key: cord-352649-6yzddeua authors: opiniano, gina a.; biana, hazel t.; dagwasi, charlie m.; joaquin, jeremiah joven b. title: should beach travel in the philippines resume during the covid-19 outbreak? date: 2020-10-19 journal: public health doi: 10.1016/j.puhe.2020.10.005 sha: doc_id: 352649 cord_uid: 6yzddeua nan the psychological stresses brought about by extreme cases such as the covid-19 outbreak. beach-going can help "confront the world's darker side and human tragedy, a reminder of one's mortality and place in a universal cycle" thereby making "one's minor troubles seem relatively insignificant". 6 perhaps, this is one of the reasons why, despite strict quarantine protocols, there have been quite a number of citizens arrested for hanging out or sailing in philippine beaches. 7 the reopening proved to be premature, however. since the restart, the number of covid-19 cases have ballooned from 12 091 in may 15 to 136 368 cases in august 10. 8 thus, proving that the health risk is still high. how, then, do we balance the economic and psychological gains of reopening beach resorts to the public given the risk? how do we weigh the cost and benefits? the philippine government has seemed to wave the white flag on this issue, and just opted to let the people decide. department of tourism. health and safety guidelines for accommodation establishments under the new normal what experts say about coronavirus in water --and what it means for beach season the risk levels of everyday activities like dining out, going to the gym, and getting a haircut, according to an infectious-disease expert 50 arrested for disobeying ecq rules in cebu | inquirer news. inquirer news coronavirus cases: philippines key: cord-344425-27q9x6hb authors: mantica, guglielmo; riccardi, niccolò; terrone, carlo; gratarola, angelo title: reply to d.g. barten et al “re: non-covid-19 visits to emergency departments during the pandemic: the impact of fear” date: 2020-07-13 journal: public health doi: 10.1016/j.puhe.2020.07.003 sha: doc_id: 344425 cord_uid: 27q9x6hb nan dear editor, we read with interest the reply letter of dg barten et al 1 to our manuscript 2 and we do strongly agree with the authors about some indirect effects of the lockdown during the covid-19 pandemic, such as social distancing, reduction of working hours, and traffic movements as co-responsible for the reduced access to the emergency departments by non-covid-19 patients. in fact, many diseases, both acute and chronic, in particular non-sars-cov-2 infections and trauma, may be influenced by these factors. however, some other pathologies, such as renal colic that should see an increase in incidence with prolonged sedentary activity levels, showed a reduction in the number of emergency department attendances, giving further support to the covid-fear theory. 3 sars-cov-2 is an ongoing pandemic with disastrous effects on a global level both from the health point of view and on the economic and social system. however, while understandably most of the media focuses on covid-19, people on every continent continue to fall ill with equally serious diseases. 4 our worry is that even people with serious or potentially serious pathologies will avoid or delay medical attention for fear of contracting the virus. while it is relatively easy to access data regarding covid-19 mortality, it is difficult to estimate the mortality related to the lack of medical attention for patients with other diseases. this could even represent the tip of the iceberg. in this perspective, streamline the workflow in emergency departments and non-covid departments as well as effective communication by the health-care system of different countries becomes fundamental in order to provide patients with covid-free pathways, thus reducing delay in diagnosis and treatment. 5 the media should stand side by side with national healthcare systems to provide clear and useful information to patients, in order to help patients with non-covid-19 pathologies and to decrease the fear of seeking medical attention during pandemic. non-covid-19 visits to emergency departments during the pandemic: the impact of fear'. public health, ahead of print non-covid-19 visits to emergency departments during the pandemic: the impact of fear stepping forward: urologists' efforts during the covid-19 outbreak in singapore treat all covid 19-positive patients, but do not forget those negative with chronic diseases risk communication during covid-19 key: cord-351065-nyfnwrtm authors: zhang, tenghao title: integrating gis technique with google trends data to analyse covid-19 severity and public interest date: 2020-09-16 journal: public health doi: 10.1016/j.puhe.2020.09.005 sha: doc_id: 351065 cord_uid: nyfnwrtm nan at the time of writing, the tally of confirmed novel coronavirus cases worldwide has exceeded 26.6 million. 1 the united states has become the global epicentre since april 2020, and now it is accounted for nearly one-quarter of the world's total cases. some studies suggest that health related issues can cause anxiety which may lead to increased public attention, typically manifested by online information search. 2,3 along the same lines, given the substantial regional disparities of covid-19 case severities across states in the united states, the relationship between regional case severities and the public interest emerges as an imperative for covid-19-based public health studies. to investigate the relationship between the above two indicators, geographic information systems (gis) techniques can play a crucial role. adams et al.'s (2020) gis-based study points out the shortcomings of using unnormalized covid-19 demographic data in choropleth mapping, and their use of the normalized data (confirmed cases per 100,000 people) presents a more accurate visualisation of pandemic severity. 4 while i entirely agree with their point of view and methods, i would like to propose an alternative gis technique which has the potential to facilitate a better understanding of the research, namely, the cartogram technique. 5,6 a cartogram is a map in which the geometry of areas is distorted to convey the value of an alternative thematic mapping variable. 6 hence, if the normalized covid-19related data is used in a cartogram, it can provide some novel perspectives on data interpretation. to perform the analysis, the data were obtained from two sources. the covid-19 case data were retrieved from the us health authority (https://cdc.gov/covid-datatracker). i retrieved the total confirmed cases per 100,000 population by state, and then i divided the new confirmed cases (during the past week of data collection) by the total previous cases and obtained a growth of new cases indicator. public interest was captured by people's google search data in each state. 7 the data were acquired from the google trends service, which uses a normalized relative search volume available from www. worldometer.info (accessed 5th the role of health anxiety in online health information search health anxiety in the digital age: an exploration of psychological determinants of online health information seeking the disguised pandemic: the importance of data normalization in covid-19 web mapping diffusion-based method for producing density-equalizing maps area cartograms: their use and creation monitoring public interest toward pertussis outbreaks: an extensive google trends -based analysis mapping the changing internet attention to the spread of coronavirus disease 2019 in china key: cord-354989-k0qktzor authors: mantica, guglielmo; niccolò riccardi,; terrone, carlo; gratarola, angelo title: non-covid-19 visits to emergency departments during the pandemic: the impact of fear date: 2020-05-07 journal: public health doi: 10.1016/j.puhe.2020.04.046 sha: doc_id: 354989 cord_uid: k0qktzor nan the novel coronavirus, sars-cov-2, and the resulting infection, covid-19, is posing an enormous threat and huge workload to emergency departments (eds) worldwide 1 . the covid-19 pandemic is a major health emergency that is impacting the behaviour of entire populations in response to a direct threat to both individuals and communities. italy saw an exponential growth in covid-19 cases from the day the first patient was identified in the north of italy until the 9th of march, when the italian government imposed the national lockdown. this measure represented a necessary and inevitable action in order to reduce the spread of infection; however, it also created an environment of strong emotions in the community, especially fear. recent studies have shown a significant reduction in ed visits related to different disciplines over the first weeks of the pandemic 2-3 . the consensus is that patients were avoiding going to hospitals because they feared getting infected with covid-19. this may highlight the over-use of eds by non-emergency and low complex cases that could be managed by general practitioners; however, there may also be a worrisome tendency to postpone consultations with specialists, even when necessary. we compared ed visits in two major referral hospitals in the north of italy from the 21st february to 16th april with covid-19 daily mortality data from the italian civil protection department 4 (see figure 1 ). it emerges that the two curves almost mirror one another, with a meeting point on the 16th of march and the lowest peak of ed visits corresponding with the highest peak in the covid-19 daily mortality trend. ed visits have recently shown a timid turnaround, reaching 150 visits/day on 16th april, which suggests the two curves will meet again in the coming next weeks. the slow upward trend of non-covid-19 visits to eds presents a milder slope than the reduction in covid-19 mortality, indicating how the behaviour of a population in a negative emotional state containing covid-19 in the emergency room: the role of improved case detection and segregation of suspect cases impact of coronavirus disease 2019 (covid-19) outbreak on st-segment-elevation myocardial infarction care in hong kong, china. circ cardiovasc qual outcomes delayed access or provision of care in italy resulting from fear of covid-19 the untold toll -the pandemic's effects on patients without covid-19 figure 1 -non-covid-19 emergency department admissions vs covid-19 daily deaths legend to figure sacro cuore don calabria hospital our sincere thanks go to the emergency departments of both institutions for their strong efforts during the covid-19 emergency.we are grateful to dr claudio duffini and dr francesco oneto for their support on providing data, and carolina benzi for the english editing. may require a longer time to change and, mostly, that the fear of what we can get might be greater than the fear of what we have 5 . key: cord-355869-r68fccx0 authors: ogle, h.l.; sharma, r.k. title: who must take responsibility for the health of the profession? us date: 2020-07-19 journal: public health doi: 10.1016/j.puhe.2020.06.018 sha: doc_id: 355869 cord_uid: r68fccx0 nan letter to the editor who must take responsibility for the health of the profession? us this letter is not a commentary on the specifics of pandemic responses by nations or healthcare services. this is a wholly inward reflection as to one vital way in which we, as healthcare workers, can and must take control of the controllable. it may be an unfortunate benefit if instigated now due to the pandemic-induced anxieties, but benefit, nonetheless. when their profession is health, it should be surprising that many doctors do not adequately manage their own. however, to most doctors, this is an accepted sacrifice superseded by the long hours and stressful nature of the work. with few spare hours, exercise cannot be made a priority, and almost one in four doctors engage in absolutely no physical activity. 1 in turn, it cannot then be a shock to see that 28.8% of healthcare professionals are obese. 2 across the profession, the benefits of an active lifestyle and healthy diets are pushed unapologetically. but why does it seem so fundamentally unachievable in ourselves? is it as suggested, a tacit inability, or is it in fact a more blatant hypocrisy? in recent times, health has dominated all aspects of our lives. the global population has become acutely aware of the existence of comorbidities and the negative consequences of poor health. from the very start, it has been apparent that those worst affected by coronavirus disease 2019 (covid-19) suffer from underlying health conditions. recent figures state that 94% of total deaths from the virus have occurred in patients with at least one comorbidity. 3 given the innate vulnerabilities of working in health care at such a time, the additional susceptibility owing to ill-health is just one factor completely within our control. healthier lifestyles are needed across the entire profession, and this is a learning opportunity that we cannot afford to ignore. the pandemic has provided abundant proof that this is a matter of life or death. promoting a healthy lifestyle within the profession must be integral as we forge the route into the 'new normal' of healthcare provision. this is before mentioning the innumerable benefits for all other parties, including employees, from longevity in the workforce through to improved patient adherence. we concede that there is a certain degree of optimism that change will be so easy to come by, but there is already evidence that small and cumulative changes make vast differences. 4 action, quite simply, must be taken. the onus, for this at least, is on us. do as we say, not as we do?" the lifestyle behaviours of hospital doctors working in ireland: a national cross-sectional study obesity prevalence by occupation in washington state, behavioral risk factor surveillance system covid-19: underlying metabolic health in the spotlight the effectiveness of worksite nutrition and physical activity interventions for controlling employee overweight and obesity key: cord-262577-70ifjvkf authors: kong, q.; jin, h.; sun, z.; kao, q.; chen, j. title: non-pharmaceutical intervention strategies for outbreak of covid-19 in hangzhou, china date: 2020-04-24 journal: public health doi: 10.1016/j.puhe.2020.03.005 sha: doc_id: 262577 cord_uid: 70ifjvkf nan letter to the editor non-pharmaceutical intervention strategies for outbreak of covid-19 in hangzhou, china hangzhou, a city with a population of more than 9.86 million in the south of china, encountered a large-scale outbreak of covid-19 with 169 confirmed cases reported from january 21 to february 19. as there were no vaccines or antivirals, the spread of the disease was controlled by non-pharmaceutical interventions for nearly 45 days. on february 28, 2020, who director-general tedros declared that the impact risk of covid-19 had increased to 'very high at a global level'. 1 in countries such as italy, the republic of korea, iran, and japan, the number of new cases has kept increasing, although the number of cases has been declining in china. 2 in the following paragraphs, we introduce intervention strategies in hangzhou and hope these strategies will help cities still suffering from covid-19. the implementation of interventions can be divided into three stages in hangzhou, as shown in fig. 1 . the first stage was from january 21, the first confirmed case reported, to february 2. the interventions were isolation of patients or suspected patients, quarantine of close contacts, and disinfection of locations where the patients had been previously. fifty-five imported cases and 37 local cases who had been close contacts of imported cases were detected and isolated from a total of 109 confirmed cases in this stage. however, seven cases of unknown origin had been reported in succession in tonglu, a county of hangzhou, since january 28. this indicated that the disease might have spread locally. what is more, more than half of the confirmed cases exhibited only mild symptoms. some patients were unaware that they were sick. this suggested that some cases unfortunately might not have been identified in time. the second stage was from february 3 to february 18. the trigger for the government stepping up interventions was that three districts/counties reported cases of unknown origin, including tonglu on february 3. the trend of local transmission was obvious. community-wide containment was added on the basis of the first stage to reduce individuals' contact with unidentified sources of infection. all enterprises and institutions closed except some essential functions, such as supermarkets and hospitals. people were advised to stay at home and allowed only to go out twice a week to buy necessities. in this stage, 19 imported cases and 40 local cases, including nine cases of unknown origin, were reported. the third stage was from february 19 until now. after 15 days of containment, the outbreak was basically under control. the containment was canceled, and businesses were allowed to resume work orderly. health status monitoring of workers and preventive disinfection of public areas were required to be carried out every day in this stage. up to march 2, no new cases were reported for 12 consecutive days, except one imported case on february 19. in the face of new infectious diseases, such as covid-19, non-pharmaceutical interventions are effective choices for governments owing to the lack of treatment and immunity vaccination methods. 3 although the effect of these interventions still needs further accurate evaluation, the large-scale outbreak was controlled in hangzhou in a short time, and these interventions played an important role. we also find that the effect of non-pharmaceutical interventions is closely related to the timing and quality of implementation, and this might be the reason why similar strategies have different effects in different cities. public health letter to the editor / public health 182 (2020) 185e186 director-general-s-opening-remarks-at-the-media-briefing-on-covid covid-19) situation isolation, quarantine, social distancing and community containment: pivotal role for old-style public healthmeasures in the novel coronavirus (2019-ncov) outbreak key: cord-031747-tnprxtoh authors: galassi, f.m.; varotto, e. title: sinophobia as the disease and palaeopathology as the cure: response to adja et al. date: 2020-09-11 journal: public health doi: 10.1016/j.puhe.2020.06.058 sha: doc_id: 31747 cord_uid: tnprxtoh nan letter to the editor sinophobia as the disease and palaeopathology as the cure: response to adja et al. we have very much enjoyed the correspondence by adja et al. 1 on the social and xenophobic stigma suffered by the italian chinese community after the outbreak of the covid-19 epidemic, which later became a pandemic. building on their correct assessment of the case, we would like to endeavour to offer some explanations for the xenophobic reaction described by the authors and propose a potential educational solution to it. the authors write that 'the human nature propelled xenophobic actions while preparedness efforts culpably lagged behind, favouring the spread of the virus'. the nature vs nurture debate on the origin of human racism is still ongoing, as shown by a recent study suggesting that the latter has a more prominent role in the absence of evidence of racial sensitivity of the amygdala until around 14 years of age. 2 however, concur with the authors and additionally stress that an in-depth scrutiny of the past of diseases and their historical interaction with human populations can help people understand that such a xenophobic response is not something new. the thucydidean episode clearly indicates an ancient mix of warrelated conspiracy theories and ethnic blame. in our opinion, the most evident and best instance of the phenomenon discussed here, that is, the act of blaming foreigners for the origin or spread of an infectious disease, is offered by venereal syphilis, a disease that devastatingly occured in europe in the 15th and 16th centuries. the italians, germans and english blamed it on the french, calling it morbus gallicus (the 'french disease'), while the french in turn accused the neapolitans, the poles the germans, the russians the poles and so forth. 