COVID-19: Expert Review of Relevant and Emerging Literature

COVID-19: Expert Reviews of Relevant and Emerging Literature2020-05-29T11:40:37-04:00

This report describes how universal, serial reverse transcription-polymerase chain reaction testing of residents in a long-term care skilled nursing facility in Los Angeles, California, helped to interrupt transmission of coronavirus disease 2019 in the facility.

On March 28, 2020, two residents of a long-term care skilled nursing facility (SNF) at the Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS) had positive test results for SARS-CoV-2.

During March 29–April 23, all SNF residents, regardless of symptoms, underwent serial (approximately weekly) nasopharyngeal SARS-CoV-2 RT-PCR testing, and positive results were communicated to the county health department. All SNF clinical and nonclinical staff members were also screened during March 29–April 10.

During this time, 19 of 99 (19%) residents and 8 of 136 (6%) staff members had positive test results; no further resident cases were identified on subsequent testing on April 13, April 22, and April 23. At the time of diagnosis, 14 of 19 residents were asymptomatic, eight of whom were presymptomatic; one patient died.

This report demonstrates the high prevalence of asymptomatic SARS-CoV-2 infection that can occur in SNFs, highlighting the potential for widespread transmission among residents and staff members before illness is recognized and demonstrating the utility of universal RT-PCR testing for COVID-19 after case identification in this setting.

This observational cohort study sought to determine mortality rates among adults with critical illness from coronavirus disease 2019.

The authors examined 217 critically ill patients with confirmed severe acute respiratory syndrome-CoV-2 disease who were admitted to any of 6 COVID-designated ICUs at 3 hospitals within an academic health center network in Atlanta, Georgia from March 6, 2020, to April 17, 2020.

Main findings included:

  • Mortality for those who required mechanical ventilation was 35.7% (59/165)
  • 4.8% of patients (8/165) were still on the ventilator at the time of the report
  • Overall mortality was 30.9% (67/217)
  • 60.4% (131/217) patients survived to hospital discharge
  • Mortality was significantly associated with older age, lower body mass index, chronic renal disease, higher Sequential Organ Failure Assessment score, lower PaO2/FIO2 ratio, higher D-dimer, higher C-reactive protein, and receipt of mechanical ventilation, vasopressors, renal replacement therapy, or vasodilator therapy

A link between SARS-CoV-2 infection and air pollution is plausible and may impact infection and mortality. This study analyzed the relationship between the concentration of air pollutants (PM 2.5 and NO2) and the COVID-19 outbreak in Italy in terms of transmission, number of patients, severity of presentation and number of deaths.

The authors correlated the numbers of COVID-19 cases, ICU admissions and the mortality rate with the severity of air pollution in regions of Italy. They found that areas in Italy with the highest incidence of cases and deaths are the ones with levels of PM 2.5 and NO2 that are chronically high or with recent increases in the 2 months prior to the outbreak.

This is a correlational study, so the findings are not reflective of a causal relationship. Nevertheless, the findings lend support to a ‘double hit’ hypothesis whereby air pollutants, (such as PM 2.5 and NO2) plus SARS-CoV-2 give a “double-hit” to the lungs leading to acute lung injury by attenuating tissue remodeling and influencing local inflammatory response.

This comment discusses the contribution of population movement to the spread of COVID-19, with a reference to the spread of SARS 17 years ago. The authors argue that the changing geography of migration, the diversification of jobs taken by migrants, the rapid growth of tourism and business trips, and the longer distance taken by people for family reunion are what make the spread of COVID-19 so differently from that of SARS. These changes in population movement are expected to continue. Hence, new strategies in disease prevention and control should be taken accordingly. These include:

  1. More equitable distribution of health resources
  2. Increased authority and standard for local authorities to raise the capability needed for dealing with public health events
  3. Better use of real-time data and new technologies for epidemiological surveillance and for disease control
  4. More emphasis on the national stockpile of medical equipment such as ventilators, masks and gowns
  5. Motivation to understand that increasingly, either internally or internationally we are all migrants
Published on :  | By Maria Brann

Review: How to talk about the coronavirus with friends and family

This podcast offers advice for communicating with family and friends about COVID-19.

