Pandemic management and developing world bioethics: bird flu in West Bengal

This paper examines the case of a recent H5N1virus (avian influenza) outbreak in West Bengal, an eastern state of India, and argues that poorly executed pandemic management may be viewed as a moral lapse. It further argues that pandemic management initiatives are intimately related to the concept of health as a social 'good' and to the moral responsibility of protection from foreseeable social harm from an infectious disease. The initiatives, therefore, have to be guided by special moral obligations towards biorisk reduction, obligations which remain unfulfilled when a public body entrusted with the responsibility fails to manage satisfactorily the prevention and control of the infection. The overall conclusion is that pandemic management has a moral dimension. The gravity of the threat that fatal infectious diseases pose for public health creates special moral obligations for public bodies in pandemic situations. However, the paper views the West Bengal case as a learning opportunity, and considers the lapses cited as challenges that better, more effectively conducted pandemic management can prepare for. It is hoped that this paper will provoke constructive bioethical deliberations, particularly pertinent to the developing world, on how to ensure that the obligations towards health are fulfilled ethically and more effectively.     

Ethics and severe pandemic influenza: maintaining essential functions through a fair and considered response

The response to severe pandemic influenza will be managed by experts in public health and infectious disease and by government officials to whom the public will turn for information and direction. Nonetheless, there remain important ethical considerations that can shape what goals are given priority, how scarce resources are distributed, how the public is included, and how we treat the most vulnerable in our response to a pandemic. This article assumes that the secondary consequences of severe pandemic influenza could be greater than deaths and illness from influenza itself. Response plans, then, must consider threats to societal as well as medical infrastructures. While some have suggested that scarce medical countermeasures be allocated primarily to first responders and then to the sickest, we suggest that an ethical public health response should set priorities based on essential functions. An ethical response also will engage the public, will coordinate interdependent sectors as a core preparedness priority, and will address how plans affect and can be understood by the least well off.     

Community engagement: leadership tool for catastrophic health events

Disasters and epidemics are immense and shocking disturbances that require the judgments and efforts of large numbers of people, not simply those who serve in an official capacity. This article reviews the Working Group on Community Engagement in Health Emergency Planning's recommendations to government decision makers on why and how to catalyze the civic infrastructure for an extreme health event. Community engagement--defined here as structured dialogue, joint problem solving, and collaborative action among formal authorities, citizens at-large, and local opinion leaders around a pressing public matter--can augment officials' abilities to govern in a crisis, improve application of communally held resources in a disaster or epidemic, and mitigate community wide losses. The case of limited medical options in an influenza pandemic serves to demonstrate the civic infrastructure's preparedness, response, and recovery capabilities and to illustrate how community engagement can improve pandemic contingency planning.     

Mitigation strategies for pandemic influenza A: balancing conflicting policy objectives

Mitigation of a severe influenza pandemic can be achieved using a range of interventions to reduce transmission. Interventions can reduce the impact of an outbreak and buy time until vaccines are developed, but they may have high social and economic costs. The non-linear effect on the epidemic dynamics means that suitable strategies crucially depend on the precise aim of the intervention. National pandemic influenza plans rarely contain clear statements of policy objectives or prioritization of potentially conflicting aims, such as minimizing mortality (depending on the severity of a pandemic) or peak prevalence or limiting the socio-economic burden of contact-reducing interventions. We use epidemiological models of influenza A to investigate how contact-reducing interventions and availability of antiviral drugs or pre-pandemic vaccines contribute to achieving particular policy objectives. Our analyses show that the ideal strategy depends on the aim of an intervention and that the achievement of one policy objective may preclude success with others, e.g., constraining peak demand for public health resources may lengthen the duration of the epidemic and hence its economic and social impact. Constraining total case numbers can be achieved by a range of strategies, whereas strategies which additionally constrain peak demand for services require a more sophisticated intervention. If, for example, there are multiple objectives which must be achieved prior to the availability of a pandemic vaccine (i.e., a time-limited intervention), our analysis shows that interventions should be implemented several weeks into the epidemic, not at the very start. This observation is shown to be robust across a range of constraints and for uncertainty in estimates of both R(0) and the timing of vaccine availability. These analyses highlight the need for more precise statements of policy objectives and their assumed consequences when planning and implementing strategies to mitigate the impact of an influenza pandemic.     