3 the described anti-chinese sentiment, or sinophobia, is based on a set of thoughts, prejudices and feelings against china, its people and culture. however, it is far from being a novel manifestation. sinophilia prevailed in european culture from about the 16th to the mid-18th century e as testified by the work novissima sinica herder's (1744e1803) 1791 ideen zur philosophie der geschichte der menschheit ('ideas on the philosophy of the history of mankind'), a work from which the idea that china's history was stagnating powerfully emerged and was epitomised by the pejorative definition of that country as 'an embalmed mummy' (eine balsamierte mumie). this change in attitude would be later exacerbated by european imperial adventures in asia, the opium wars (1839e1842 between china and the british empire, 1856e1860 also involving france), the boxer rebellion (1899e1901), world war 2 (with an intra-asian anti-chinese sentiment fuelled by the invading japanese empire), and the current economic and political tensions between china and its opposing superpower, the united states of america. hence, the current episodes of sinophobia should be interpreted as the latest manifestations of a phenomenon which is over two centuries old. in light of the presented facts and wishing to corroborate the authors' stance, we strongly believe that a comprehensive study of the history of medicine and palaeopathology, the science that examines diseases in past populations providing information on both chronic and infectious conditions, 5,6 can help biomedical scientists and the general public understand that such disease-related xenophobic events are nothing new and can be effectively tackled in their early stages. this is in the interest of public health and the preservation of the integrity of the very fabric of our own nations and communities. 7 data are publicly available. ethical approval none sought. none declared. a the latin quotation is from the second edition of leibniz's work (hannover: f€ orster, 1699). public health jo u rn a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / p u h e pandemics and social stigma: who's next? italy's experience with covid-19 amygdala sensitivity to race is not present in childhood but emerges over adolescence brief history of syphilis from sinophilia to sinophobia: china, history, and recognition poliomyelitis in ancient egypt? gout in duke federico of montefeltro (1422-1482): a new pearl of the italian renaissance the covid-19 pandemic as a communication responsibility and opportunity for paleopathology none declared. key: cord-302272-ahwyfn1n authors: legkauskas, v. title: recommendations for ‘responsible behaviour’ is not a sufficient policy tool in public health emergencies date: 2020-05-01 journal: public health doi: 10.1016/j.puhe.2020.04.026 sha: doc_id: 302272 cord_uid: ahwyfn1n nan letter to the editor recommendations for 'responsible behaviour' is not a sufficient policy tool in public health emergencies in response to the ongoing coronavirus disease 2019 (covid-19) pandemic, several countries including the usa, the uk, and sweden initially relied on recommendations for 'responsible behaviour' of their citizens in reducing the spread of infection. among simple things such as increased handwashing, these recommendations suggested a few unusual and inconvenient behaviours, collectively termed 'social distancing'. that meant no more handshakes, embraces, parties and even conversations among friends, neighbours, colleagues and acquaintances in close physical proximity. for these social distancing recommendations to make an impact on the covid-19 spread rate, they had to be adhered to by the absolute majoritydas much as 90%dof the population. 1 most countries (e.g., italy, france, denmark, lithuania and so on) deemed unrealistic that the required majority of the population will be responsible enough to adhere to such recommendations voluntarily and imposed enforced restrictions of movement, including large fines for violation of social distancing regimes. such measures have been shown to be effective in reducing the spread of a pandemic in china 2 and reducing deaths by as many as 3.7 times in italy. 3 some countries, such as the usa and the uk, were quite late to do that, which led to detrimental effects in terms of thousands of extra deaths. at the time of writing, some countries, such as sweden and belorussia, still rely on responsible behaviour instead of mandatory orders. at the time of writing, covid-19 deaths per million of the population in sweden stood at 132, which is very unfavourable when compared with the neighbouring countries, which initiated population lockdownsd55 in denmark, 28 in norway and 14 in finland. 4 as these mortality comparisons suggest, recommendations for responsible behaviour alone is not a viable policy tool in public health emergencies such as pandemics of highly contagious and deadly diseases such as covid-19. for responsible behaviour to be effective, it should be practiced voluntarily by the absolute majority of the population. this is unrealistic, given that current social distancing recommendations are both unusual and inconvenient, i.e., they contradict both prevailing social customs and personal habits. psychological research has shown that it takes at least 18 days to develop a new habit, but the average time is about 2 months. 5 making responsible decisions concerning daily behaviours involves conscious choices with the regard to behaviours, which used to be automatic. this also requires a personal reflection on causes of behaviour, which is additionally inconvenient and may even be anxiety arousing for many. furthermore, about half of the people fail to adhere to inconvenient health recommendations. 6 conscious choices in favour of inconvenient behaviour tend to require significant amount of knowledge and understanding concerning the reasons for such behaviour change. alternatively, people may switch to inconvenient, but adaptive, behaviour if they have very high trust in the source of such recommendations. although approval ratings for stefan l€ ofven, the prime minister of sweden, almost doubled since the beginning of the covid-19 crisis, at the time of writing, they were at about 50%, which was not enough to expect sufficiently high adherence to inconvenient social distancing recommendations. thus, in emergency situations involving large populations, implementation of enforced restrictions is unavoidable. effectiveness of social distancing strategies for protecting a community from a pandemic with a data driven contact network based on census and real-world mobility data who. coronavirus disease 2019 (covid-19) situation report-44 estimating the number of infections and the impact of non-pharmaceutical interventions on covid-19 in 11 european countries how are habits formed: modelling habit formation in the real world patient's compliance with allergen immunotherapy jonavos str. 66, lt-44191 kaunas, lithuania e-mail address: visvaldas.legkauskas@vdu.lt the royal society for public health key: cord-263057-1pty32l1 authors: bhopal, sunil; bagaria, jay; bhopal, raj title: children's mortality from covid-19 compared with all-deaths and other relevant causes of death: epidemiological information for decision-making by parents, teachers, clinicians and policymakers date: 2020-05-30 journal: public health doi: 10.1016/j.puhe.2020.05.047 sha: doc_id: 263057 cord_uid: 1pty32l1 nan governments are grappling with the challenge of returning societies to quasi-normal following "lockdowns" to control the covid-19 pandemic. policymakers, the public, and especially parents are understandably anxious about the implications of re-opening nurseries and schools. in europe, norway, denmark, france and germany have already re-opened schools. the uk government signalled its intention to do so from 1 june 2020 to vast unease and controversy amongst the public, not least from teachers' unions whose arguments against premature reopening have polarised opinion. others have described "collateral damage" to children through social distancing measures 1 and questioned compatibility with the un convention on the rights of the child. while decisions about allowing children to exit their homes, and to restart schooling, are ultimately value judgements, we think that understanding current risks to children from covid-19 can be aided through epidemiology and that this understanding should underpin decision-makers' and parents' views 2 . we accept that there is much to learn about this new disease, and that the virus is likely to change during the pandemic and add new complexities. we synthesised information on covid-19 in relation to other causes of death in line with a previous call for increased focus on age-specific mortality 3 . we examined mortality as an important outcome providing accurate data, while recognising that reports about a multisystem hyper-inflammatory state in children need investigation and may modify our conclusions in due course 4 . fortunately, the number of hospitalisations and icu admissions in children remains low 5 . we examined age-specific data on covid-19 deaths which had been collated from official government sources for seven countries up to 8-19 may 2020 6 . these countries were chosen due to data availability and high burden of adult covid-19 death. the data were first extracted by sb and then cross-checked by sb and jb together to ensure accuracy. we obtained estimated numbers of deaths from other causes from global burden of disease estimates 7 except for influenza for which we examined official government statistical websites and extracted age-specific death counts for up to the last five years (2015-2019). to help to compare like-with-like we adjusted mortality counts to reflect a three-month time period (table 1) . for this time period, in these seven countries combined, 44 covid-19 deaths were reported in 42,846 confirmed cases (this latter number is likely to be a massive underestimate; data were not available for france) in those aged 0-19 years (0-14 in usa). this compares with 13,200 estimated deaths from all-causes, including 1,056 from unintentional injury, and 308 from lower respiratory tract infection (107 from influenza). the situation in each country was almost identical, and in accordance with early data from china 8 i.e. covid rarely kills children, even compared with influenza, against which many children are already vaccinated. our data show that for mortality covid-19 is like flu, or less severe, in children whilst being the opposite in adults. our analysis should help parents, teachers and policymakers to make important decisions and possibly feel reassured about the direct impact of covid-19 upon children. political leaders, communities, clinicians and parents should appreciate that the main reason we are keeping children at home and socially isolated is to protect adults. the ethics of this choice needs public debate. adults,-especially those at increased risk, including those with comorbidities or the elderly, who are -in close contact with children, need shielding. in children, at least in this wave of the pandemic and hopefully in the future, covid-19 is a comparatively rare cause of death. we need to maintain close surveillance of covid-19 in children in case this conclusion changes as the pandemic unfolds and the virus (sars-cov-2), evolves. wider collateral damage to children in the uk because of the social distancing measures designed to reduce the impact of covid-19 in adults risks to children during the pandemic: some essential epidemiology for parents, clinicians and policymakers covid-19 worldwide: we need precise data by age group and sex urgently royal college of paediatrics & child health. guidance -paediatric multisystem inflammatory syndrome temporally associated with covid-19 coronavirus disease 2019 and children: what pediatric health care clinicians need to know national institute for demographic studies (ined) (distributor). the demography of deaths by covid-19 global burden of disease study 2017 (gbd 2017) data resources | ghdx sars-cov-2 infection in children united kingdom from public health england italy from: istituto superiore di sanità for usa: from centers for disease control up to 8 key: cord-337096-ulc7mnwb authors: okazawa, mitsushi; suzuki, sadao title: japanese tactics for suppressing covid-19 spread date: 2020-07-14 journal: public health doi: 10.1016/j.puhe.2020.07.012 sha: doc_id: 337096 cord_uid: ulc7mnwb abstract covid-19 infection is overwhelming the world and death toll is steadily increasing. the first wave in japan seemed to converge with lower death rate than that in most developed countries. in this letter, we describe how japanese government suppressed the first wave of copd-19 spread. letter to the editor, sars-cov-2 infection is overwhelming the world, and the covid-19 death toll is steadily increasing. the first wave of infection in japan seemed to culminate with a death rate lower than that in most developed countries [1] . since the outbreak in a cruise ship harbored in yokohama, the japanese government on february 7 th , designated covid-19 as a "designated infectious disease" comparable with second category diseases such as tuberculosis, poliomyelitis, sars, mers, diphtheria, h5n1 and h7n9 influenzas based on the infectious disease law. by law, a complete contact survey had to be performed by a public health center (hokenjo) and the identified patient had to be reported to the prefectural government and isolated. all medical bills are covered through public expenses. currently, pcr is the only reliable test for identifying patients; however, sensitivity of pcr tests is only up to 70% [2] . although specificity is very high, there is still a possibility of obtaining false-positive results because of contamination or low quality of the test kits [3] . indeed, false positive results were revealed in two cities in japan, leading us to assume that the specificity of pcr is lower than 100% and the positive predictive value may be low if it is used for screening tests in the community with low prevalence. in contrast, if pcr is used on symptomatic patients, the positive predictive value must be high for identifying truly infected subjects. the expert meeting on new coronavirus disease control (emndc) of the japanese government set a plan for the identification of clusters through truly infected patients based on the complete contact survey. the key role of this plan was performed by "hokenjo". they initially performed pcr only for the following individuals: those with body temperature > 37.5 ºc for 4 days, history of returning from travel abroad or to the cities of outbreak in the past 2 weeks, contact with the sick patients, and serious illness with pneumonia. the government also reinforced travel restrictions to and from other countries. the initial guidelines were effective in identifying truly infected patients and clusters, preventing people in panic from rushing to the hospital for pcr testing, and isolating infected subjects and sick patients for supportive therapy. the initial guidelines also seemed to protect hospitals from medical overload. hokenjo has profound expertise in conducting sick contact surveys, which had been established through tuberculosis management. the identification of clusters has two significant benefits. first, infected patients could be isolated or hospitalised depending on their condition. second, the cluster investigation group in emndc could use the data for predicting the trend of spread. they used the sir epidemiological model for prediction of the disease spread [4] , as illustrated in figure 1 . the peak and the duration before convergence of the infectious curve (thick line) will vary based on the infectious coefficient "β", recovery coefficient "γ" and basic reproduction number "r0". β is thought to be dependent on the infectious ability of the virus, frequency of people's social contact, distance between individuals, housing situation, prevention method, and ultimately the vaccine. γ is thought to be dependent on effective medicines. r0 is the expected number of subjects directly infected from one infectious subject where all the other subjects are susceptible to infection, and was estimated to be ~2.4 for covid19 in japan [5 6] . during the spread of infection, the effective reproduction number "rt", which is the average number of subjects who become infected by infectious subjects, was calculated using daily data. rt was larger than 1 from mid-march to the end of march, indicating that infectious subjects increased toward a peak, as shown in figure 2 . since we do not have effective vaccines or medicines for the prevention of covid-19 infection, emndc proposed recommendations to prevent crowded situations, close physical contact with other people, and closed areas with poor ventilation (3cs) to decrease the infectious coefficient β. the government made a slogan: avoid 3cs and stay home. at the same time, emndc pointed out that night clubs, bars, cabarets, karaoke clubs, and game houses were at high risk to create clusters. they also postulated that an 80% restriction in social activity would be necessary for converging the spread of infection in a month by achieving an rt of ~0.5. the slogan was repeatedly broadcasted on television channels every day, to convince people that the only method to suppress covid-19 spread would be to follow the slogan. since the japanese public tends to be diligent and co-operative, a large number of people had already tried to fulfil the recommendations before the declaration of the state of emergency on april 7 th . the following are the possible factors that could ) travel restrictions, (5) precise prediction of the spread using the data of truly infected patients variation in false-negative rate of reverse transcriptase polymerase chain reaction-based sars-cov-2 tests by time since exposure false positive in reverse transcription pcr testing for sars-cov-2. secondary false positive in reverse transcription pcr testing for sars discussion: the kermack-mckendrick epidemic threshold theorem prediction of the epidemic peak of coronavirus disease in japan estimation of the reproductive number of novel coronavirus (covid-19) and the probable outbreak size on the diamond princess cruise ship: a data-driven analysis key: cord-265996-97xxpe8m authors: din, m.; asghar, m.; ali, m. title: delays in polio vaccination programs due to covid-19 in pakistan: a major threat to pakistan's long war against polio virus date: 2020-10-13 journal: public health doi: 10.1016/j.puhe.2020.09.004 sha: doc_id: 265996 cord_uid: 97xxpe8m nan letter to the editor delays in polio vaccination programs due to covid-19 in pakistan: a major threat to pakistan's long war against polio virus the disruptions caused by the covid-19 pandemic have devastating impact over vaccination programs around the globe especially in underdeveloped countries. the delays in immunization campaigns could increase infectious diseases such as polio, measles, and human papillomavirus. the pandemic is overstretching the health-care sectors and countries with limited capacity to deal major outbreaks are at breaking point. in accordance with world health organization (who), more than 116 million infants were vaccinated in 2019, and still more than 13 million children miss vaccination around the world and that the number could have been increased due to covid-19. 