The two-step flow theory states that information starts with the media and then people take that information and filter it out to other people in an attempt to help friends and family members understand information. Science communicators offer four tips for how to communicate about coronavirus with friends and family:

  • Start where you are with the people you are close to
    • Understand your identity as a messenger to know who you can relate to and how to relate to them
  • Pick your battles
    • People process information through different lenses and so it is important not to attack people’s identities (e.g., do not confuse political arguments with science communication)
    • Identify and affirm a shared identity first so that you are trusted and then the person will be more likely to listen because s/he does not feel attacked
  • Avoid unforced errors
    • Do not reinforce misinformation because the more someone hears something, the more likely that person is to believe it, even if untrue
  • Be honest and transparent
Published on :  | By Maria Brann

Review: How to correct misinformation, according to science

This podcast discusses what to do to combat misinformation.

This podcast promotes evidence-based strategies to effectively combat misinformation. It is recommended to present information from a source that the person you are trying to correct finds credible. Be careful to avoid the overkill backfire effect, which occurs when too many different messages become overwhelming and are too difficult to remember so it is easier to believe the one myth. It is also important not to repeat the misinformation because this leads to the familiarity backfire effect where people hear the misinformation and because it is familiar, they are likely to believe it. Other suggestions include finding common ground, avoiding insults and instead promoting a dialogue, and asking questions (e.g., why do you think this information is true?)

When communicating with others about misinformation, the following best practices are recommended:

  • Correct the misinformation as early as you can
  • Provide correct information in bite-size chunks
  • Offer an alternative to the misinformation
  • Be sure the alternative affirms, not threatens, the person’s worldviews and identity

Specific recommendations for correcting misinformation on social media include:

  • Linking to an expert source
  • Saying facts as simple as possible (without repeating the myth)
  • Having multiple people offer corrections

Findings from this small study suggested that a qualitative fit test alone is unable to fully assess mask integrity and that at the doses required for sterilization, gamma radiation degrades the filtration efficiency of N95 masks.

  • A set of 3M 8210, 1805, and 9105 masks were irradiated using a cobalt-60 irradiator at the Massachusetts Institute of Technology. Three masks of each type received 0 kGy (control), 1 kGy, 10 kGy, and 50 kGy of approximately 1.3 MeV gamma radiation from the source, at a dose rate of 2.2 kGy per hour.
  • Three different particle sizes—0.3, 0.5, and 1 μm—were tested, and the single-pass filtration efficiency was measured using an optical particle counter (Aerotrak 9306; TSI Inc). The measurement system, which was not calibrated for N95 mask certification, was only used to assess the relative changes in the filtration efficiency.
  • All masks (both control and irradiated masks) passed the qualitative fit test.
  • There was statistically significant degradation of filtration efficiency for treated masks.

Public trust in immunization and the rise of vaccine hesitancy are important topics to consider as scientists work to develop vaccines against SARS-CoV-2. This editorial presents data from an online survey about these topics that was administered to a representative sample of the French population aged 18 years and older 10 days after the nationwide lockdown was introduced (March 27–29).

The authors found that 26% of respondents would not use a vaccine against SARS-CoV-2 if/when it becomes available. This attitude was more prevalent among low-income people (37%), who are generally more exposed to infectious disease, among young women (aged 18–35 years; 36%), who play a crucial role regarding childhood vaccination, and among people aged older than 75 years (22%), who are probably at an increased risk for severe illness from COVID-19. Moreover, participants’ acceptation of a vaccine against SARS-CoV-2 strongly depended on their vote at the first round of the 2017 presidential election, such that those who had voted for a far left or far right candidate were much more likely to state that they would refuse the vaccine, as well as those who abstained from voting

This prospective observational cohort study presents information on the epidemiology, clinical course, and outcomes of critically ill patients with COVID-19 in New York City.

The study took place at two New York-Presbyterian hospitals affiliated with Columbia University Irving Medical Center in northern Manhattan. The authors prospectively identified 1150 adult patients (aged ≥18 years) who were admitted to both hospitals from March 2 to April 1, 2020 with diagnosed, laboratory-confirmed COVID-19. Outcomes included rate of in-hospital death, frequency and duration of invasive mechanical ventilation, frequency of vasopressor use and renal replacement therapy, and time to in-hospital clinical deterioration following admission.