Early warning of vulnerable counties in a pandemic using socio-economic variables

In the U.S. in early 2020, heterogenous and incomplete county-scale data on COVID-19 hindered effective interventions in the pandemic. While numbers of deaths can be used to estimate actual number of infections after a time lag, counties with low death counts early on have considerable uncertainty about true numbers of cases in the future. Here we show that supplementing county-scale mortality statistics with socioeconomic data helps estimate true numbers of COVID-19 infections in low-data counties, and hence provide an early warning of future concern. We fit a LASSO negative binomial regression to select a parsimonious set of five predictive variables from thirty-one county-level covariates. Of these, population density, public transportation use, voting patterns and % African-American population are most predictive of higher COVID-19 death rates. To test the model, we show that counties identified as under-estimating COVID-19 on an early date (April 17) have relatively higher deaths later (July 1) in the pandemic.     

The evolutionary emergence of pandemic influenza

Pandemic influenza remains a serious public health threat and the processes involved in the evolutionary emergence of pandemic influenza strains remain incompletely understood. Here, we develop a stochastic model for the evolutionary emergence of pandemic influenza, and use it to address three main questions. (i) What is the minimum annual number of avian influenza virus infections required in humans to explain the historical rate of pandemic emergence? (ii) Are such avian influenza infections in humans more likely to give rise to pandemic strains if they are driven by repeated cross-species introductions, or by low-level transmission of avian influenza viruses between humans? (iii) What are the most effective interventions for reducing the probability that an influenza strain with pandemic potential will evolve? Our results suggest that if evolutionary emergence of past pandemics has occurred primarily through viral reassortment in humans, then thousands of avian influenza virus infections in humans must have occurred each year for the past 250 years. Analyses also show that if there is epidemiologically significant variation among avian influenza virus genotypes, then avian virus outbreaks stemming from repeated cross-species transmission events result in a greater likelihood of a pandemic strain evolving than those caused by low-level transmission between humans. Finally, public health interventions aimed at reducing the duration of avian virus infections in humans give the greatest reduction in the probability that a pandemic strain will evolve.     

COVID 19: challenges for virologists in the food industry

The COVID-19 pandemic is not only a challenge for public health and hospitals, but affects many aspects of our societies. This Lilliput minireview deals with problems that the pandemic causes for the food industry, addressing the presence and persistence of SARS-CoV-2 in the food environment, methods of virus inactivation and the protection of the food worker and the consumer. So far food has not been implicated in the transmission of the infection, but social disruptions caused by the pandemic could cause problems with food security.     

“Pandemic Public Health Paradox”: Time Series Analysis of the 2009/10 Influenza A / H1N1 Epidemiology,Media Attention,Risk Perception and Public Reactions in 5 European Countries

In 2009, influenza A H₁N₁ caused the first pandemic of the 21^st century. Although a vaccine against this influenza subtype was offered before or at the onset of the second epidemic wave that caused most of the fatal cases in Europe, vaccination rates for that season were lower than expected. We propose that the contradiction between high risk of infection and low use of available prevention measures represents a pandemic public health paradox. This research aims for a better understanding of this paradox by exploring the time-dependent interplay among changing influenza epidemiology, media attention, pandemic control measures, risk perception and public health behavior among five European countries (Czech Republic, Denmark, Germany, Spain and the UK). Findings suggest that asynchronicity between media curves and epidemiological curves may potentially explain the pandemic public health paradox; media attention for influenza A H₁N₁ in Europe declined long before the epidemic reached its peak, and public risk perceptions and behaviors may have followed media logic, rather than epidemiological logic.     

