is important to deal with the mental health difficulties in situations of the pandemic . Similarly , additional changes likeisolation , social distancing , selfquarantine , restriction of travel and the ever - spreading rumors in social media are also likely to affect mental health adversely ( Banerjee , 2020 ) . In our study , we found approximately 28 % of people reporting sleep difficulties . More than two - thirds of participants reported themselves worried after seeing posts about COVID - 19 pandemic in various social media platforms and approximately 46 % of participants reported their worries related to the discussion of COVID - 19 pandemic in news channels and print media . This indicates that a significant proportion of participants in the survey , despite having adequate awareness about coronavirus infection , are largely influenced by media information . Media influences the mental well - being and add to the level of anxiety . The swine flu pandemic of 2009 - 2010 , which resulted in high mortality worldwide also caught global media attention and evoked anxiety among the public significantly ( Everts , 2013 ) .

This type of information is inaccurate and unreliable but the distributer of that information disseminates it inadvertently and pays little attention to the effects of this information on the society ( 2 ) . In the Coronavirus crisis , bad news that was spread through online social networks such as WhatsApp , Telegram , etc . regarding the number of infected and dead people increased the fear and anxiety among people . However , if this kind of news is produced and distributed on purpose , it is no longer called misinformation ; it is named disinformation because the producer ( s ) pursued inhumane purposes .

Fear , prejudice , and discrimination can considerably impede anti - SARS - CoV - 2 efforts [ 34 ] . A recent study of 138 hospitalized COVID - 19 patients shows that SARS - CoV - 2 can be transmitted from person to person through droplets and hand contact during an incubation period as well as on acute attack [ 2 ] . The closer we are to the truth , the farther we are from fear or panic . We think that open and transparent information on the outbreak to the public in China and the world , and administrative warning from authorities in every country are necessary to reduce fear and discrimination [ 34 ] . The health authorities should make the SARS - CoV - 2 epidemic and essential preventive measures to the public in China and the world openly and transparently in time through radio , television , newspaper , WeChat , and the internet , i . e . washing hands and wearing a mask . A 24 - h free hotline 7 d a week should be set up for public to respond to all the questions and concerns , relive the worries and panic , and clear the rumor or misinformation . The public hospitals should open COVID - 19 clinics and mental health clinics to consult with people to clear panic and misinformation .