Of the 1150 patients:

  • 57 (22%) were critically ill
  • The median age was 62 years (IQR 51–72)
  • 171 (67%) were men
  • 212 (82%) had at least one chronic illness, the most common of which were hypertension (162 [63%]) and diabetes (92 [36%])
  • 119 (46%) had obesity
  • As of April 28, 2020, 101 (39%) patients had died and 94 (37%) remained hospitalised
  • 203 (79%) patients received invasive mechanical ventilation for a median of 18 days (IQR 9–28)
  • 170 (66%) of 257 patients received vasopressors and 79 (31%) received renal replacement therapy
  • The median time to in-hospital deterioration was 3 days (IQR 1–6)

Using cox proportional hazards regression, the following factors were independently associated with in-hospital mortality: older age (adjusted hazard ratio [aHR] 1.31 [1.09–1.57] per 10-year increase), chronic cardiac disease (aHR 1.76 [1.08–2.86]), chronic pulmonary disease (aHR 2.94 [1.48–5.84]), higher concentrations of interleukin-6 (aHR 1.11 [95%CI 1.02–1.20] per decile increase), and higher concentrations of D-dimer (aHR 1.10 [1.01–1.19] per decile increase).


Published on :  | By Megan McHenry

Review: Remdesivir for the treatment of COVID-19 — Preliminary report

This preliminary report from a double-blind, randomized, placebo-controlled study found remdesivir was superior to placebo in shortening the time to recovery in adults hospitalized with Covid-19 and evidence of lower respiratory tract infection. 

  • Enrollment for ACTT-1 began on February 21, 2020, and ended on April 19, 2020 and 73 trial sites/subsites:  United States (45 sites), Denmark (8), the United Kingdom (5), Greece (4), Germany (3), Korea (2), Mexico (2), Spain (2), Japan (1), and Singapore (1)
  • Participants had to meet one of the following criteria suggestive of lower respiratory tract infection at the time of enrollment: radiographic infiltrates by imaging study, peripheral oxygen saturation (SpO2) ≤94% on room air, or requiring supplemental oxygen, mechanical ventilation, or extracorporeal membrane oxygenation (ECMO). Initially had a requirement for RT-PCR positive SAR-CoV-2 test result but this was modified due to limited testing capacity.
  • Patients were randomly assigned to receive either remdesivir (200 mg loading dose on day 1, followed by 100 mg daily for up to 9 additional days) or placebo for up to 10 days.
  • The primary outcome measure was the time to recovery, defined as the first day, during the 28 days after enrollment, on which a patient satisfied categories 1, 2, or 3 on the eight-category ordinal scale.
  • Of the 1107 patients who were assessed for eligibility, 1063 underwent randomization; 541 were assigned to the remdesivir group and 522 to the placebo group
  • Patients in the remdesivir group had a shorter time to recovery than patients in the placebo group (median, 11 days, as compared with 15 days; rate ratio for recovery, 1.32; 95% confidence interval [CI], 1.12 to 1.55; P<0.001; 1059 patients)
  • The odds of improvement in the ordinal scale score were higher in the remdesivir group, as determined by a proportional odds model at the day 15 visit, than in the placebo group (odds ratio for improvement, 1.50; 95% CI, 1.18 to 1.91; P=0.001; 844 patients)
  • Mortality was numerically lower in the remdesivir group than in the placebo group, but the difference was not significant (hazard ratio for death, 0.70; 95% CI, 0.47 to 1.04; 1059 patients)
  • Safety outcomes analysis did not show statistically significant concerns for the use of remdesivir

Ethical framework for managing the health services response to Covid-19 proposed by UK experts  The authors of “Ethical anchors and explicit objectives: ensuring optimal health outcomes in the Covid 19 pandemic” attempt to fill a gap caused by what they see as a lack of “an overall ethical framework for managing the health service response to the covid-19 pandemic” being offered by either the UK government or national professional bodies. While action plans have been created, the authors fear this effort “falls short of providing a clear set of objectives for desired patient and population outcomes which can be adopted by institutions and professional and patient bodies.”