1 during the ongoing covid-19 pandemic, pakistan has had to delay vaccination for another life-threatening contagion, poliovirus. since april, around 40 million children missed the polio vaccination due to the cancellation of vaccination campaign nationwide. pakistan stopped the mass vaccination on the 26th of march under the commands of global polio eradication initiative (gpei). millions of the children are at risk of missing lifesaving vaccines due to rising urge of social distancing, vaccine supply disturbance, blocked borders, and elevated shipment costs which led to the deferment of polio campaigns. although majority of the countries have already removed all the three types of polioviruses, pakistan, alongside afghanistan, is one of the two countries in the whole world where polio is still endemic. it was nearly close to become polio free with only 12 reported cases in 2018 but unfortunately, the number of cases rose to 147 in 2019. 2, 3 in the same year, pakistan was accused of facing the emergence of the p2 virus strain with 22 reported cases. this strain was thought to have been removed in 2014. the year 2020 was thought to be the year for the transformation in polio campaigns to halt transmission in 2021 but the country is now facing covid-19 operations. therefore, any disruption due to covid-19 in the polio program plans would have significant and drastic impact on this objective. it could be concluded that diverting public health funds to fight against other outbreaks disrupted polio eradication plans, which could lead to the spread the of poliovirus in areas of low immunization coverage and immunity. pakistan could face setbacks due to suspension in the polio vaccination due to covid-19. on july 26 of 2020, there have been 107 reported cases of polio in pakistan. 2 the immunization campaigns have been paused or delayed in various countries as the local health-care authorities are putting all their efforts to control coronavirus. therefore, the planned vaccination in many countries may now not take place. this will cause a serious threat to the recently born infants who might now miss out their routine vaccination services. moreover, those children who have not yet received the significant amount of polio vaccine are also at high risk. the who is ready to resume the vaccination plans but as pakistan is witnessing an increase in the number of covid-19 cases, with the next few weeks crucial, the resumption of polio vaccination campaigns might be delayed. meanwhile, if the polio outbreak gets out of hand, it would pressurize the already overstretched health-care sectors across the countries. at worst, it could even lead to the next global health emergency. the health-care experts in pakistan, agree to resume the polio vaccination campaigns, otherwise the covid-19 would destroy all the progress being carried out in the last thirty years against the polio virus. the consequences of gaps in vaccination programs could have long lasting drastic effects. the gpei has recommended the countries to postpone the vaccination programmed until the second half of the 2020, taking the decision in deep regret by knowing that as a result of delaying immunization plans, more of the children may get paralyzed by polio. postponing or pausing the routine vaccination campaigns for now seems to be the correct decision, given the urge to avoid further transmission of covid-19. however, the fear is that having won the fight against the novel threat basically exhausted and overburdened the health-care sector which could be inundated with other infections especially polio cases. in accordance with who, past outbreaks have clearly showed that when the health-care sectors are overwhelmed, mortality from vaccine preventable and other treatable diseases also increase drastically. in fact, during the 2014e2015 ebola outbreak, majority of the deaths caused by malaria, measles, aids, tb and polio, and these deaths exceeded from the deaths due to ebola. 4 given the complexity of the issue, the health-care authorities do need to prioritize the fight against covid-19, they must try to mitigate the effect of older diseases reappearing. there is an urge to resume the polio vaccination campaign to aid protecting children's lives in outbreak. similar to the climate crises, the covid-19 pandemic could be regarded as a child-rights crisis because it will have life-threatening impact over all the children, who need immunization, now and in long-term. therefore, the health-care authorities must intensify the efforts to track the unvaccinated children so that most susceptible populations such as pakistan, can be supplied with the polio vaccines as soon as possible. otherwise, the impact could span the generations and even borders. public health j o u r n a l h o me p a g e : w w w . e l s e v i e r . c o m/ l o ca t e / p u h e polio cases in provinces efforts to eradicate polio virus in pakistan and afghanistan ebola virus disease outbreak in west africa key: cord-311636-8l7jlvvj authors: oikonomou, evangelos; aznaouridis, konstantinos; barbetseas, john; charalambous, georgios; gastouniotis, ioannis; fotopoulos, vasileios; gkini, konstantia-paraskevi; katsivas, apostolos; koudounis, georgios; koudounis, panagiotis; koutouzis, michael; lamprinos, dimitrios; lazaris, evangelos; lazaris, efstathios; lazaros, george; marinos, george; platogiannis, nikolaos; platogiannis, dimitrios; siasos, gerasimos; terentes-printzios, dimitrios; theodoropoulou, alexandra; theofilis, panagiotis; toutouzas, konstantinos; tsalamandris, sotiris; tsiafoutis, ioannis; vavouranakis, manolis; vogiatzi, georgia; zografos, theodoros; baka, eleni; tousoulis, dimitris; vlachopoulos, charalambos title: hospital attendance and admission trends for cardiac diseases during the covid-19 outbreak and lockdown in greece date: 2020-08-18 journal: public health doi: 10.1016/j.puhe.2020.08.007 sha: doc_id: 311636 cord_uid: 8l7jlvvj abstract objectives the covid-19 outbreak, along with implementation of lockdown and strict public movement restrictions, in greece have affected hospital visits and admissions. we aimed to investigate trends for cardiac diseases admissions during the outbreak of the pandemic and possible associations with the applied restrictive measures. study design retrospective observational study. methods data for 4,970 patients admitted via the cardiology emergency department (ed) across 3 large volume urban hospitals in athens and 2 regional/rural hospitals from 3rd february 2020 and up to 12th april was recorded. data from the equivalent (for covid-19 outbreak) time period of 2019 and from the post lockdown time period were also collected. results a falling trend of cardiology ed visits and hospital admissions starting from the week that the restrictive measures due to covid-19 were implemented was observed. compared to the pre-covid-19 outbreak time period, acs [145 (29/week) vs. 60 (12/week), -59%, p<.001], stemi [46 (9.2/week) vs. 21 (4.2/week), -54%, p=.002] and nste-acs [99 cases (19.8/week) vs. 39 (7.8/week), -60% p<.001] were reduced at the covid-19 outbreak time period. reductions were also noted for heart failure worsening and arrhythmias. the ed visits in the post-lockdown period were significantly higher compared to the covid-19 outbreak time period (1,511 vs 660; p<0.05). conclusion our data show significant drops in cardiology visits and admissions during the covid-19 outbreak. whether this results from restrictive measures or depicts a true reduction of cardiac disease cases warrants further investigation. have been recorded, as well as a significant lag between symptom onset and first 32 medical contact, suggesting that patients are reluctant to seek medical care 1 . while 33 anecdotal reports are many, true registries of cardiac visits to hospitals and admissions 34 are scarce. in spain, there was a 40% decrease in patients treated with percutaneous 35 coronary intervention (pci) for stemi 2 , corroborated by similar decreases from data 36 in catheterization laboratories in the united states of america (usa) 3 . this observed reduction could be attributed to misdiagnosis in the setting of 38 healthcare overload, reluctance to seek medical help in an environment that is 39 perceived to precipitate infection, hindered access due to strict movement restrictions 40 during lockdown, or to a true paradoxical reduction of acute cardiovascular events, 41 possibly due to beneficial changes in lifestyle. the course of the pandemic in greece merits particular attendance. lockdown hospital, athens) and 2 are regional hospitals of the national health system outside 56 athens metropolitan area (kalamata general hospital and trikala general hospital). 57 we opted for representativeness including both university and non-university, as 58 well as metropolitan and regional hospitals. data were collected for the period from 59 3 rd february 2020 and up to 13 th april (pre-and during pandemia outbreak) and from 60 the equivalent (covid-19 outbreak) time period of 2019. following the lifting of 61 restrictive measures we also collected data from an equivalent (4/5/2020 -7/6/2020) 62 time period (post lockdown period). based on an ad hoc design form, we collected demographic data (such as age and 64 gender), as well as patients' medical history, the reason of the visit, and diagnosis of (presented as mean ± sd) were tested for normality of distribution with kolmogorov-72 smirnov test and by visual inspection of p-p plots. a student's t-test was used to test 73 for differences between 2 categories of normally distributed continuous data. differences between categorical variables were tested by forming contingency tables 75 and performing χ2-tests. adjustment for multiple comparisons was performed as we observed a falling trend of cardiology ed visits and admissions starting from 95 the week that the restrictive measures due to covid-19 were implemented. as it is 96 shown in table 1 and figure 1a , the cumulative visits at the pre-covid-19 table 2 ) and in all age ranges (>65 years as well as in 126 younger subjects) (supplementary table 3) . 127 to further validate our findings, we analyzed cardiology ed visits and cardiology compared to the covid-19 lockdown period, in the post-lockdown period a 135 significant increase was observed in cardiology ed visits and cardiology department 136 admissions, especially for acs cases. as shown in table 1 and figure 1a , the 137 cumulative visits in the post-lockdown period was higher than the covid-19 we performed a separate (exploratory) analysis for regional hospitals outside impact of coronavirus 238 disease 2019 (covid-19) outbreak on st-segment-elevation myocardial infarction care impacto de la pandemia de covid-19 sobre la actividad asistencial en 243 cardiología intervencionista en españa reduction in st-segment elevation cardiac catheterization laboratory activations in the 246 united states during covid-19 pandemic an interactive web-based dashboard to track covid-19 in 249 real time covid-19 and mental health: a review of the existing literature pathway for acute coronary syndrome patients during the covid-19 outbreak: initial 254 experience under real-world suboptimal conditions this research did not receive any specific grant from funding agencies in the public, 215 commercial, or not-for-profit sectors. key: cord-255078-jfwzax5l authors: spantideas, nikolaos; drosou, eirini; barsoum, mina; bougea, anastasia title: covid-19 and holy communion date: 2020-08-20 journal: public health doi: 10.1016/j.puhe.2020.08.012 sha: doc_id: 255078 cord_uid: jfwzax5l nan the coronavirus disease 2019 (covid-19) pandemic has revived the long-standing discussion regarding the potential hazards of infectious disease transmission through the shared communion cup. widespread concern about this potential risk dates back to the 19 th century when the first scientific article appeared in the literature as early as 1894. [1] since then, many christian leaders have expressed their views in religious journals and media, and many scientists have published their experimental studies in scientific journals. these concerns re-emerge today with the rapidly growing covid-19 pandemic that has already infected more than 15 million people and has claimed the lives of hundreds of thousands of patients. despite recommended prophylactic measures, people continue to attend religious activities participating in the sacrament of holy communion, and this practice will increase after the reopening of churches. despite the importance of this subject to public health, a search in the pubmed/medline and cochrane databases and preprints.com from the beginning of the covid-19 pandemic up to 30 june 2020 using all possible term combinations revealed no study related to holy communion and possible severe acute respiratory syndrome coronavirus 2 (sars-cov-2) [the strain of coronavirus causing covid-19] transmission. since people are looking for an answer to this hot topic, we extended our search to look for similar situations in the past. unfortunately, the literature on this topic is limited, consisting of only four experimental studies [2] [3] [4] [5] , one clinical survey [6] and three reviews [7] [8] [9] . all four experimental studies that were performed during the last 100 years showed that some microorganisms were present in the wine or on the chalice rim. these organisms stay alive significantly longer than the time that usually elapses between two parishioner's participation in receiving communion. the authors of these studies came to a common conclusion that the possibility of spread of an infection through this religious ritual does exist. neither the material from which the chalice and the spoon are made (usually heavy metal, like silver) nor the sacramental wine seem to pose significant disinfectant activity to prevent the transmission of potential pathogens. however, all these statements are based on the theoretical view of each investigator as no study, to date, has been performed to investigate, retrospectively or prospectively, whether the existence of these microorganisms in the wine or on the chalice can be the source of infectious disease transmission. it should be noted that all authors have focused their investigations on bacterial isolation from the chalice or the sacramental wine and none has investigated the viability and transmissibility of viral agents via the common communion cup. we also know that during an ordinary communion service, the rim of the chalice becomes inevitably contaminated with the saliva of the participants and that the organisms present in the saliva of one person can be transmitted subsequent participants. unfortunately, the role of the bacterial or viral load in the communicants' saliva, which could be considered as the infective dose, has not been investigated. this parameter is very important, especially for respiratory viruses like the common cold, influenza and sars-cov-2. colonisation of an individual with a potential viral pathogen does not mean that this virus can produce an infection as this depends on the immune status of each individual. loving and wolf, in a prospective study with 681 participants, showed that there was no significant health difference between individuals who received holy communion as often as daily and those who did not attend christian services at all. [9] based on these findings, in 1998 the centers for disease control and prevention (cdc) reported that there had never been an outbreak of infection related to the communion cup and that a theoretical risk of transmitting infectious diseases by using a common communion cup exists, but that the risk is so small that it is undetectable. [10] according to the christian orthodox practice, after the completion of the religious ritual of the holy communion, the priest has to drink all the remaining sacramental material of the chalice, which carries the microorganisms of all communicants who participated in the religious ritual. this practice is also applied to hospitalised patients who ask to receive communion as a last will before dying. as a corollary of this practice, increased morbidity rates for specific infectious diseases, and especially those of the respiratory and gastrointestinal tract, among officiating clergymen might be expected; however, there does not appear to be an obvious increased prevalence of such infections in this occupation. in summary, the common communion cup may theoretically serve as a vehicle of transmitting infection, but the potential risk of transmission is very small. currently, available data do not provide any support for the suggestion that the practice of sharing a common communion cup can contribute to the spread of covid-19 because sars-cov-2 transmission from a covid-19 patient or asymptomatic carrier to other people has not been reported. the reopening of churches will bring faithful christians back to services and many of them will ask for holy communion. the importance of receiving holy communion for religious j o u r n a l p r e -p r o o f christians cannot be overlooked and the medical community should try to address this need with providing an evidence-based risk-benefit assessment of receiving holy communion during the pandemic. unfortunately, current scientific data come mainly from clinical studies examining the risk of infection by bacterial strains transmitted via saliva. the need for well designed, large-scale, cohort studies targeting viral transmission is apparent. for immunocompromised patients, the risk of covid-19 seems to be higher and these individuals may require alternate means of receiving holy communion, should they insist on receiving it. some orthodox churches keep those individuals' share aside before holly communion is offered to the rest of the congregation. any individual experiencing respiratory infections, like the common cold, influenza and covid-19, as well as those with obvious lip or mouth lesions, like a herpes sore on the lip, should avoid receiving communion, thus minimising the unproven but theoretical risk of contaminating the rim of the chalice and passing on their infection to healthy people. eirini drosou mrs: athens speech language and swallowing institute e-mail: eirinidr@gmail prophylaxis in churches needed by the adoption of individual communion chalices or cups communion cup and bacteria survival of bacteria on the silver communion cup infection hazards of the common communion cup experiments on the communion cup the effects of receiving holy communion on health the hazards of infection from the shared communion cup risk of the common communion cup infections associated with religious rituals risk of infectious disease transmission from a common communion cup key: cord-346370-jdfsacds authors: sergi, consolato m.; leung, alexander k.c. title: the facemask in public and healthcare workers– a need not a belief date: 2020-05-13 journal: public health doi: 10.1016/j.puhe.2020.05.009 sha: doc_id: 346370 cord_uid: jdfsacds abstract since the declaration of the covid-19 pandemic, a lot of data has invaded our lives, and the conflicting findings have caused us to be frantic about the correct course action. strict isolation and social distancing measures can flatten the coronavirus infectious curve, and the use of facemask needs to be encouraged and facilitated in crowded places, particularly in hospitals where the 6-feet social distancing cannot be adopted because of physical barriers. since the declaration of the covid-19 pandemic, a lot of data has invaded our lives, and the conflicting findings have caused us to be frantic about the correct course action. although the application of social distancing has been accepted worldwide, the level of enforcement varies in each country ranging from voluntary to strict legal measures. some countries are currently verifying the utility of these measures 1 . despite these steps, the number of infections and deaths are continuing to increase worldwide, posing a responsibility for the most developed countries to step-up in this time of crisis to support the most vulnerable layers of our society. the overwhelming stress and level of danger that our frontline healthcare