Latin American healthcare systems in times of pandemic

The COVID‐ 19 pandemic is a critical test for the already overburdened and mostly underfunded public healthcare systems of Latin America. In a region that suffers from severe inequalities, public healthcare systems are the only source of medical care for a large sector of the population who work in the informal economy or are unemployed. State‐run hospitals and clinics are already overstressed by continuous demand for treatment of vector‐borne diseases and community‐acquired infections as well as high rates of non‐communicable diseases. Ideological misconceptions and denial among Latin America’s political leaders prevented timely preparations for the pandemic and added to chronic governance problems. As ethical expertise in Latin America focuses on research ethics, few hospitals in the region have functioning clinical ethics committees or clinical ethics policy, forcing healthcare personnel to make excruciating treatment decisions in an environment dominated by material scarcity and public distrust. This essay examines the emergence of COVID‐19 in Latin America and the serious challenge that it poses for Latin America's public healthcare systems.     

Mass vaccination for the 2009 H1N1 pandemic: approaches, challenges, and recommendations

The 2009 H1N1 pandemic stimulated a nationwide response that included a mass vaccination effort coordinated at the federal, state, and local levels. This article examines a sampling of state and local efforts during the pandemic in order to better prepare for future public health emergencies involving mass distribution, dispensing, and administration of medical countermeasures. In this analysis, the authors interviewed national, state, and local leaders to gain a better understanding of the accomplishments and challenges of H1N1 vaccination programs during the 2009-10 influenza season. State and local health departments distributed and administered H1N1 vaccine using a combination of public and private efforts. Challenges encountered during the vaccination campaign included the supply of and demand for vaccine, prioritization strategies, and local logistics. To improve the response capabilities to deal with infectious disease emergencies, the authors recommend investing in technologies that will assure a more timely availability of the needed quantities of vaccine, developing local public health capacity and relationships with healthcare providers, and enhancing federal support of state and local activities. The authors support in principle the CDC recommendation to vaccinate annually all Americans over 6 months of age against seasonal influenza to establish a standard of practice on which to expand the ability to vaccinate during a pandemic. However, expanding seasonal influenza vaccination efforts will be an expensive and long-term investment that will need to be weighed against anticipated benefits and other public health needs. Such investments in public health infrastructure could be important for building capacity and practice for distributing, dispensing, and administering countermeasures in response to a future pandemic or biological weapons attack.     

Assessment of Local Public Health Workers' Willingness to Respond to Pandemic Influenza through Application of the Extended Parallel Process Model

Background

Local public health agencies play a central role in response to an influenza pandemic, and understanding the willingness of their employees to report to work is therefore a critically relevant concern for pandemic influenza planning efforts. Witte''s Extended Parallel Process Model (EPPM) has been found useful for understanding adaptive behavior in the face of unknown risk, and thus offers a framework for examining scenario-specific willingness to respond among local public health workers. We thus aim to use the EPPM as a lens for examining the influences of perceived threat and efficacy on local public health workers'' response willingness to pandemic influenza.

Methodology/Principal Findings

We administered an online, EPPM-based survey about attitudes/beliefs toward emergency response (Johns Hopkins∼Public Health Infrastructure Response Survey Tool), to local public health employees in three states between November 2006 – December 2007. A total of 1835 responses were collected for an overall response rate of 83%. With some regional variation, overall 16% of the workers in 2006-7 were not willing to “respond to a pandemic flu emergency regardless of its severity”. Local health department employees with a perception of high threat and high efficacy – i.e., those fitting a ‘concerned and confident’ profile in the EPPM analysis – had the highest declared rates of willingness to respond to an influenza pandemic if required by their agency, which was 31.7 times higher than those fitting a ‘low threat/low efficacy’ EPPM profile.

Conclusions/Significance

In the context of pandemic influenza planning, the EPPM provides a useful framework to inform nuanced understanding of baseline levels of – and gaps in – local public health workers'' response willingness. Within local health departments, ‘concerned and confident’ employees are most likely to be willing to respond. This finding may allow public health agencies to design, implement, and evaluate training programs focused on emergency response attitudes in health departments.     