They suggest that the health system be guided by a primary ethical requirement: to achieve the best possible health outcomes while working to address issues such as the distribution of finite resources and balancing the need to protect care providers as well as provide care to patients. This results in the creation of four objectives for health services pursuing the best possible outcomes:

  1. for those infected with covid-19;
  2. for those suffering from non covid-19 related illnesses and long term conditions;
  3. for the workforce looking after all of these patients;
  4. and for future generations of patients that the health care system will need to continue to look after.

The authors also suggest adopting the ethical principle: Treat people as equals, requiring that any decision to treat people differently within the system be justified on morally and legally defensible grounds. Finally, they suggest a third guiding ethical principle: Treat people with respect, as a way to support the following fifth objective:

5. People—at both individual and population levels – should be kept as informed as possible; they should have the chance to express their views on matters that affect them (for example in decisions about admission to hospital or ICU or the risks of visiting infected relatives); and their views about their treatment and care should be appropriately respected.

How has Japan succeeded without lockdowns or mass testing? According to Bloomberg Law, Japan is on the verge of ending their emergency, and they achieved this without restricting peoples’ movements, closing restaurants or hairdressers, testing most of its population (they’ve only tested 0.2% of their residents), or high tech tracking apps. While there has been no silver bullet, experts point to the Japanese peoples’ strong health consciousness, as well as the following, as contributors to their success:

  1. Strong contact tracing that began with the discovery of the first infections in January and has focused on tracking and then containing clusters of infections that may have arisen in clubs and/or hospitals. Japan has invested in strong local public health infrastructures, including their local public health centers, who prior to the outbreak already employed more than 25,000 public health nurses experienced in contact tracing.
  2. Lessons learned from the Diamond Princess cruise ship response, which (a) helped their residents to see the seriousness and contagiousness of the virus, and (b) led the Japanese public to look to medical and scientific leaders, rather than politicians, for response guidance.
  3. “The Three C’s” – Closed Spaces, Crowded Spaces, and Close-Contact Settings – this easy-to-understand messaging campaign helped people learn the most dangerous situations to avoid.

Mitch Daniels Opinion piece in the Washington Post: Purdue has a duty to reopen with in person classes this Fall According to the former Indiana governor, the core pieces of data driving this decision include that “[m]ore than 80 percent of the total campus population is 35 and under” and that “this bug…poses a near-zero risk to young people.” He continues, “The challenge for Purdue is to devise maximum protection for the unusually small minority who could be at genuinely serious risk in order to serve the young people who are our reason for existing at all.” The piece describes ways they will reduce campus density, including requiring “at least one-third of our staff” to work remotely, redesigning classrooms, labs and dormitory rooms to reduce occupancy, and offering courses online as well as in person. Daniels also promises systematic testing and tracing, and not allowing “concerts, convocations and social occasions” such as fraternity parties.

New Medicare rule encourages Medicare Advantage plans to increase telehealth offerings to those living in rural areas.  The new rule will make Medicare Advantage plans “eligible to receive a 10-percentage point credit towards the percentage of beneficiaries residing within published time and distance standards when they contract with telehealth providers in the following provider specialty types: Dermatology, Psychiatry, Cardiology, Otolaryngology, Neurology, Ophthalmology, Allergy and
Immunology, Nephrology, Primary Care, Gynecology/ OB/GYN, Endocrinology, and Infectious Diseases.”

Courts uphold Executive Orders of California & Michigan governors. The 9th Circuit Federal Court of Appeals, in a 2-1 decision, upheld the California governor’s authority to apply its stay at home order to restrict in-person religious services along with other types of gatherings. The challenge to the order was being led by a southern California church. According to the Court, “We’re dealing here with a highly contagious and often fatal disease for which there presently is no known cure. In the words of Justice Robert Jackson, if a ‘[c]ourt does not temper its doctrinaire logic with a little practical wisdom, it will convert the constitutional Bill of Rights into a suicide pact.'”  An appellate court in Michigan upheld an executive order by that state’s governor over a challenge by their state legislature, indicating that the governor had authority under a 1945 state emergency powers law.


This commentary calls on health care providers, social media platforms, professional bodies, and the public to identify and combat the spread of misinformation.

A global infodemic (an epidemic of misinformation) is spreading rapidly through social media and other outlets, creating serious obstacles to public health interventions. This misinformation is creating fear, confusion, and stigmatization, which may lead people to engage in dangerous practices. The World Health Organization is working to control the spread of misinformation, but it needs help from social media companies, health care providers, and others to be successful. Updated information must be disseminated from credible sources, and fact-checking must occur before sharing any information.