is subjecting themselves to in this pandemic as they perform their duty to serve the public has triggered astonishing questions of whether they are just a resource that can be exploited, exhausted, and used up 2 . during this pandemic, numerous healthcare workers in the world have died, and many have committed suicide in a tragedy that has touched all continents 3, 4 . our infrastructure is posing a considerable risk to our healthcare workers, because numerous hospitals in canada are old, and their ventilation systems are not up-to-date to handle a pandemic 5 . in numerous hospitals with a lack of window access, the circulation of aerosols may be quite dramatic for both patients and healthcare workers. the 6-feet distancing is not respected inside many hospitals in several provinces because corridors, stairwells, and passages are narrow. although experts have expressed different opinions on the airborne status of sars-cov-2, the virus has been isolated in the ventilation systems of several hospitals, which endangers everyone without proper personal protective equipment (ppe) in the building. the recent proof of aerosolized droplets being able to travel well over 6 feet supports the question of whether our current social distancing guidelines are even adequate 6 . there have been anecdotal reports of hospital administrative bodies not allowing their staff from wearing their own ppe originating from outside of the hospital's supplies with the concern of not being able to validate the quality is not sustainable from both a legal and an ethical point of view. the concept of "primum non nocere" should still be valid for all administrators 7 . the preposterous indication that some ppe may be faulty argues against our charter of freedom. it should not be an excuse to forbid healthcare workers or patients entering hospital facilities to wear their ppe 5 . the number of community transmission is increasing exponentially and asymptomatic carriers can infect their close contacts 8 . healthcare workers, patients, and visitors entering the hospital facilities should be allowed to wear their ppe even when they are not interacting with symptomatic patients. in facilities where social distancing is not or cannot be implemented (e.g., laboratories, elevators, and stairwells), although initially, the r 0 of sars-cov-2 was 2.4, more recent and comprehensive data indicates that it is 5.7 13 . in other words, without containment measures, sars-cov-2 spreads far and fast. unfortunately, many countries were slow in implementing strong public health measures, hindered by trying to maintain political correctness instead. this was evidenced by the late decision to ban non-essential air/land/sea travel in many countries. i if most people wear a mask in public at any time the transmission rate can easily decrease beneath 1.0, thus stopping the spread of the disease and limit the long-standing lockdown measures 13 . the number of covid-19 cases in south korea started decreasing in february 2020, when the government supplied facemasks to every citizen. in contrast, the number of cases in italy continued to climb in the same time period where facemasks were not freely supplied 14 . it is important to emphasize that while a protective mask may reduce the likelihood of infection, it will not eliminate the risk, particularly when a disease has more than one route of transmission, as identified in sars-cov-2. vaccines against covid-19 take time to develop. in a situation where there is a short supply of ppe, an improvised facemask should be viewed as the last possible alternative if a commercial product is not available. in china, hong kong, taiwan, japan, south korea, and thailand, the broad assumption is that anyone could be a carrier of the virus, even seemingly healthy people, leads to terrific results in these countries with the widespread wearing of facemasks. the widespread public acceptance of using facemasks in these countries, even before the onset of covid-19, may be attributed to their experience of facing several epidemics in the past. to a certain extent, pollution has triggered the use of facemasks for protection in these countries 15 . in conclusion, all citizens should wear a mask. while strict isolation and social distancing measures can flatten the infectious curve, the use of facemask needs to be encouraged and facilitated where the 6-feet social distancing cannot be implemented because of physical barriers. preservation of n95 respirators for high risk, aerosol-generating procedures in this pandemic should be considered when in short supply, but surgical facemasks should be provided to everybody. only strict quarantine measures can curb the coronavirus disease (covid-19) outbreak in italy ich bin es wert prevalence and predictors of ptss during covid-19 outbreak in china hardest-hit areas: gender differences matter clinician wellness during the covid-19 pandemic: extraordinary times and unusual challenges for the allergist/immunologist understanding and addressing sources of anxiety among health care professionals during the covid-19 pandemic turbulent gas clouds and respiratory pathogen emissions: potential implications for reducing transmission of covid-19 how we treat patients with lung cancer during the sars-cov-2 pandemic: primum non nocere covid-19 transmission through asymptomatic carriers is a challenge to containment. influenza other respir viruses guide on respiratory protection against bioaerosols-recommendations on its selection and use medical masks vs n95 respirators for preventing covid-19 in health care workers a systematic review and meta-analysis of randomized trials. influenza other respir viruses physical interventions to interrupt or reduce the spread of respiratory viruses. part 1 -face masks, eye protection and person distancing: systematic review and meta-analysis. medrxiv effectiveness of surgical and cotton masks in blocking sars-cov-2: a controlled comparison in 4 patients high contagiousness and rapid spread of severe acute respiratory syndrome coronavirus 2 masks for all? the science says yes personal strategies to minimise effects of air pollution on respiratory health: advice for providers, patients and the public key: cord-332142-lk95akg5 authors: skovdal, morten; pickles, michael r.; hallett, timothy b.; nyamukapa, constance; gregson, simon title: complexities to consider when communicating risk of covid-19 date: 2020-07-23 journal: public health doi: 10.1016/j.puhe.2020.07.015 sha: doc_id: 332142 cord_uid: lk95akg5 nan the response to the spread of sars-cov-2 around the world has so far been characterised 28 by governments issuing instructions about the action to take. however, as governments 29 begin to ease restrictions, the potential for covid-19 to spread is increased. we argue that 30 correct understanding of individuals' risks of becoming infected and dying is a prerequisite 31 for people and communities to take responsibility and engage in prevention practices, both 32 for self and others; and also to reduce unnecessary anxieties and other unintended negative 33 outcomes. at the same time, effective communication of these risks is fraught with difficulty 34 and there are important complexities that must be recognised and addressed. in our view, 35 there has been little scientific discussion on the complexities, determinants and impacts of 36 covid-19 risk communication. here, we highlight seven major complexities in 37 communicating risk and suggest directions for addressing these (see panel). they serve as a 38 framework for governments, researchers, policy and public health workers to critically 39 appraise covid-19 risk messaging efforts. as we are trying to highlight complexities that 40 are widely applicable (rather than specific to certain countries or regions), their relevance will 41 differ from context to context. one: the risks of acquiring sars-cov-2 infection and of dying from covid-19 disease 45 once infected vary considerably by epidemic context and between individuals 1 . nevertheless, 46 it is apparent that the risk of infection varies with the stage of the epidemic, which varies by micro-region, and an individual's exposure, which is often much higher for healthcare 48 workers and carers, and elevated for those with jobs that cannot be done from home, amongst 49 whom ethnic minority groups and people living in greater depravation may be over-50 represented 2 . the risk of death from covid-19, given infection, varies substantially 51 according to age, male-sex, obesity and other factors 3 . thus, there is no "one number" to 52 quote to people for their risk; but, at the same time, everyone should know the range in which 53 their risk is likely to fall. finding ways to provide clear and targeted information about who is 54 at increased risk whilst also recognising the intersectionality of these factors is essential. two: unintended outcomes -such as anxiety, avoiding going to work, and limited healthcare 56 seeking -can result for some people. thus, over-estimating one's own risk could be as 57 unhelpful to economic wellbeing and health overall as under-stating one's own risk. 58 moreover, some people aware of their individual risk may (un)willingly take risks, for 59 instance by doing a trade-off between risk and maintaining a livelihood. communicating risk 60 of sars-cov-2 infection must be considered in the broader context of a group of risks as 61 great or greater than that from covid-19. therefore, developing strategies to mitigate these 62 risks is important too. • avoid over-simplified 'one-size-fits-all' risk messages • distinguish between risk of sars-cov-2 infection and risk of severe covid-19 disease • target risk messages to people according to their levels of risk and capacity to adopt alternative prevention methods • communicate the uncertainty of risk estimates and that new data may lead to changes • develop risk messaging that reflects the broader socio-economic and health context and is actionable by local people. • include messaging to mitigate other forms of risk (e.g. young women should still adhere to government advice but not put off trips to hospital for breast cancer screening) • avoid using unhelpful metaphors (e.g. war, enemy) in risk messaging. • avoid using language that can cast shame or blame to people • monitor the emergence and spread of myths and misinformation on social media and within the community • utilize locally trusted institutions and individuals to address misinformation and channels that are widely used by the relevant population • promote trust in official sources by ensuring that messaging from all such sources is consistent reflect changes in the nature of risk and risk perception as the epidemic evolves • review, revise and explain changes in risk messages as the epidemic evolves • develop risk messages that counteract innate tendencies for message 'fatigue' • use data on risk to stimulate and strengthen motivation to follow government guidance • encourage people to think creatively and tailor prevention methods to their own circumstances (e.g. to find effective ways to shield vulnerable family members) • foster a sense of collective responsibility (e.g., risk messaging that emphasises that your actions benefit others) • recognise and address social and health inequities, discrimination, and political agendas, which put some people at greater risk, or prevent them from engaging with risk-reducing practices. • freely avail health services and equipment to assist risk-reducing practices panel: considerations and recommendations to communicate risk in the covid-19 response • avoid over-simplified 'one-size-fits-all' risk messages • distinguish between risk of sars-cov-2 infection and risk of severe covid-19 disease • target risk messages to people according to their levels of risk and capacity to adopt alternative prevention methods • communicate the uncertainty of risk estimates and that new data may lead to changes • develop risk messaging that reflects the broader socio-economic and health context and is actionable by local people. • include messaging to mitigate other forms of risk (e.g. young women should still adhere to government advice but not put off trips to hospital for breast cancer screening) avoid negative social consequences of risk messaging • avoid using unhelpful metaphors (e.g. war, enemy) in risk messaging. • avoid using language that can cast shame or blame to people • monitor the emergence and spread of myths and misinformation on social media and within the community • utilize locally trusted institutions and individuals to address misinformation and channels that are widely used by the relevant population • promote trust in official sources by ensuring that messaging from all such sources is consistent reflect changes in the nature of risk and risk perception as the epidemic evolves • review, revise and explain changes in risk messages as the epidemic evolves • develop risk messages that counteract innate tendencies for message 'fatigue' • use data on risk to stimulate and strengthen motivation to follow government guidance • encourage people to think creatively and tailor prevention methods to their own circumstances (e.g. to find effective ways to shield vulnerable family members) • foster a sense of collective responsibility (e.g., risk messaging that emphasises that your actions benefit others) • recognise and address social and health inequities, discrimination, and political agendas, which put some people at greater risk, or prevent them from engaging with risk-reducing practices. • freely avail health services and equipment to assist risk-reducing practices estimates of the severity of covid-19 disease opensafely: factors associated with covid-19-123 related hospital death in the linked electronic health records of 17 million adult nhs 124 patients estimating excess 1-year mortality associated with the covid-126 19 pandemic according to underlying conditions and age: a population-based cohort study online first how do we balance tensions between covid-19 public health responses 129 and stigma mitigation? learning from hiv research coronavirus: the spread of misinformation risk perceptions of covid-19 around the world relationships between changes in hiv risk perception and 136 condom use in east zimbabwe 2003-2013: population-based longitudinal analyses key: cord-334401-i5dz7ufc authors: adja, k.y.c.; golinelli, d.; lenzi, j.; fantini, m.p.; wu, e. title: pandemics and social stigma: who's next? italy's experience with covid-19 date: 2020-06-04 journal: public health doi: 10.1016/j.puhe.2020.05.054 sha: doc_id: 334401 cord_uid: i5dz7ufc nan on december 31, 2019, chinese authorities reported to the world health organization the first case of what is now known as covid-19, a respiratory syndrome caused by sars-cov q2 -2. four months later, the virus caused a pandemic that has changed the lives of billions of people. in the weeks after the announcement of the first covid-19 case, while some asian countries (i.e. south korea, singapore, taiwan) 1,2 promptly equipped themselves to face a probable national outbreak, most western nations minimized the risks posed by the virus and limited their actions to travel bans, whose effectiveness is still debated. 3 italy, one of the first and most severely hit countries in the western world, was among them. however, discussions on whether to admit people coming from the outbreak epicenter in china raged immediately not only at the political level but also on the media and social media, paired with xenophobic comments on chinese wet markets and culinary habits. nowadays, it is a short step from digital discussions to real life, and at first, it was not the virus to hit italy but another dangerous enemy: prejudice. weeks before the national lockdown of march 11, 2020, when the bel paese had declared the state of emergency but everyday life was going on as always, the sentiment toward the chinese community changed: their restaurants were left empty, more and more parents did not want their children to go to school if they had a chinese classmate, and a high-profile politician offended the chinese by saying on tv that 'we have all seen them eat live mice'. this behavior is not new to the humankind: covid-19, similar to other epidemics before, has gone hand in hand with xenophobia. foreign populations were stigmatized and scapegoated when facing novel pathogens across history and, sadly, this time is no exception. we can find some parallel to today's pandemic-related xenophobia already in the 5th century bc when tucidide, narrating the plague of athens, writes that athenians were accusing spartans of poisoning the water, or in the 14th century, when during the black death, an outbreak of the bubonic plague, jews were accused of the same thing. more recently, in 1918, when the spanish flu was not already being referred to as such, brazilians called it the german flu and the senegalese called it the brazilian flu, underlying the tendency for some kind of need to find someone to blame. italians too were accused in the us of the spreading of the flu, as reported in two newspaper clips. 