Vulnerable Populations

This study by Clift, et al. from the United Kingdom assessed COVID-19 mortality risk among persons with Down syndrome. Down syndrome has not been included among known risk factors by UK or US health authorities, but it is associated with immune dysfunction and other potentially relevant pathologies. The authors observed a 4-fold increase in risk of hospitalization and a 10-fold increase in risk of death among persons with Down syndrome, even after adjusting for cardiovascular and pulmonary diseases and residence in care homes. Additional research would help understand potential increased risks for this population, but the results of the study warrant additional public health and health care attention.

Health Care Workers

This CDC MMWR provides data on health care worker (HCW) exposure and infection from March to July in Minnesota. The report found that among over 21,000 HCW exposures, 25% were in higher-risk exposures (including aerosol-generating procedures or being within 6 feet for over 15 minutes). Of these, 66% of exposures involved patient care, and 34% involved non-patient contacts. HCWs working in congregate living and long-term care settings were found to be more likely to return to work after an exposure, to work while symptomatic, and to have positive test results. These findings indicate substantial risk of transmission to residents and highlight the importance of prevention measures, including diligent mask use, and the need for adequate leave and testing policies to reduce risk.

This article by Kates, Gerolamo and Pogorzelska-Maziarz addresses the impact of COVID-19 on hospice and palliative care workforce and service delivery. The study of 36 members of this workforce found a majority (70%) reporting increased palliative care services during the pandemic and a majority (78%) reporting having cared for confirmed COVID-19 patients. However, only 58% reported access to laboratory facilities for surveillance and detection and only 55% had the ability to test patients and providers for COVID-19. While this is a small study, the context provided by qualitative comments from the workforce members highlights critical issues with respect to the challenges facing this sector in addressing the impact of social distancing measures, visitation restrictions, staffing and supply shortages, and psychological stress.

This commentary by Armstrong et al. reviews literature on several related issues related to health care workforce and examines the relationships of these issues to the present pandemic. The reviewed articles include discussions of the evolving role of medical assistants in primary care, advanced practice clinicians in community health centers, gender diversity in dentistry, occupational and physical therapy assistants in skilled nursing facilities, and nurses in home-based care.

Resource Allocation

This Health Affairs blog by Millum argues against the use of weighted lotteries for allocation of scarce treatment resources for COVID-19. The blog states that two general values are broadly supported in health care priority ethics: maximizing community benefit and reducing rather than exacerbating exiting inequities. The author argues that the widely cited “Pittsburgh policy”  (developed by a team at the University of Pittsburgh), by using a weighted lottery system among eligible patients to balance existing inequities, fails to achieve these goals. Of note, however, many resource allocation policies that implement a lottery system of any type use them only to assign priority among groups of patients already similarly scored based on other metrics.

This commentary by Cheung and Parent challenges prioritization of health care workers (HCWs) under existing resource allocation guidelines for situations of scarcity. Specifically, the authors first argue that prioritization of HCWs may exacerbate public mistrust by creating the appearance of biased allocation, insomuch as these policies appear to favor those responsible for allocations and for creation of the policies themselves. Second, they argue that HCW prioritization is often based on justifications that are inconsistent with the general ethical principles supporting other aspects of existing guidelines. Specifically, this type of prioritization is usually grounded in either reciprocity (a duty of society to HCWs for their above-average level of risk) or in narrow social utility (the instrumental value of HCWs in addressing the event that is causing scarcity). However, these principles are arguably an inconsistent exception to the overall ethical frameworks adopted in allocation plans that are centered on resource stewardship and benefit maximization.