Published on :  | By Maria Brann

Review: Public engagement is key for containing COVID-19 pandemic

This commentary highlights the importance of educating and empowering the community for effective non-pharmaceutical interventions in responding to the COVID-19 outbreak.

Multiple factors collectively increase risk vulnerability to COVID-19, which must be addressed with appropriate communication tools to promote prevention and response to the pandemic. Public engagement is key for effective responses, and that engagement is predicated on trust and transparency. Messages must be tailored to meet the needs of individuals and influences affecting their decisions (e.g., culture). At the same time, the communication must counter the misinformation circulating to reduce stigma and discrimination.

Published on :  | By Erika Cheng

Review: COVID-19 in pregnant women

This case series describes characteristics of pregnant women in New York City with confirmed or presumed coronavirus disease (COVID-19) infection.

Beginning March 22, 2020, the authors contacted all pregnant women from one large obstetrical practice in New York City to inquire about symptoms of COVID-19 (fever, cough, shortness of breath, malaise, anosmia), or sick contacts. They kept a running log of these patients, as well as all patients who underwent COVID-19 testing.

From March 22, 2020 until April 30, 2020, they evaluated 757 pregnant women, 92 of whom had known or suspected COVID-19 (12.2%, 95% confidence interval [CI]: 10.0-14.7%).

Of these 92 women, 33 (36%) had positive COVID-19 test results. Only one woman required hospital admission for 5 days due to COVID-19 (1.1%, 95% CI: 0.2-5.9%). One other woman received home oxygen. No women required mechanical ventilation and there were no maternal deaths. One woman had an unexplained fetal demise at 14 weeks’ gestation around the time of her COVID-19 symptoms. At the time of publication, 21 of the 92 women  delivered, and all were uncomplicated.

A new study revealed that African American COVID-19 patients in Northern California are 2.7 times more likely to be hospitalized than Non-Hispanic White patients and tend to arrive at healthcare facilities sicker and with more severe symptoms.

The authors examined retrospective data from a cohort of 1,052 COVID-19 patients at Sutter Health, a large integrated health care system in northern California. They identified adults with suspected and confirmed COVID-19 from January 1-April 8, 2020 used multivariable logistic regression to assess risk of hospitalization, adjusting for known risk factors, including race/ethnicity, sex, age, health, and socioeconomic variables.

The find suggest that African Americans with COVID-19 have greater odds of hospital admission suggest that they present for testing and medical care at more advanced or severe stages of illness. The authors propose a variety of mechanisms that could account for this delay, including unknown or unmeasured genetic or biological factors that increase the severity of COVID-19, societal factors that either result in barriers to timely access to care or create circumstances in which patients view delaying care as the most sensible option, and unconscious biases on the part of providers and prior negative experiences that lead to distrust.



Published on :  | By Aaron Carroll

ICYMI – The COVID-19 week in review (May 22, 2020).

This will be an ongoing, weekly post that will highlight the things you should have read (at least in MY opinion).

Articles you might have missed:

  1. Moderna Coronavirus Vaccine Trial Shows Promising Early Results, by Denise Grady. It’s only 8 people, and it’s only phase 1, but it’s progress.
  2. ‘I Can’t Turn My Brain Off’: PTSD and Burnout Threaten Medical Workers, by Jan Hoffman. Medical workers are at risk for mental health issues because of work and the pandemic.
  3. America’s Patchwork Pandemic Is Fraying Even Further, by Ed Yong. Always read Ed Yong.
  4. Group fitness class responsible for more than 100 coronavirus cases, study warns, by Vincent Barone. A CDC report should concern us all as gyms open.
  5. Lockdown Delays Cost at Least 36,000 Lives, Data Show, by James Glanz and Campbell Robertson. Based on a new study.

Documents for your review:

  1. Pandemic Resilience: Getting it Done. From the Edmond J. Safra Center for Ethics at Harvard. This is a plan with some heft, providing numbers and benchmarks. Worth a read.