4 'catastrophes reveal the weakness of human memory', 5 this time it was the chinese who got targeted. however, despite facing episodes of xenophobia, their behavior has been nothing but commendable. notably, one of the most important and populated chinese communities in europe is in prato, 6 a city in tuscany, italy, that is famous for its textile manufacturers, where they represent the 9.9% of the resident population (the national figure is 0.4%). this created fear among italian authorities, especially when it was reported that in late january 2500 people were returning from china, after the chinese new year celebrations. what was remarkable at the time and is worthy of praise now is that the chinese took the threat raised by the virus very seriously from the beginning, after closely what was happening in china. this led to a change in habits that is now common to everybody but that nobody had ever experienced before. the chinese living in prato started to take measures to contain the spread of the virus voluntarily, before the government began acting. social networks allowed them to keep in contact with relatives and friends in china to try to understand firsthand what was happening and consequently how to behave. moreover, the members of the community have close relationships, and everyone was involved, trying to be proactive. whenever meeting the chinese around the city, they were always using masks, both on the streets and at the workplace, asking everybody to do the same when exchanging contacts with them. italians were taking no precautions at that time and this worried the chinese community who knew how serious the situation was and that it was fundamental to adopt non-pharmaceutical public health measures to mitigate the risk of covid-19. some of them also stopped sending kids to school, while still open, and started a voluntary quarantine; in the meantime, italians took advantage of the eventual closure of the schools to go skiing. the italian national institute of statistics has released on may 4 the all-cause mortality data of the first quarter of the year 7 to evaluate the impact of covid-19 across the country. the comparison with q3 2015e19 data has shown us that not only was prato not among the worst-hit areas but, quite surprisingly, was one of the least affected provinces of the country (the only province under 0% of excess mortality in north-central italy, fig. 1 ). public health 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 the behavior of the chinese community may have played an important role in avoiding the spread of the virus, and had their conduct been taken as an example from the start, nobody knows what the history of the pandemic could have been. however, instead of trying to understand, the human nature propelled xenophobic actions while preparedness efforts culpably lagged behind, favoring the spread of the virus. there will always be new and unknown threats to cope with in the future for humankind, but it is time that we start learning some lessons from our past. unfortunately, old habits die hard, and once more it has been proven that diseases do not discriminatedpeople do. nevertheless, with our actions as humans and scientists, we can actively help dissipate the harm that prejudice and stigma cause by providing accurate information. while all our efforts are addressed toward the battle against this virus that we will hopefully beat in the foreseeable future, it is clear that there is another long standing fight that we must win: the time to eradicate the stigma pandemic is now, and only united we will be victorious. none sought. none declared. letter to the editor / public health xxx (xxxx) xxx 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 puhe3893_proof ■ 3 june 2020 ■ 3/3 covid-19 in singaporedcurrent experience: critical global issues that require attention and action response to covid-19 in taiwan: big data analytics, new technology, and proactive testing spanish flu": when infectious disease names blur origins and stigmatize those infected twentieth-century lessons for a modern coronavirus pandemic coronavirus is the greatest global science policy failure in a generation. the guardian none declared. data are publicly available. key: cord-346160-n9i0blv1 authors: gogoi, mayuri; armitage, richard; brown, gavin; ryan, bernard; eborall, helen; qureshi, nadeem; o’donnell, catherine a.; ciftci, yusuf; pareek, manish; nellums, laura b. title: putting the voices and insights of migrants and diverse ethnic groups at the centre of our response to covid-19 date: 2020-10-10 journal: public health doi: 10.1016/j.puhe.2020.09.019 sha: doc_id: 346160 cord_uid: n9i0blv1 there is increasing evidence of inequities in covid-19 infection, disease severity, and mortality across diverse ethnic groups. despite calls to ensure ethnicity is integral to covid-19 research, opportunities have been missed to engage with individuals from ethnic minority groups, and even more notably, recent migrants. there is an urgent need to strengthen patient and public involvement and engagement (ppie) and participatory research, as well as collaboration with healthcare workers from diverse migrant and ethnic backgrounds. this will require addressing multiple barriers to involvement, and a commitment to community-centred research to address the acute needs of the populations hardest hit by the pandemic. there is an urgent need to strengthen patient and public involvement and engagement (ppie) and participatory research, as well as collaboration with healthcare workers from diverse migrant and ethnic backgrounds. this will require addressing multiple barriers to involvement, and a commitment to communitycentred research to address the acute needs of the populations hardest hit by the pandemic. evidence demonstrates that individuals from ethnic minority groups are at increased risk of covid-19 infection, severe disease, and mortality, 1-4 even accounting for socioeconomic deprivation. 5 despite calls to ensure ethnicity is integral to covid-19 research, 6 opportunities have been missed to engage with these communities, and even more notably, recent migrants. wide participation is needed to avoid continued tragedy in future pandemic waves. community engagement during covid-19 has lacked urgency and transparency. the absence of the insights and voices of migrants and diverse ethnic groups was highlighted by the omission of stakeholder contributions in public health england's (phe) report on covid-19 disparities, 7 which was criticised for failing to advance understandings of risk factors and discrimination, or provide actionable recommendations. 8 community viewpoints were subsequently published two weeks later, 9,10 following condemnation by over 30 organisations. 8 a key finding of phe's disparities report was the relationship between country of birth and covid-19 mortality. 7 however, this went unreported, and an opportunity to robustly examine migration as a risk factor for poor outcomes was missed, echoing the stark absence of attention to country of birth and migration status during covid-19. this highlights the need for safe and confidential mechanisms to improve collection and reporting of migrant data across health services and research, supported by adequate funding. 3 despite the risks faced by newly-arrived migrants during covid-19, 11 these groups have not been meaningfully included in engagement activities or recommendations, reflected in their underrepresentation in phe's stakeholder report. 9 migrant views are also notably absent as new strategies to monitor or react to covid-19 develop, including testing, contact tracing, or social distancing and lockdown measures. migrants should be explicitly integrated within the covid-19 narrative through patient and public involvement and engagement (ppie) and participatory research, as well as collaboration with clinical and non-clinical healthcare workers from diverse migrant and ethnic backgrounds (see fig 1) . such involvement of migrants and other underrepresented groups is essential to guide research, inform policy and practice, and promote accountability. this is critical in light of concerns that urgency in developing the evidence base is taking precedence over robust ethical approval processes, informed consent, and ppie. 12 research ethics committees and funders should critically evaluate proposals indicating these communities will not be recruited as they are considered too hard to reach. achieving meaningful engagement necessitates addressing multiple barriers to involvement across very diverse communities, including mental and physical health and disability, caring and employment responsibilities, and legal status, alongside the implications this may have for entitlement to healthcare, fears around immigration enforcement or stigmatisation, and trust and willingness to engage with researchers. 13 transparency and inclusion is also vital, and requires ongoing communication (particularly whilst social distancing), sharing and facilitating access to updated information (e.g. appropriate languages, multiple formats, and provision of professional linkworker services), and inclusion of stakeholders in planning and j o u r n a l p r e -p r o o f responding to the pandemic. the shift to the virtual space during covid-19 may also impact on recruitment, accessibility, and development of trust and rapport, particularly for those facing barriers due to internet access, digital literacy, or language. this digital divide will disproportionately affect ethnic minority and migrant groups. 14 the expertise these individuals bring through their lived experience, and its value in informing appropriate, effective, and equitable policy and practice, should be meaningfully recognised. 13 as such, engagement with migrants should be mutually beneficial, for example the provision of ppie payments or material contributions in recognition of the expertise these individuals have shared. 15 such contributions should be prompt and appropriate, and organisations should consider access to banking (including online banking), permission to work, and recourse to public funds, ensuring such contributions don't have legal repercussions for those participating. providing payments in cash can overcome some of these barriers. however, social distancing restrictions have made it necessary to consider virtual methods of providing ppie payments. mobile wallets, credit, and vouchers may bypass these barriers, though it is important to consider their accessibility for those who are digitally excluded, as well the relevance and convenience of selected vendors. defining material contributions as a recognition or 'thank you' for shared expertise, and determining the amount of these contributions by the type of activity (e.g. research interview, stakeholder meeting, or co-producing a resource), rather than an hourly rate, may both avoid framing such payments as income, and support meaningful engagement. it is also important to consider that ppie payments may also incentivise participation, which could be coercive or lead to risk-taking by target groups. discussing these issues with target communities may be an effective and inclusive strategy for determining how to recognise ppie contributions. there is an urgent need to reorient research, policy, and practice to address the acute needs of the populations hardest hit by the pandemic. to achieve this, it is imperative to commit to community-centred research. 16 in line with good ppie practice, 17 research teams must innovatively strengthen involvement to ensure research is appropriate and impactful, and proactively involve migrants and diverse ethnic groups from the outset. the increasing recognition of inequities in covid-19 outcomes, and pledges to challenge disparities across political, health, and academic sectors, will only be realised with financial commitments. funding bodies should adequately and equitably support migrant-focused research, and promote inclusion of migrantspecific ppie activities. we must move beyond descriptive needs assessments, to generate concrete actions responding to these populations, aligning with their requests for community-based research, co-produced policy and health services, and targeted communications. 9 ultimately, organisations, funders and journals will be judged by their actions -not their words. is ethnicity linked to incidence or outcomes of covid-19? covid-19 in ethnic minority groups: where do we go following phe's report? the impact of ethnicity on clinical outcomes in covid-19: a systematic review ethnicity and covid-19: an urgent public health research priority ethnic and socioeconomic differences in sars-cov-2 infection: prospective cohort study using uk biobank covid-19 and ethnicity: who will research results apply to? the lancet response to the 'disparities in the risk and outcomes of covid-19 delaying part of phe's report on covid-19 and ethnic minorities turned a potential triumph into a pr disaster global call to action for inclusion of migrants and refugees in the covid-19 response whistleblowing and patient safety during covid-19 integrated screening of migrants for multiple infectious diseases: qualitative study of a city-wide programme bridging the digital divide in health care: the role of health information technology in addressing racial and ethnic disparities briefing notes for researchers: public involvment in nhs, public health, and social care research community participation is crucial in a pandemic what is public involvement in research key: cord-297197-klr208kp authors: weizman, yehuda; tan, adin m.; konstantin, franz f. title: use of wearable technology to enhance response to the covid-19 pandemic date: 2020-07-01 journal: public health doi: 10.1016/j.puhe.2020.06.048 sha: doc_id: 297197 cord_uid: klr208kp abstract introduction as part of the covid-19 outbreak response, numerous technology-based solutions have been created to enable contact tracing, track movements of the population and ensure social control. wearable biometric bracelets are widespread and commonly used in the form of wrist-worn activity trackers that are both familiar and liked by the general population. objectives/study design/methods the authors propose an innovative approach a wearable bracelet that can be used to curb the spread of covid-19. the bracelet would facilitate 3 functions; screening on a population level, digital contact tracing and real-time immunity status tracking. results/conclusions utilising the internet of things, data would then be transfer over a network to interactive web-based dashboard and big data analytics employed to augment response within a defined geographic region. in december 2019, an outbreak of pneumonia of unknown origin was detected in china and quickly determined to be caused by novel coronavirus -sars-cov-2. with highly infectious properties, the outbreak was declared a global pandemic by the world health organisation on march 11, 2020. combating the spread of the virus has been a global challenge. on the positive side, access to unprecedented technology and widespread communication networks are helping to enhance global response. from australia to israel, more than 30 countries have implemented systems for population surveillance and contact tracing, mostly in the form of smartphone apps. in recent years, wearable sensors have become popular in many applications. these are electronic devices, worn on the body, containing sensors which log information on physiological parameters and user interaction with the environment. in 2017 in the u.s alone, 17% of adults used a wearable device [1] . with advances in technology, there is now an opportunity to benefit from data collected from wearable devices at a population level. the internet of things (iot) is a grid of interconnected devices, machines, objects or people with unique identifiers (uids) that transfer data over a network. iot can facilitate extrapolation of associations, patterns and trends within extremely large data sets to provide near-real-time insights to ensure a data-driven, informed response to the pandemic. such wearables can offer a centralised solution for simultaneously tracking covid-19 data and digital diagnostics at both individual and population levels. in this instance, we propose a customized biometric bracelet with a wireless communication circuit and a subscriber identity module (sim card), that has three built-in features: (1) an infrared thermometer, (2) a global positioning system (gps), and (3) a radio-frequency identification (rfid) with an uid number. the bracelet would employ the iot to transfer data over a network to an interactive web-based dashboard that tracks covid-19 in real-time. wearing the bracelet would be recommended within a predefined geographic area. big data analytics could then provide a centralized bird's eye perspective of emerging trends and patterns to enhance response and containment. the need for early screening at a population level has been one of the main challenges of the pandemic. with fever being one of the most common presenting symptoms, (43.8% upon hospital admission, 88.7% during hospitalisation) [2] many countries have employed devices such as 'temperature guns' to measure fever as a barrier of entry into public places. still, tracking fever mostly requires people to self-report and actively seek medical care, leaving numerous cases unreported. as fever is easy to gauge objectively, a biometric bracelet could continuously measure fluctuations in temperature using an integrated infrared sensor. thus, if a person has a fever, they could automatically be contacted by a healthcare professional, screened or tested for sars-cov-2, as required. if an individual then tested positive for sars-cov-2, the database could automatically trace back anyone they had come in contact with in the past 14 days using a gps feature (described below). potential carriers could then self-isolate, be tested and treated as required. contact tracing plays an important role in the control of emerging infectious diseases and has been utilized successfully to mitigate the spread of numerous past outbreaks including smallpox and sars [3] . in this instance, the biometric bracelet's gps feature would continuously track movements of individuals within a geographical area and communicate back to the covid-19 database platform saving input on the population whereabouts at each timepoint. the database could then use advanced data analytics to extract a list of other people that were within a predefined distance of an infected individual at a certain day and time. the bracelet could also send an alert using a beeping sound or vibration to people at risk of having been in contact with a confirmed positive case. to date, only incomplete information is available on the host innate immune status of sars-cov-2 infected patients. based on published research from other coronaviruses, some form of active immunity can be expected [4] . the global race to develop and approve an accurate, widespread antibody tests for sars-cov-2 is well on its way. although, several practical questions remain due to an incomplete understanding of how the virus triggers immune recognition and neutralisation [5] . as more people are infected, most are likely to generate an immune response. this may lead to a need for a community-wide immunity status classification, for example: (1) previously infected, now immune, non-infectious, (2) currently infected, and (3) immunologically naïve, still susceptible to infection. in time, we may see different sets of restrictions/privileges for people with different immune statuses. importantly, as more people recover, we need to consider how to best utilise people with active immunity to reignite our economy, restore critical facilities and provide much needed relief to workers in healthcare and essential services. but how will we know an individual's immune status in real-time? a radio-frequency identification (rfid) within a biometric bracelet could be the solution. the bracelet would have a unique personal id and be configured to communicate with a second deviceeither hand-held or freestanding. the second device can be located at the entrance to hospitals, public facilities, parks, grocery shops and workplaces. a quick scan of the bracelet could retrieve an individual's health status instantaneously displaying a 'clear' or 'block' signal to the device. possible status codes could be colour-coded or show classifications such as: "currently sick", "recovered", "in quarantine" or "unknown". logically, any government-sanctioned surveillance programme raises privacy concerns regarding data security, potential leaks and hacks, access to private companies and more. however, during an extraordinary crisis, many governments are willing to decrease privacy restrictions to save lives. most democratic countries already have privacy laws in place to govern the regulation, storing and use of personally identifiable information, healthcare and financial information. as the coronavirus pandemic continues to spread, some privacy commissioners are lifting data restrictions for health officials to keep track of the outbreak. for example, in march, israel passed an emergency law to use mobile phone data for contact tracing [6] . beyond protecting private data, a crucial role of government is to coordinate public health efforts to suppress and mitigate the pandemic. as the world braces for the next phase of the pandemic -why not leverage existing technology to design a centralised solution, a one-stop-shop to undertake three major tasks for enhancing a unified response to sars-cov-2. all authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication. the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. ethical approval was not required for this study as this is a short communication manuscript and no research conducted. mobile devices and health clinical characteristics of coronavirus disease 2019 in china immune responses in covid-19 and potential vaccines: lessons learned from sars and mers epidemic profile of specific antibodies to the sars-associated coronavirus developing antibody tests for sars-cov-2. the lancet coronavirus: israel enables emergency spy powers key: cord-318737-b32tk5ze authors: stickley, andrew; matsubayashi, tetsuya; sueki, hajime; ueda, michiko title: covid-19 preventive behaviours among people with anxiety and depressive symptoms: findings from japan date: 2020-10-10 journal: public health doi: 10.1016/j.puhe.2020.09.017 sha: doc_id: 318737 cord_uid: b32tk5ze objectives to examine covid-19 preventive behaviours among individuals with mental health problems. study design a pooled cross-sectional study. methods online survey data were analyzed from 2000 japanese adults collected in april and may, 2020. information was obtained on 13 covid-19 preventive behaviours, and anxiety and depressive symptoms using the generalized anxiety disorder scale (gad-7) and the patient health questionnaire (phq-9), respectively. linear regression analysis was used to examine the associations. results in models adjusted for demographic and socioeconomic factors, anxiety (coefficient: -0.77, 95% confidence interval [ci]: -1.30,-0.24) and depressive symptoms (coefficient: -0.82, 95%ci: -1.34,-0.30) were both associated with significantly lower engagement in covid-19 preventive behaviours. conclusion our results highlight the importance of facilitating the performance of preventive behaviours in individuals with mental health problems to prevent the spread of covid-19 in this population. as yet, there has been little research on the association between common mental disorders (cmds) and infectious disease, and it is thus uncertain how the presence of pre-existing cmds such as anxiety and depression might be linked to health behaviours during the ongoing covid-19 pandemic. a recent editorial has suggested for example, that differing levels of health anxiety might result in either a maladaptive engagement in (e.g. excessive hand washing [high anxiety]) or a disregard for (e.g. no hand washing [low anxiety]) preventive behaviours. 