Coinfection can trigger multiple pandemic waves

Sequences of epidemic waves have been observed in past influenza pandemics, such as the Spanish influenza. Possible explanations may be sought either in mechanisms altering the structure of the network of contacts, such as those induced by changes in the rates of movement of people or by public health measures, or in the genetic drift of the influenza virus, since the appearance of new strains can reduce or eliminate herd immunity. The pandemic outbreaks may also be influenced by coinfection with other acute respiratory infections (ARI) that increase transmissibility of influenza virus (by coughing, sneezing, running nose). In fact, some viruses (e.g., Rhinovirus and Adenovirus) have been found to induce “clouds” of bacteria and increase the transmissibility of Staphylococcus aureus. Moreover, Rhinovirus and Adenovirus were detected in patients during past pandemics, and their presence is linked to superspreading events. In this paper, by assuming increased transmissibility in coinfected individuals, we propose and study a model where multiple pandemic waves are triggered by coinfection with ARI. The model agrees well with mortality excess data during the 1918 pandemic influenza, thereby providing indications for potential pandemic mitigation.     

Mobile SARS‑CoV‑2 screening facilities for rapid deployment and university-based diagnostic laboratory

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has created a public crisis. Many medical and public institutions and businesses went into isolation in response to the pandemic. Because SARS-CoV-2 can spread irrespective of a patient's course of disease, these institutions’ continued operation or reopening based on the assessment and control of virus spread can be supported by targeted population screening. For this purpose, virus testing in the form of polymerase chain reaction (PCR) analysis and antibody detection in blood can be central. Mobile SARS-CoV-2 screening facilities with a built-in biosafety level (BSL)-2 laboratory were set up to allow the testing offer to be brought close to the subject group's workplace. University staff members, their expertise, and already available equipment were used to implement and operate the screening facilities and a certified diagnostic laboratory. This operation also included specimen collection, transport, PCR and antibody analysis, and informing subjects as well as public health departments. Screening facilities were established at different locations such as educational institutions, nursing homes, and companies providing critical supply chains for health care. Less than 4 weeks after the first imposed lockdown in Germany, a first mobile testing station was established featuring a build-in laboratory with two similar stations commencing operation until June 2020. During the 15-month project period, approximately 33,000 PCR tests and close to 7000 antibody detection tests were collected and analyzed. The presented approach describes the required procedures that enabled the screening facilities and laboratories to collect and process several hundred specimens each day under difficult conditions. This report can assist others in establishing similar setups for pandemic scenarios.     

Changes in ischemic stroke presentations,management and outcomes during the first year of the COVID-19 pandemic in Alberta: a population study

Background:Pandemics may promote hospital avoidance, and added precautions may exacerbate treatment delays for medical emergencies such as stroke. We sought to evaluate ischemic stroke presentations, management and outcomes during the first year of the COVID-19 pandemic.Methods:We conducted a population-based study, using linked administrative and stroke registry data from Alberta to identify all patients presenting with stroke before the pandemic (Jan. 1, 2016 to Feb. 27, 2020) and in 5 periods over the first pandemic year (Feb. 28, 2020 to Mar. 31, 2021), reflecting changes in case numbers and restrictions. We evaluated changes in hospital admissions, emergency department presentations, thrombolysis, endovascular therapy, workflow times and outcomes.Results:The study included 19 531 patients in the prepandemic period and 4900 patients across the 5 pandemic periods. Presentations for ischemic stroke dropped in the first pandemic wave (weekly adjusted incidence rate ratio [IRR] 0.54, 95% confidence interval [CI] 0.50 to 0.59). Population-level incidence of thrombolysis (adjusted IRR 0.50, 95% CI 0.41 to 0.62) and endovascular therapy (adjusted IRR 0.63, 95% CI 0.47 to 0.84) also decreased during the first wave, but proportions of patients presenting with stroke who received acute therapies did not decline. Rates of patients presenting with stroke did not return to prepandemic levels, even during a lull in COVID-19 cases between the first 2 waves of the pandemic, and fell further in subsequent waves. In-hospital delays in thrombolysis or endovascular therapy occurred in several pandemic periods. The likelihood of in-hospital death increased in Wave 2 (adjusted odds ratio [OR] 1.48, 95% CI 1.25 to 1.74) and Wave 3 (adjusted OR 1.46, 95% CI 1.07 to 2.00). Out-of-hospital deaths, as a proportion of stroke-related deaths, rose during 4 of 5 pandemic periods.Interpretation:The first year of the COVID-19 pandemic saw persistently reduced rates of patients presenting with ischemic stroke, recurrent treatment delays and higher risk of in-hospital death in later waves. These findings support public health messaging that encourages care-seeking for medical emergencies during pandemic periods, and stroke systems should re-evaluate protocols to mitigate inefficiencies.