What I’m writing:

Published on :  | By Daniel Orenstein

Ethics, Law & Policy Roundup: Resource Allocation and Triage

Resource allocation and disability rights: Growing consensus against categorical exclusions

There is growing consensus among ethical, legal, health policy experts that protocols for triage or allocation of scarce resources during a public health emergency must be improved to ensure they serve their intended goals while avoiding disadvantaging persons with disabilities or other populations. Two perspective articles in the New England Journal of Medicine address issues surrounding which criteria should and should not be considered in allocating scarce resources, and both reject the application of rigid exclusionary criteria.

  • In the first of the NEJM pieces, the authors argue that policies must meet dual goals of optimizing health outcomes and protecting core values such as the equal moral worth of all persons. They recommend focusing on near-term survivability, prioritizing patients who are both most likely to die without an intervention and also most likely to survive with that intervention based on best available clinical evidence. They argue that survivability can and should be assessed independent of disability and that scoring systems should not include measures of quality-adjusted or disability-adjusted life-years due to their potential for discrimination and bias. In contrast, the authors note the appropriate (though contentious) goal of saving the most life-years, arguing that it is ethically appropriate as a tiebreaker among patients with similar clinical scoring if supported by clinical evidence and individualized assessments rather than stereotypes or generalizations.
  • The authors of the second NEJM piece emphasize the role of existing anti-discrimination laws and the importance of honoring commitments to anti-discrimination principles while appropriately stewarding scarce resources during a public health emergency. The authors catalogue objections raised by disability rights advocates to various state resource allocation plans and argue that allocation decisions must be based on an individualized assessment of a patient’s prospects of benefiting from treatment. This means rejecting the application of categorical exclusionary criteria, particularly those based on disability, as well as the incorporation of any imposed calculations of quality of life, which are heavily influenced by biases regarding disability. In contrast to the first NEJM piece, the authors argue that long-term life expectancy should also be avoided as a criteria due to uncertainty and bias, but they do acknowledge that consideration of near-term prognosis is acceptable and commonly applied in other scarce resource contexts, such as organ transplantation.

Additionally, this article in American Journal of Bioethics, which shares two authors with the second NEJM perspective, evaluates various state crisis standards of care (CSC) plans from ethical, legal, disability, and implementation perspectives. The authors conclude that an optimal CSC policy for scarce resource allocation (including use of cardiopulmonary resuscitation) during a public health emergency should not apply categorical exclusions.


Allocating scarce inpatient medications: Guidance for who should receive priority for existing and future drug interventions

There are currently no drugs with demonstrated efficacy in treating or preventing COVID-19, though the FDA has issued emergency use authorizations allowing drugs that are otherwise unapproved (remdesivir) or approved for other conditions (hydroxychloroquine) to be used based on limited preliminary evidence of possible efficacy. While many hope for rapid development of more effective drugs or treatments in the future, even in the best case scenarios allocation of both existing and newly developed drugs will pose ethical and policy challenges regarding who should receive initial allocations.

This JAMA viewpoint offers ethical principles to guide decision-making for current and future drug interventions for COVID-19 based on goals of:

  • saving the most lives, reducing duration of hospitalization or mechanical ventilation, and preventing new cases
  • decreasing disparities in case-fatality rates (e.g., due to social determinants of health)
  • strengthening the community’s ability to respond by protecting essential workers
  • preserving supplies of existing medications for patients with chronic illnesses who depend on them
  • reserving sufficient supplies of the drug to conduct additional well-designed clinical trials (to save more lives in the long run with a stronger evidence base).

Toward those ends, the authors offer the following practical recommendations:

  • Allocation should be evidence-based with priority to patient groups shown to benefit in rigorous clinical trials (e.g., those who meet study inclusion criteria) and evidence should be reviewed continuously
  • Prioritization should not exclude patients based on factors such as age, disability, race/ethnicity, gender, or perceived quality of life
  • For existing FDA-approved medications, patients already receiving the drug for other serious conditions (based on good clinical evidence) should continue to receive it
  • Base judgments on which patients might benefit the most or least on rigorous evidence and avoid making inferences about the benefits of a scarce drug based on anecdotal experience, observational data on disease trajectory, or post hoc subgroup analyses of small trials
  • Use random allocation (e.g., lottery) rather than first-come, first-served, and potentially give some priority to essential workers within lottery
  • Provide clinicians support in difficult discussions with patients who do not receive the drug and with their families.
Published on :  | By Daniel Orenstein