1 in addition, other authors have previously hypothesized that characteristics associated with cmds such as depression, including lower levels of energy, a decreased focus, and greater hopelessness might also be important for (non-)engagement in necessary health behaviours. 2 the few studies that have examined how cmds are linked to infectious disease preventive behaviours have produced mixed results. an earlier study from hong kong found that compared to those with low anxiety, individuals with high, and especially moderate levels of anxiety had significantly higher odds for adopting ≥ 5 precautionary measures against severe acute respiratory syndrome (sars). 3 support for the notion that cmds might be associated with increased engagement in preventive behaviours also comes from another study from hong kong, which recently found that people with symptoms of anxiety were more likely to adopt social distancing measures in response to the threat of covid-19. 4 in contrast, other research from china found that anxiety was not related to any differences in the adoption of preventive measures, while people with depression took fewer preventive measures in response to the covid-19 pandemic. 5 the current study will examine the effects of anxiety and depressive symptoms on covid-19 preventive behaviours in a sample of the japanese general population. a focus on japan may be particularly instructive. although the effects of covid-19 have not been as severe in japan as in many other countries -at least in terms of the number of deaths -coronavirus cases began to increase quickly from early-mid july following the ending of a nationwide state of emergency in late may. this increase may be linked to several factors including the use/non-use of preventive measures. specifically, a recent study has reported that although the vast majority of japanese adults have adopted preventive measures, around 20% of the working-age population (age 20-64) is reluctant to do so. 6 however, that study did not specifically focus on the possible effects of cmds in the non-use of preventive behaviours. linear and logistic regression analyses were performed to examine the association between anxiety and depressive symptoms and preventive behaviours. in the first analysis a combined preventive behaviour score variable was created by summing the responses for each preventive behaviour and linear regression analysis was used to examine the associations. in the second analysis the association between anxiety and depressive symptoms and each of the individual preventive behaviours was examined using binomial logistic regression. all analyses were adjusted for the above-listed covariates. the standard errors were heteroskedasticity-robust, and clustered by prefecture. the analysis was conducted using stata/mp (version 16, stata corporation, college station, tx). the results are presented as coefficients (coef.) and odds ratios (or) with 95% confidence intervals (ci). the level of statistical significance was set at p < 0.05 (two-tailed). the frequency of anxiety and depressive symptoms was 10.9% and 17.3%, respectively. both anxiety (coef: -0.77, 95%ci: -1.30,-0.24) and depression (coef: -0.82, 95%ci: -1.34,-0.30) were associated with significantly reduced engagement in all of the preventive behaviours combined (table 1) . for anxiety, in the logistic regression analyses ors were negative for 11 of the 13 preventive behaviours (appendix a). individuals with symptoms of anxiety were significantly less likely to engage in six of the preventive behaviours. specifically, they had a 40-49% reduction in the odds for washing hands, wearing a mask and avoiding crowds, and a 26-38% reduction in the odds for using a tissue/sleeve when coughing/sneezing, avoid touching face and cancel going out. depressive symptoms were also associated with significantly reduced odds for the same six preventive behaviours. in addition, they were also associated with a 27% reduction in the odds for avoiding engaging in gatherings (or: 0.73, 95%ci: 0.58-0.90). although a study from china reported that neither state nor trait anxiety was associated with covid-19 preventive behaviours, 5 other recent studies have all linked anxiety with an increased likelihood of engaging in preventive behaviours. 4, 9, 10 this conflicts with our finding that anxiety symptoms were associated with reduced preventive behaviour. it is uncertain what underlies this difference, but underlines the need for future studies to collect information on the specific causes of anxiety, especially as it has been suggested that high levels of health anxiety might be linked to engaging in excessive preventive behaviour. 1 regarding depression, our findings accord with those from the above-mentioned chinese study, which showed that depressive symptoms may inhibit preventive behaviours in response to the covid-19 pandemic. 5 it is possible that various mechanisms might underlie the association between cmds and reduced preventive behaviour in japanese adults. for example, it can be speculated that symptoms that are characteristic of these disorders such as fatigue and reduced concentration might be important in this regard. this study has some limitations. the use of cross-sectional data meant that we were not able to establish causality or the direction of the observed associations. in addition, we also lacked information on prior psychiatric diagnoses of the respondents. it is possible therefore, that poorer mental health might have been a psychological response to the threat of covid-19 or the rigours of quarantine. keeping this in mind, the results of this study indicate that people with mental health problems may be at increased risk for covid-19 infection given their lower engagement in a number of preventive behaviours. this highlights the importance of educating individuals with poorer mental health about the dangers of covid-19 and how to protect j o u r n a l p r e -p r o o f themselves against the virus. in addition, our findings also suggest that further research on the effects of covid-19 among individuals with mental health problems is now urgently warranted. j o u r n a l p r e -p r o o f table 1 association between anxiety and depressive symptoms and all covid-19 preventive behaviours combined among japanese adults † how health anxiety influences responses to viral outbreaks like covid-19: what all decision-makers, health authorities, and health care professionals need to know depression and medication adherence in outpatients with coronary heart disease: findings from the heart and soul study the impact of community psychological responses on outbreak control for severe acute respiratory syndrome in hong kong community responses during early phase of covid-19 epidemic psychological status and behavior changes of the public during the covid-19 epidemic in china japanese citizens' behavioral changes and preparedness against covid-19: an online survey during the early phase of the pandemic validation and utility of a self-report version of prime-md: the phq primary care study. primary care evaluation of mental disorders. patient health questionnaire a brief measure for assessing generalized anxiety disorder: the gad-7 public perceptions and preventive behaviours during the early phase of the covid-19 pandemic: a comparative study between assessment of community psycho-behavioral responses during the outbreak of novel coronavirus (2019-ncov): a cross sectional study anxiety and depressive symptoms were the exposures; covid-19 preventive behaviours were the outcomes coef: coefficient; ci: confidence interval both analyses were adjusted for age (ref. young), sex (ref. female), education (ref. less than college), income (ref. high income), household financial situation (ref. better/same as in previous year), employment (ref. unemployed not in the labour force) this study was approved by the ethics committee of waseda university (approval case number: 2020-050) and osaka school of international public policy, osaka university. the survey participants were informed of the purpose of the study prior to their participation and had the option to quit the survey at any time. the respondents provided explicit consent that the information they provided could be used for the purpose of this study. the data are completely anonymous. number 20h01584. the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. the authors declare that they have no conflicting interests. mu and tm were responsible for data acquisition. as wrote the main text. mu analyzed the data and contributed to the writing of the text. tm, hs reviewed and revised the manuscript. key: cord-254904-4eduslpb authors: griffiths, s.; reith, g.; wardle, h.; mackie, p. title: pandemics and epidemics: public health and gambling harms date: 2020-07-22 journal: public health doi: 10.1016/j.puhe.2020.06.022 sha: doc_id: 254904 cord_uid: 4eduslpb nan when we started the process of creating this special issue of public health, we were seeking to respond to an increasing call to recognise gambling harms as a public health problem and to address concerns about a potential growing epidemic of harms that threatened the health and well-being of populations across the globe. that this is increasingly being accepted as a public health issue, albeit among a relatively small field of gambling researchers and practitioners, is not in question. however, the question that faced us was what such a response, for this journal, at this point in time, should look like. we began to realise that what was needed was a kind of 'next step'. an evolution of discussion that goes beyond the simple repetition that 'gambling is a public health problem' brings the issue to a wider audience of academics, public health and healthcare professionals. and for this to include what public health policy and practice might be in the future. to facilitate mature debate, we needed to help public health, primary care and healthcare professionals see that gambling is not necessarily a harmless pastime, and to understand that gambling harms contribute to many of the social and economic inequalities that are determinants of health and well-being for individuals, their families and the communities in which they live. in short, we needed to bring what was known from the evidence base to the readers of this journal. as with any issue of public health, we wanted to do that in a way which helped readers see both the reason for the concerns relating to gambling harms across the globe and the potential for translating such evidence into public health action. this issue is the result of those discussions. what we did not discuss was how you present a special issue of public health on what some are coming to see as an epidemic of gambling-related harms, when the world is experiencing a global pandemic. at the time of writing, covid-19 is still an emerging disease. whilst we await population surveillance based on antibody testing, containment measures will continue to focus on the isolation of symptomatic cases and social lockdowns. across the world, public health attention has, naturally, been directed towards the pandemic response, whether locally or as advisors for national and local politicians. yet, even in the midst of this pandemic, we need to be aware that gambling harms are still occurring. the pandemic has not interrupted gambling, merely changed how it is happening. we can but speculate on how keeping people in their own homes, many without their usual occupations, activities and social networks, might impact their use of online gambling platforms. obviously, sporting events have been cancelled and land-based venues closed during lockdowns, vastly reducing the availability of gambling, but other options online have sprung up. as competitive sports and horse racing restart, albeit behind 'closed doors', and social distancing continues to affect the footfall in gambling venues, in the us at least, one company has created 'drive-thru' gambling centres. 1 debate has already started about the impact the covid-19 pandemic has had on gambling behaviour. industry commentators point to lost revenues, which are likely to be significant. the industry will regroup and a critical business consideration for them will be how to future-proof itself against such shocks of this nature. a greater push to online gambling seems inevitable. it may also be tempting for governments to use gambling expansion and its subsequent revenues to recover resources which will be a priority with the inevitable economic depression looming. however, from a public health perspective, we need to focus on people, not purses. we need to consider the impact on individuals and communities and to assess how gambling harms are changing in the context of our vastly altered postecovid-19 world. in britain, as elsewhere, one of the aims of gambling legislation is stated to be the protection of the vulnerable. importantly, vulnerability is not a static state but something that may vary for individuals based on their life experiences and conditions. in the context of great economic and social uncertainty, it is vital to understand who are the new 'vulnerable' and what measures should be put in place to protect them. this may mean taking and maintaining a more precautionary approach to gambling regulation whilst the knowledge about impact is generated. covid-19 is likely to create many more vulnerable people and to exacerbate existing inequalities: inequalities that are already expressed in the distribution of gambling harms. it is vital that politicians, regulators and public health officials are sighted of these changes and able to respond rapidly. what this collection of special articles shows is how varied and diverse the experience of gambling harms can be, how far reaching for individuals, families and communities, and how global the potential impact could be. vulnerability to harms is manifest through socio-economic or cultural status, through the areas in which people live and through the practices engaged in by the industry. these things are not simply the preserve of the individual but of individuals embedded within their broader social and environmental contexts. it is particularly heartening to see the local actions being undertaken that are sensitive to these contexts. at the same time, covid-19 aptly reminds us of the global reach of gambling and the need to embed local responses within global strategies to reduce harm. that the world health organization (who) is starting to take interest in championing strategy in this area is positive. yet, there is much still to do. research and policy nearly always plays catchup to industry developments. the industry, especially the online industry, is sophisticated in its use of data and technology to promote, protect and expand its services. increasingly, researchers interested public health jo u rn a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / p u h e in gambling will have to also be interested in data science and technological infrastructure if they are to truly understand the nature of gambling products, the industries responsible for generating them and their impacts. we agree a new framing is necessary: we need to acknowledge that the context of people's lives, broader social, economic and environmental circumstances and the actions of politicians, regulators and corporations, along with individual characteristics, can all influence behaviours. this is a public health framing, one where responsibility lies with multiple actors and agencies for preventing gambling harms. in britain, as politicians begin the process of reviewing the 2005 gambling act and updating it for the digital world, there is the potential for such change to occur. but it requires bold thinking and e crucially e action to overcome challenges in how to deliver such a joined-up, global and systems-based approach to reducing gambling harms. the articles in this special issue offer hope that with sustained effort and action, this may be possible. we all recognise that the world into which we will return will be very different, and within that new world, we will have an opportunity to do things differently. once the immediate pandemic is past its peak and lockdown is slowly released, the public health community will refocus on what recovery will be needed and begin planning for the new normal. with this pandemic, we are already seeing questions being asked about how we can 'reset' rather than 'recover'. paine 2 (1737e1809), the british-born american political theorist and revolutionary, wrote: 'we have it in our power to begin the world over again'. as we reset from the covid-19 pandemic, should we not see this as a real opportunity to rebuild the world in a way that also addresses and reduces gambling harms? if we are to have the sort of mature discussion around building the public health response to gambling harms, this is an important time to start. competing interests p.m. reports serving as an advisor to the scottish chief medical officer and the scottish government on the public health response to gambling harms. p.m. reports being invited to speak at the launch of the gambling commission's national strategy to reduce gambling harms in scotland. he reports not being remunerated for this. he reports receiving funding from the gambling commission to undertake a project developing a public health strategy to prevent gambling harms in glasgow for his employing agency, public health scotland. this funding was provided as part of a regulatory settlement to the gambling commission. between may 2015 and march 2020, h.w. reports serving as the deputy chair of the advisory board for safer gambling, an independent group that provides advice on gambling policy and research to the gambling commission and was remunerated by them. she reports working on one project funded by gambleaware on gambling and suicidality in the last three years. h.w. reports running a research consultancy, heather wardle research ltd. she reports not providing consultancy or any other services for the industry. she reports providing evidence at the house of lords select committee enquiry into the social and economic impact of gambling as an unpaid expert witness in summer 2019. she reports serving as a member of who panel on gambling. s.g. reports serving as an emeritus professor at the chinese university of hong kong which has institutionally received charitable and research support from the hong kong jockey club. she reports being the deputy chair