In response to the COVID-19 pandemic, affected countries implemented various public health measures to decrease viral transmission. An unintended consequence of these measures could be hospital avoidance by patients with medical emergencies, as observed during other outbreaks in the 2000s.^1,2 Some public health messaging specifically warned groups at high cardiovascular risk, such as older people or those with heart disease, that they were at elevated risk of severe COVID-19.³ Physical distancing may also result in loss of services and support networks, impairing patients’ ability to seek medical assistance.⁴ Furthermore, pandemics generate new challenges of managing personal protective equipment and cleaning protocols,⁵ and additional information bottlenecks, which could result in workflow delays for emergencies like stroke.⁶Previous studies have reported declines in patients presenting to hospital with stroke or acute coronary syndrome during the pandemic.^7,8 A World Stroke Organization survey of members in several countries indicated a sharp reduction in stroke admissions by 50%–80% in the first weeks of the pandemic.⁹ A cross-sectional study reported a global decline in hospital admissions for stroke.¹⁰ Patients who present to hospital seem to be doing so later than usual, perhaps waiting until their condition becomes more severe.^11–14 However, studies have not been at a population level, consequently suffering from selection bias, and have generally focused only on the first wave of the pandemic. As the associations between the pandemic and the incidence, treatment, workflow and outcomes of stroke are likely to be modified by several events — including changing COVID-19 case counts, public health restrictions and health system strains — it is important to explore population data from pandemic periods beyond the first wave to better understand these phenomena.Verifying and quantifying the pandemic’s effect on stroke presentations and workflow can help tailor public health messaging to continue emphasizing the time-critical nature of emergencies like stroke. Such data may also help optimize pandemic stroke workflow protocols. We sought to explore patterns of hospital admissions, treatment rates, workflow delays and outcomes for ischemic stroke during the first year of the COVID-19 pandemic in Alberta, Canada.     

The psychological burden of the COVID-19 pandemic severity

The alarming levels of spread and severity of COVID-19 have dominated global attention. In this time of crisis, there is an urgent need for studies identifying the linkages between the pandemic and social welfare. To help policymakers respond to the situation better, we investigate how the severity of the COVID-19 pandemic can condition people's psychological well-being. Employing the latest weekly panel data within an individual fixed effects framework, we uncover the damaging consequences of the COVID-19 severity, as measured by mortality rate, on the incidences of daily anxiety, worry, displeasure, and depression in the United States. Our work underlines the importance of public spending on mental health, both during and after the pandemic.     

What Does Public Health Ethics Tell (Or Not Tell) Us About Intervening in Non-Communicable Diseases?

Obesity has been described as pandemic and a public health crisis. It has been argued that concerted research efforts are needed to enhance our understanding and develop effective interventions for the complex and multiple dimensions of the health challenges posed by obesity. This would provide a secure evidence base in order to justify clinical interventions and public policy. This paper critically examines these claims through the examination of models of public health and public health ethics. I argue that the concept of an effective public health intervention is unclear and underdeveloped and, as a consequence, normative frameworks reliant on meeting the effectiveness criterion may miss morally salient dimensions of the problems. I conclude by arguing for the need to consider both an ecological model of public health and inclusion of a critical public health ethics perspective for an adequate account of the public health challenges posed by obesity.     

Persistent Pandemics

We ask whether mortality from historical pandemics has any predictive content for mortality in the Covid-19 pandemic. We find strong persistence in public health performance. Places that performed worse in terms of mortality in the 1918 influenza pandemic also have higher Covid-19 mortality today. This is true across countries as well as across a sample of large US cities. Experience with SARS in 2003 is associated with slightly lower mortality today. We discuss some socio-political factors that may account for persistence including distrust of expert advice, lack of cooperation, over-confidence, and health care supply shortages. Multi-generational effects of past pandemics may also matter.     