Ethics, Law & Policy Roundup: Health Care Workforce

Ethical Challenges: Protecting patients and providers

The COVID-19 pandemic poses significant ethical challenges for health care professionals, including nurses, who represent the largest share of the global health care workforce. While facing the danger of infection is an accepted part of working in the field, the well-documented absence of adequate protection due to the scarcity of personal protective equipment (PPE) presents more complicated ethical and professional questions about the duty to care and the limits of that duty. Nurses have a primary duty to the recipient of care, but they also have a duty to promote their own health and safety. Shortage of PPE may increase demands on nurses as facilities restrict the number of personnel entering patient rooms, but nursing perspectives are not consistently included in resource allocation decision-making. Difficult allocation decisions that may result from resource scarcity (e.g., denial or withdrawal of ventilator support) may also exacerbate moral and emotional discomfort, and nurses and other frontline workers often report different perceptions of these actions compared to bioethicists and others.

It is also important to pay attention to how the health care workforce itself is allocated. Some staff may be allocated to higher-risk roles in managing patients, and the process used to make these decisions raises ethical questions. For example, giving staff no choice or ability to opt-out of assignment to high-risk roles may be efficient, but it is likely to be unfair and potentially unethical, as some staff inevitably face greater risks based on their own health and other factors.

Whether to prioritize frontline health care workers is a contentious ethical issue, but the authors of this article in the American Journal of Bioethics make three related arguments favoring priority. First, benefits to providers also benefits those they care for, creating a multiplier effect, provided that the provider will be able to return to practice in time to assist others. Second, as part of the social contract, health care workers receive privileges and powers in exchange for agreeing to serve society by helping the sick even at personal risk, and society in turn agrees to care for these workers if they fall ill. Third, and closely related to the second, health care workers are owed a duty of reciprocity by society on the basis of the risks they face in providing care during a pandemic.


Liability Protections for Health Care Providers

In providing care amid case surge, constrained resources, and other challenges, many health care providers are concerned about the potential that they may face malpractice lawsuits for failing to provide the usual standard of care, but many states have acted to shield providers against civil liability in these circumstance. Governors in several states (e.g., Connecticut and Illinois) have provided protections for providers by executive order, and other states (e.g., New York and New Jersey) have created new protections under state law. Such protections typically immunize providers from liability for simple negligence (failure to meet the usual standard of care), meaning they can only be held liable for more egregious failures (gross negligence or willful misconduct, which are uncommon). These protections are in some cases tied to implementation of crisis standards of care (CSC) that recognize an inability to provide usual care due to surrounding circumstances, and they are conceptually related to protections provided to “good Samaritans” who provide care during an emergency. Some states have existing statutes that immunize providers during a declared public health emergency without requiring any additional state action such as an executive order. This approach may help eliminate uncertainty faced by providers in other states who may be providing care while awaiting the governor to issue an order.

Indiana (along with Louisiana, Maryland, and Virginia) has statutes that provide immunity for providers during a declared emergency without additional state action.

This article proposes that team reflexivity among government officials can reduce errors and biases in decision-making during a crisis.

Team reflexivity is a deliberate process of discussing team goals, processes, or outcomes. This communicative process has been shown to be effective at reducing information-processing failures, such as groupthink. This is particularly important during the COVID-19 pandemic when governments must make decisions based on limited information. Policymakers should utilize team reflexivity to reduce the risk of bias and errors in decision-making to avoid widespread damage.

This study cautions against spending too much time on social media for COVID-19 information because of its possible link to anxiety and depression.

One-fifth of the general population and one-fifth of the health professional population in China reported anxiety and depression, and about one-third of each of these populations spent more than two hours per day consuming COVID-19 information on social media. Caution is warranted when searching social media for COVID-19 news given the infodemic and emotional contagion disseminated through online platforms. However, the internet may be used positively by monitoring the effect of the pandemic on mental health (possibly thorough online social support) and by restoring daily routines and telemedicine opportunities.

COVID-19 Digest Links
Creative Commons License The literature reviews on this blog were created under a Creative Commons Attribution-NonCommercial 4.0 International License , which allows the reuse and adaptation of the work by noncommercial entities. These rights do not extend to the articles that the authors are reviewing.
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