and trustee of gambleaware, which is unremunerated, chair of the safer gambling board which is responsible for the betregret campaign. in addition, s.g. reports being an associate non-executive board member of the public health england board global health committee. g.r. reports currently being a member of the world health organization's panel on gambling and the howard league's commission on problem gambling and crime. neither position is remunerated. she reports receiving research funds from the national institute for health research, the economic and social research council, the medical research council and the british academy in the past three years. between 2009 and 2014, she reports being a remunerated member of the responsible gambling strategy board (now the advisory board for safer gambling): an independent body that advised the gambling commission on research and strategy. william hill punters bet on table tennis in sports lull common sense: (appendix) key: cord-263255-zdufwtn4 authors: cato, susumu; iida, takashi; ishida, kenji; ito, asei; mcelwain, kenneth mori; shoji, masahiro title: social distancing as a public good under the covid-19 pandemic date: 2020-08-13 journal: public health doi: 10.1016/j.puhe.2020.08.005 sha: doc_id: 263255 cord_uid: zdufwtn4 abstract objectives the purpose of this study is to show that social distancing is a public good under the covid-19 pandemic. study design we apply economic theory to analyze a cross-sectional survey. methods economic theory is complemented with empirical evidence. an online survey of those aged 30-49 in japan (n=2,177) was conducted between april 28 may 7. respondents were selected by quota sampling with regard to age group, gender and prefecture of residence. our main figure shows the proportion of people who increased/did not change/decreased social distancing, relative to the level of altruism and sensitivity to public shaming. the results of ols and logit models are shown in supplementary materials. results social distancing is a public good under the covid-19 pandemic, for which the free-rider problem is particularly severe. altruism and social norms are crucial factors in overcoming this problem. using an original survey, we show that people with higher altruistic concerns and sensitivity to shaming are more likely to follow social-distancing measures. conclusions altruism and social norms are important for reducing the economic cost of the pandemic. the concept of public goods has been explored in various fields of the social sciences. by definition, public goods are non-rivalrous (their usage by one individual does not reduce their availability to others) and non-excludable (individuals cannot be excluded from using them). as a result, people have an incentive to freeride: receiving the benefits without paying for the costs. i social distancing during the covid-19 pandemic is one such public good. consider a selfish individual who maximizes his/her own utility, which consists solely of personal benefits and costs. the personal benefit of social distancing is the reduction of one's probability of infection, while the personal cost (assuming employment opportunities are unchanged) comes from foregoing enjoyable activities, such as dining out. he/she chooses the degree of social distancing by balancing these benefits and costs. however, selfish individuals do not take the social benefit of social distancing into account. because social distancing by one individual decreases not only the probability of his/her own infection but also that of others, the social benefit of social distancing is greater than its personal benefit. this gap results in the insufficient provision of social distancing. the management of covid-19 thus requires the resolution of a collective action problem, where the lack of alignment between individual incentives and common objectives produces socially suboptimal outcomes. crucially, inefficiency due to this collective action problem can be particularly severe in the case of covid-19. for one, social distancing is beneficial to society as a whole, but public goods are more difficult to provide in larger groups, where freeriding incentives are stronger. ii for another, because the health effects of covid-19 are heterogeneous, those who expect minimal symptoms, such as younger age cohorts, have weaker incentives to maintain social distance. even if the share of such people is small, the collective consequences can be dire. in sum, even if some people follow social distancing measures for self-preservation reasons alone, the social average is likely to be substantially lower than the level required to eradicate the pandemic. however, social and psychological mechanisms can mitigate the collective action problem. the first is altruism. although the argument thus far has relied on the assumption of selfishness, numerous studies in ethics, psychology, and economics have demonstrated that people care about others. iii in particular, the empathy-altruism hypothesis suggests that people have intrinsic motivations to help others because of empathy, or the incorporation of the utility of others into one's own utility function. this claim is consistent with the traditions of moral philosophy since adam smith and david hume. figure 1 shows the results from an original social survey in japan, where we measured respondents' psychological traits and inquired about various social distancing actions. those who agreed that "it is important to help people around you and make them happy" (top row) were more likely to have reduced how often they dined out. thus, we find a positive effect of altruism on social distancing behaviours. this pattern is robust in ols and logit models that control for respondents' demographic characteristics (supplementary material (1)). this evidence is theoretically explained as follows. an altruistic individual takes the probability of being a silent spreader into account when they choose his/her level of social distancing. thus, his/her willingness to dine out or engage in other public activities is lower than that of selfish individuals. as a consequence, altruistic individuals are expected to maintain social distance more than selfish individuals. this mechanism might not always work. in figure 1 , we examine one specific type of behaviour: dining out. other types of social distancing may be reduced by altruism. for example, somebody with strong empathy for those facing physical or emotional hardships, especially family and friends, may feel compelled to engage them in face-to-face interactions for altruistic reasons. in such a case, altruistic concerns may have a negative influence on social distancing, as well as a positive one. a second mechanism that can mitigate the collective action problem is shaming, an extrinsic motivation driven by social norms and obligations. iv v people who violated social distancing j o u r n a l p r e -p r o o f guidelines have been publicly criticized in many countries, including japan, the uk, and the u.s. (2)). fear of these implicit or explicit sanctions-such as peer pressure, public shame, exclusion, and criticism from neighbours and colleagues-can generate incentives to abide by social norms. the third and fourth rows in figure 1 provide evidence of this. survey respondents who agreed that "it is important to always avoid doing anything people would say is wrong" were more likely to have reduced the frequency of dining out. this observation suggests that public shame can encourage social distancing (supplementary material (1) ). however, if shaming results in the stigmatization of infected persons as norm-breakers, not to say as public health risks, then that can generate the worse outcome of people hiding their illness. it is incumbent upon policymakers to provide accurate local information about infections and promote altruism without stigmatization, for example, by avoiding naming individuals or businesses with confirmed infections. [ figure 1 around here] the above-mentioned two mechanisms rely on voluntary actions, but not all individuals are sufficiently altruistic or norm-abiding. as such, legal enforcement, including extensive monitoring and penalties for violations, may be necessary for infection control. however, the cost of enforcement is tremendously high: the epicentres of infection are mainly metropolitan areas, whose lockdown-even if temporary-can result in severe economic damages. vi since voluntary or nudgebased approaches are not accompanied with high economic cost, these can help to reduce collective costs; moreover, these might successfully preserve civil liberties. at the same time, in the presence of altruistic, other-regarding concerns, small legal sanctions may be enough. designing these sanctions can be tricky: seemingly simple penalties, such as imposing a fee, can reduce altruistic behaviour, if j o u r n a l p r e -p r o o f individuals come to believe that they are absolved morally for violating social norms as long as they pay the fee. vii viii we should note here that the results of our survey on japan should be generalized only with caution. altruistic concerns or social norms change over time,and their effectiveness also varies across cultural backgrounds. further studies from different countries are essential before we can reliably conclude how policymakers can overcome collective action problems during this pandemic. that said, the economic argument and social-psychological evidence discussed above point to the following policy implication. each of the three mechanisms for mitigating collection action problems-altruism, shaming, and legal sanctions-have inherent advantages and disadvantages, and none may be strong enough individually to produce socially optimal outcomes. however, combining these mechanisms may yield sufficient social distancing with low economic costs, because there are possible complementary effects between them. thus, an important task for policymakers is to integrate psychological, social, and legal measures to ensure that these public goods are provided adequately. figure 1 : social distancing by altruism and sensitivity to shame note: each row shows the distribution of responses to the following question: has your frequency of going out for dinners increased or decreased since last march? the first two rows divide the sample according to the respondent's altruism, elicited by the following question: do you think it is important to help people around you and make them happy? the first row presents those who answered affirmatively, whereas the second row corresponds to those with neutral or negative responses. likewise, the third and fourth rows divide the sample by the respondents' sensitivity to shame, elicited by the following question: do you think it is important to avoid doing anything people would say is wrong? these questions on altruism and sensitivity to shame are modified from the world values survey. our survey (n=2,177) was conducted between april 28 and may 7, using an access panel provided by rakuten insight. j o u r n a l p r e -p r o o f the pure theory of public expenditure the logic of collective action: public goods and the theory of group incentives and prosocial behavior collective action and the evolution of social norms health vs. wealth? public health policies and the economy during covid-19 (no. w27099) economic incentives and social preferences: substitutes or complements? we thank an anonymous referee for helpful comments. this paper was supported by kakenhi (jp17h02478, jp18k01501, jp20k01689), and the group-joint-research project grant ("social sciences of digitalization") of the institute of social science, the university of tokyo. there is no conflict.authors contributions: cato (survey design, writing, data analysis); iida (survey design, data collection); ishida (survey design, data analysis); ito (survey design, data interpretation); mcelwain (survey design, writing, data interpretation); shoji (survey design, writing, data analysis) key: cord-259727-u2zj7zf6 authors: wallar, l. e.; mcewen, s. a.; sargeant, j. m.; mercer, n. j.; garland, s. e.; papadopoulos, a. title: development of a tiered framework for public health capacity in canada date: 2016-07-31 journal: public health doi: 10.1016/j.puhe.2016.03.009 sha: doc_id: 259727 cord_uid: u2zj7zf6 • select sars reports were qualitatively analyzed for usage of “capacity”/“capacities”. • public health capacity can be sub-divided into 17 individual capacity components. • these components can be organized into five tiers to build a capacity framework. • this framework can be used to guide capacity assessment and building efforts. in the early 2000s, successive canadian public health crises revealed that public health systems were ill-equipped to meet unexpected, increased population health demands. in 2003, the severe acute respiratory syndrome (sars) pandemic created a panicked state of preparation in anticipation of a high mortality rate and broad geographical spread. although this was not realized, large gaps in capacity to meet potential emergency health demands were revealed. 1 after sars, the first and only comprehensive and objective review of the canadian and ontario public health systems was conducted. it strongly emphasized the need for enhanced public health capacity and a strong public health workforce to prevent the occurrence of future crises. over time, these efforts have been hampered by a muddied understanding of what public health capacity actually means. 2e4 the objective of this study was to regain a clear understanding of the components of public health capacity, and how they relate to a stronger public health system. in this study, twelve publicly available canadian or ontario sars reports published between 2003 and 2006 were identified using a key informant (executive director of the association of local public health agencies (1998e2004)), and were accessed from internet websites between october 2012 and january 2014 (n ¼ 12) using the names of the reports, or the reports' commissioners or committee chairs as key words. for a complete listing of these reports, see supplementary data in appendix a. manifest content analysis was used to analyze the use of the terms "capacity" and "capacities" related to public health. 5 tables of contents, chapter headings, executive summaries, recommendations and terms that were unrelated to public health (e.g. bed capacity) were excluded. the remaining terms were coded by report name and type of capacity by lew. for example, epidemiological capacity was coded as "epidemiological". all coding was independently reviewed by seg. disagreements between reviewers related to the addition, deletion and naming of codings (n ¼ 90) were discussed and consensus was achieved. similar codes were deductively organized by lew into families that represented separate components of public health capacity. families and their codes were reviewed by seg and consensus was achieved through critical discussion. these families were then organized by lew and ap into a tiered public health capacity framework where capacity within each tier builds upon the capacities within the preceding tiers, and moves from the individual to the systems level. here, we present this framework of public health capacity that identifies individual components and suggests how they relate to and support one another for the purpose of enhancing overall capacity in public health systems. seventeen components of public health capacity were identified and organized into five tiers, namely: human resources; foundation components; program components; integrative components; and enhanced public health (fig. 1 ). this framework arranges the components of public health capacity from the individual to the systems level. human resources form the bottom tier of the capacity framework as they provide the necessary manpower, skills and competencies to support the succeeding tiers, and ultimately maintain and improve population health and wellbeing. their critical importance was discussed by all of the reviewed reports. as the national advisory committee on sars and public health noted, "no attempt to improve public health will succeed that does not recognize the fundamental importance of providing and maintaining in every local health agency across canada an adequate staff of highly skilled and motivated public health professionals." 6 the foundation components of public health capacity provide the necessary underlying infrastructure by supporting one another to effectively fulfill the programmatic and integrative public health functions, and maintain the smooth functioning of the public health system. for example, research and k* capacity is supported by partnerships and collaboration between various public health stakeholders on the same tier level. this tier also supports succeeding tiers. for example, epidemiology and surveillance capacity is supported by timely access to quality data and information, collaborative linkages, investigative research, common reporting structures, and modern disease information systems. the program components of public health capacity represent more traditional public health functions that support the integrative capacity components which combine these functions. for example, emergency management is supported by public health laboratories that are equipped to handle high volumes of testing, field epidemiologists, surveillance systems and networks, infection control standards, and training of front line workers. the integrative components of public health capacity include systems-level, complex, and inter-connected public health functions that require the integration of human resources, foundation and program capacity components in order to be effective. emergency management refers to planning and preparedness, detection and response, and control and mitigation of outbreaks, emerging and resurgent public health threats, unforeseen events, epidemics, and health crises. population health management refers to meeting community needs and responding to public health issues and challenges within the local and provincial public health systems. delivery of programs and services is primarily discussed in relation to ontario's public health units although the need for human, physical and financial resources applies to public health organizations as well. governance is related to policy and planning procedures, strategic capacity, leadership and management, performance management, and risk assessment and planning. these complex capacity components require the integration of the lower-tiered capacity components to impact local, provincial and federal public health capacity. as the standing senate committee on social affairs, science and technology noted, "capacity enhancement is a broad term which encompasses a number of areas: surveillance systems; fig. 1 e tiered framework of public health capacity and its components. the components of public health capacity were identified through analysis of the usage of public health-related "capacity" or "capacities" in post-sars reports. these components were organized into five tiers from the individual to the systems level. k* indicates knowledge exchange, management and transfer. bold font indicates the five tiers. emergency preparedness and response; human resources; public health laboratories; information technology; communications and research." 7 public health capacity exists at all societal levels, and is supported by human resources, and foundation, program and integrative components. as each component is enhanced, public health systems are able to more effectively meet public health needs. this study presents a cumulative conceptual framework of public health capacity where each capacity tier builds upon the capacities of the underlying tiers from the individual to the systems level. this organization is consistent with the united nations development programme's capacity assessment and development framework and lafond, brown and macintyre's health sector capacity framework. 