COVID-19 and children: medical impact and collateral damage

Children mostly experience mild SARS-CoV-2 infections, but the extent of paediatric COVID-19 disease differs between geographical regions and the distinct pandemic waves. Not all infections in children are mild, some children even show a strong inflammatory reaction resulting in a multisystem inflammatory syndrome. The assessments of paediatric vaccination depend on the efficacy of protection conferred by vaccination, the risk of adverse reactions and whether children contribute to herd immunity against COVID-19. Children were also the target of consequential public health actions such as school closure which caused substantial harm to children (educational deficits, sociopsychological problems) and working parents. It is, therefore, important to understand the transmission dynamics of SARS-CoV-2 infections by children to assess the efficacy of school closures and paediatric vaccination. The societal restrictions to contain the COVID-19 pandemic had additional negative effects on children’s health, such as missed routine vaccinations, nutritional deprivation and lesser mother–child medical care in developing countries causing increased child mortality as a collateral damage. In this complex epidemiological context, it is important to have an evidence-based approach to public health approaches. The present review summaries pertinent published data on the role of children in the pandemic, whether they are drivers or followers of the infection chains and whether they are (after elderlies) major sufferers or mere bystanders of the COVID-19 pandemic.     

战“疫”时期“病毒生物学”课程的教学调整与思考

2020年春天,全球进入对抗新型冠状病毒(Severe Acute Respiratory Syndrome Coronavirus 2,SARS-CoV-2)感染引起的"新冠"肺炎(Coronavirus Disease,COVID-19)疫情的斗争中。为了适应全民抗"疫"的新形势,引导学生理性地、科学地认识此次病毒疫情,"病毒生物学"课程的教学从内容到形式也进行了同步设计与微调。除了将教学模式由线下教学变成线上直播,本课程结合疫情发展情况在学期初进行COVID-19的专题讲座,以及通过"COVID-19-5 min"形式每次上课进行疫情周报解读,分析国内外疫情并传授病毒流行病学相关知识。另外,对"病毒生物学"的教学计划和教学内容做了适当微调,更多关注病毒性传染疾病发展和相关科学研究的进展。通过对在线教学从教学模式、教学过程和教学内容的设计和调整,强化教学效果的反馈和改善,引导学生不信谣、不传谣,帮助学生加强对新型冠状病毒(SARS-CoV-2)及疫情的科学认识。通过教学内容和教学形式的调整以及病毒疫情相关知识点的强化,激发了生物学专业学生对病毒学、流行病学及公共卫生健康等问题的关注。     

The evolving role of preprints in the dissemination of COVID-19 research and their impact on the science communication landscape

The world continues to face a life-threatening viral pandemic. The virus underlying the Coronavirus Disease 2019 (COVID-19), Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), has caused over 98 million confirmed cases and 2.2 million deaths since January 2020. Although the most recent respiratory viral pandemic swept the globe only a decade ago, the way science operates and responds to current events has experienced a cultural shift in the interim. The scientific community has responded rapidly to the COVID-19 pandemic, releasing over 125,000 COVID-19–related scientific articles within 10 months of the first confirmed case, of which more than 30,000 were hosted by preprint servers. We focused our analysis on bioRxiv and medRxiv, 2 growing preprint servers for biomedical research, investigating the attributes of COVID-19 preprints, their access and usage rates, as well as characteristics of their propagation on online platforms. Our data provide evidence for increased scientific and public engagement with preprints related to COVID-19 (COVID-19 preprints are accessed more, cited more, and shared more on various online platforms than non-COVID-19 preprints), as well as changes in the use of preprints by journalists and policymakers. We also find evidence for changes in preprinting and publishing behaviour: COVID-19 preprints are shorter and reviewed faster. Our results highlight the unprecedented role of preprints and preprint servers in the dissemination of COVID-19 science and the impact of the pandemic on the scientific communication landscape.

An analysis of bioRxiv and medRxiv during the first 10 months of the COVID-19 pandemic reveals that the pandemic has resulted in a cultural shift in the use of preprints for disseminating pandemic-related science.