2, 8 by organizing public health capacity components in this way, it emphasizes how individual capacity components relate to and support one another. this is in contrast to other discussions of capacity in public health that have a more singular focus on specific capacities such as epidemiology or health promotion. 9,10 based on this framework, capacitybuilding efforts are predicted to be potentially more impactful when directed at the lower tiers (human resources, foundation) as these tiers support capacity within the above tiers. this framework is intended for a diverse audience including public health professionals, organizations, academia, government, and professional associations who are interested or engaged in assessing and enhancing the types of public health capacities that are present and/or absent within their respective units. we suggest that this framework can be applied by each actor using an iterative, developmental approach according to the following steps: 1) identify the capacity components that individuals, agencies, and systems should possess given their particular mandate; 2) identify the capacity components that individuals, agencies, and systems possess, and examine how these components relate to the other capacity components in the framework; 3) identify the components that individuals, agencies, and systems do not currently possess in relation to the ideal state; and 4) examine the potential for building these capacities internally or externally via strategic partnerships with other actors who already possess these desired capacities. this conceptual framework provides a common structure of public health capacity components that can be utilized by any actor to better coordinate and target capacity-building efforts to specific components identified using the framework. this framework has some limitations. it is descriptive in nature rather than prescriptive with respect to how each component should be enhanced in current public health systems. it is incumbent on each user of this framework to decide how best to modify and apply it to meet their particular needs. the framework is based on government and governmentcommissioned sars reports that reviewed the canadian and ontario public health systems with an emphasis on community public health outbreaks and emergencies. certain components such as maternal and child health were not addressed in these reports and are therefore not included in this framework. lastly, this framework has not been validated using any real-world applications or scenarios. as this framework is implemented, it will be important to collect and receive feedback on its utility and applicability. as public health continues to meet new and existing challenges, enhancing public health capacity with a renewed focus on where individual capacity components exist within the system, and how these can be effectively leveraged through strategic partnerships will strengthen the ability of public health systems to maintain and improve population health into the future. final report: spring of fear. toronto: ministry of health and long-term care mapping capacity in the health sector: a conceptual framework the development and pilot testing of a rapid assessment tool to improve local public health system capacity in australia four approaches to capacity building in health: consequences for measurement and accountability rethinking validity and reliability in content analysis learning from sars: renewal of public health in canada e a report of the national advisory committee on sars and public health. ottawa: health canada standing senate committee on social affairs, science and technology. reforming health protection and promotion in canada: time to act. ottawa: government of canada united nations development programme bureau for development policy. capacity assessment and development in a systems and strategic management context development policy assessment of epidemiologic capacity in state and territorial health departmentseunited states assessing public health capacity to support community-based heart health promotion: the canadian heart health initiative, ontario project (chhiop) not required (no human participants or animals were used to conduct this research). none. key: cord-326852-gm98s8a3 authors: teo, wan-yee title: implications for border containment strategies when covid-19 presents atypically date: 2020-07-24 journal: public health doi: 10.1016/j.puhe.2020.07.019 sha: doc_id: 326852 cord_uid: gm98s8a3 abstract objectives for a large part of covid-19 pandemic, singapore had managed to keep local cases in the single digits daily, with decisive measures. yet we saw this critical time point when the imported cases surged through our borders. the gaps which we can and have efficiently closed, using a public health approach and global border containment strategies, are aptly illustrated through this case. this critical point of imported case surge, has resulted in large spike of daily local cases sustained through community transmission, up to 120/day within a very short time frame. we were able to rapidly bring this under control. study design this is a case study of a patient who passed through our borders, with covid-19 masquerading as a resolved sore throat. methods the events were prospectively documented. results we present a case of a 21 year-old student returning from nottingham. he presented with sore throat as the only symptom the few days prior his return, and on arrival at our border (day 7 from initial symptoms), his sore throat had already resolved. the events leading up to his covid-19 diagnosis highlight the gaps of the international screening processes at the global border entry, and the potential consequences of community chain transmission through imported covid-19 cases. conclusions an important global border control measure to implement quickly, will be to expand the symptom list to isolated sore throat, and/or a prior history of recent symptoms (resolved). this may capture a larger proportion of imported cases at border entry point, for more effective containment. this piece will be equally relevant to the general physicians, emergency care physicians, otolaryngologists and anaesthetists, who are at higher risk of encountering a throat visualization during intubation and routine examination. this information can be useful to countries with low resources or insufficient covid-19 testing kits. in the early months of the covid-19 pandemic, singapore had managed to keep the number of local cases down to single figures daily through decisive measures. we identified a critical time point when the number of imported cases surged through our borders that resulted in a large spike of daily local cases, up to 120/day within a very short time frame, that was further sustained through community transmission. using a public health approach and global border containment strategies, we were able to rapidly bring this under control. this short communication highlights how an atypical presentation of covid-19 (sore throat) could breach border containment. we present some effective strategies for covid-19 screening at border entry. a 21 year old student returning from nottingham presented with sore throat as the only symptom a few days prior his return. on arrival at our border (day 7 from initial symptoms), his sore throat had already resolved. self-taken photographs by the patient during the initial symptomatic phase (day 5) with the sensation of sore throat, and on day 7 and 12, when the sensation of sore throat had resolved, revealed persistent pharyngitis. the patient had no fever during his symptomatic phase and had performed temperature checks twice-a-day with a thermometer. he had experienced some nasal congestion initially which was attributed to his underlying allergic rhinitis. at border entry, this patient had declared his symptom of sore throat, which had resolved. the patient directly moved from the airport to his stay home notice (shn) hotel to stay in isolation. following the instructions on the information sheet from singapore global network (a division in the singapore economic development board which broadens and deepens the overseas network of singapore citizens) available online, 2 the patient and his family contacted the people's association (a government-supported statutory board to promote racial harmony and social cohesion in singapore) to clarify the symptom of a resolved sore throat, and highlighted patient's contact history with an italy-returning medical student during a fencing sparring. italy, at that point, had the most covid-19 cases globally. staff at people's association rapidly facilitated the patient to be picked up in a dedicated ambulance to national center of infection disease, singapore, where a chest x-ray done was normal, and the swab test was positive for covid-19 (day 8 of initial symptoms). this patient's parents transported him from the airport to his shn hotel. all 3 individuals (patient and patient's parents) were wearing surgical masks in the enclosed air-conditioned car space (windows were not wound down). the duration of transport was around 1 hour or less. the patient had changed to a new surgical mask, wiped down his suitcase and personal belongings with disinfecting wipes, and washed his hands before meeting his parents and getting into the car. about 36 hours later, the father started experiencing dry throat, dry cough and runny nose. patient's mother experienced dry throat. patient's brother (whom did not have any direct contact with the patient, was picked up in the same car but separately from the patient about 1.5 hours after) developed fever of 37.7рхњc, bodyache, nasal congestion and throat discomfort ~48 hours later from the car ride. it is unclear if a chain transmission occurred through parents at home, to the patient's brother who did not come into contact with the patient, or through the consecutive use of a common transport vehicle. swab test results were however negative for the rest of the family*. in retrospect, patient recalled unusual/impaired sense of smell for the first 4 days during initial symptoms. the events leading up to his covid-19 diagnosis highlight the gaps of the international screening processes at the global border entry, and the potential consequences of community chain transmission through imported covid-19 cases. here, we emphasize some effective strategies for covid-19 screening at the global border entry. fever and/or other respiratory symptoms are frequently highlighted at the global border entry as indications for swab tests. however, sore throat alone may be an unclear symptom for individuals to declare. this is a case of covid-19 with isolated sore throat, which has recovered. we will suggest a detailed breakdown of the symptoms/education posters placed at global border entry points to facilitate declarations and diagnosis. this patient had declared his symptom of sore throat, which had resolved. overseas returning persons to singapore have been placed on a mandatory 14-day stay home notice (shn) since 20 march 2359h. the availability of the instructions on the information sheet online from singapore global network, 2 and the provision of a hotline assistance from the people's association (government-supported), were the key factors and contact point which allowed the patient to be identified and rapidly facilitated to be picked up while isolated in his shn hotel, in a dedicated ambulance to national center of infection disease, singapore. we highlight the importance and efficiency of a national online covid-19 network resource for overseas returning persons, facilitation through government agency and a closed loop transportation in the containment of covid-19 spread. this patient's parents who transported him from the airport to his shn hotel, and patient's brother (whom did not have direct contact with the patient, but was picked up in a common transport vehicle afterwards) developed symptoms despite negative swab test results*. a study on environmental contamination by symptomatic covid-19 patients in airborne infection isolation rooms, demonstrated that air samples were negative despite the extent of environmental contamination. 3 however, swabs taken from the air exhaust outlets tested positive, suggesting that small virus-laden droplets may be displaced by airflows and deposited on vents. 3 in retrospect, patient recalled unusual/impaired sense of smell for the first 4 days during initial symptoms. some new reports suggest loss of smell or taste as covid-19 symptoms. [4] [5] [6] loss of smell and loss of taste occurred between 68-85.6%, and 71-88% respectively in two european cohorts reported very recently. [5] [6] but this knowledge was not available at the earlier phase of the covid-19 pandemic when the patient was symptomatic, and these symptoms may not be readily offered by a non-suspecting patient. physicians need to actively probe for this history. our frontline physicians worldwide also need a high index of suspicion encountering at least 3 geographic variants of covid-19 that have been reported so far. while loss of smell and taste were reported in two large european cohorts, 5-6 a report 7 published mid-april 2020 on 393 patients in new york city indicated gastrointestinal symptoms of diarrhea (23.7%), nausea and vomiting (19.1%) appeared to be more common than in china (where these symptoms occurred in 4 to 5% of patients). coupled with the knowledge that covid-19 can spread asymptomatically, these unusual symptoms may be the initial manifestation of the illness. we hope that global collaborative efforts at border screening can contain and slow down the rapid spread of covid-19 internationally. availability of a government-supported go-to online resource can unite efforts between returning persons and national directions in containing this pandemic. another strategy to ease the border point screening and declaration logistics, can be to set up an online pre-arrival declaration by government agency, where returning persons/students can selfreport any symptoms or resolution of symptoms, contact history, which can be reviewed prior arrival. returning individuals can then be pre-issued an electronic qr code/tagged queue number through email, which allows the suspect cases to be channelled to a separate queue or screening area with physical distancing precautions. this will allow suspect cases to be effectively prioritized during declaration screening. as of 17 march 2020, our ministry of foreign affairs in singapore has issued a statement to encourage singaporean students studying overseas to consider returning home soon. 8 we will expect an increase in the number of imported cases from this group. a high index of suspicion for covid-19 when identifying an isolated sore throat on clinical examination, will be equally relevant to the general physicians, emergency care physicians, otolaryngologists and anaesthetists, 9 who are at higher risk of encountering a throat visualization during intubation and routine examination (fig. 1) . this information can be useful to countries with low resources or insufficient covid-19 testing kits. our ministry of health released the figures -90% of singapore's imported cases over 3 days (18-21 march) did not show any symptoms at border entry. 10 an important global border control measure to implement quickly, will be to expand the symptom list to isolated sore throat, and/or a prior history of recent symptoms (resolved). this may capture a larger proportion of imported cases at border entry point, for more effective containment. majority 70.8% (34/48) imported cases (cohort from 23 march, fig. 2) were returning from the united kingdom. 8 this is an important message to deliver to the larger global community in our efforts to control the rapidly escalating pandemic. china medical treatment expert group for covid-19. clinical characteristics of coronavirus disease 2019 in china surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus from a symptomatic patient practice management -anosmia, hyposmia, and dysgeusia symptoms of coronavirus disease association of chemosensory dysfunction and covid-19 in patients presenting with influenza-like symptoms. int forum allergy rhinol olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (covid-19): a multicenter european study clinical characteristics of covid-19 in new york city advisory for singaporean students studying overseas covid-19 -what should anaethesiologists and intensivists know about it? anaesthesiol intensive ther recent-days-did-not-show-symptomsat?utm_source=stsmartphone&utm_medium=share&utm_term=2020-03-23+21%3a50%3a54 the author thanks the patient and his family for providing the information, case history and images. key: cord-301426-i9a5g86x authors: bray, i.; gibson, a.; white, j. title: covid-19 mortality: a multivariate ecological analysis in relation to ethnicity, population density, obesity, deprivation and pollution date: 2020-07-07 journal: public health doi: 10.1016/j.puhe.2020.06.056 sha: doc_id: 301426 cord_uid: i9a5g86x background: there is emerging evidence about characteristics that may increase the risk of covid-19 mortality, but they are highly correlated. methods: an ecological analysis was used to estimate associations between these variables and age-standardised covid-19 mortality rates at the local authority level. results: ethnicity, population density and overweight/obesity were all found to have strong independent associations with covid-19 mortality, at the local authority level. discussion: this analysis provides some preliminary evidence about which variables are independently associated with covid-19 mortality and suggests that others (deprivation and pollution) are not directly linked. it highlights the importance of multivariate analyses to understand the factors that increase vulnerability to covid-19. there is emerging evidence that certain groups are more susceptible to complications from covid-19 (for example, people who are obese 1 and people from ethnic minorities 2, 3, 4 ) and that neighbourhood characteristics, such as population density 5 and pollution, 6 might also play a role. estimating the importance of the various risk factors is complicated by the fact that they are highly correlated, so it is difficult to work out the relative contribution of each or if some are simply confounders. however, these factors are all positively associated with deprivation. research on health inequalities, from the black report 7 to the marmot review, 8 has emphasised the importance of material and social inequality as causes of health inequality, and age-standardised rates of deaths involving covid-19 in the most deprived areas of england are more than double those in the more affluent areas. 9 we hypothesize that deprivation is an important underlying risk factor for covid-19. although several sociodemographic factors have been considered in isolation, there is no analysis to date which simultaneously includes and adjusts for all these variables. this is because the data are not yet available to do so. however, these variables are available at a local authority level, allowing an ecological approach to be taken. the aim of this study is to estimate the effect of deprivation on covid-19 mortality rates, while taking into account the effects of other known risk factors. age-standardised rates of deaths involving covid-19 for the period 1st march 2020 to 17th april 2020 were published by the ons q2 on 1st may 2020, for each local authority in england and wales. 9 we have conducted an ecological analysis to assess possible associations with a range of sociodemographic variables using routinely available data for local authorities e ethnicity, overweight and obesity, population density, deprivation and pollution. these variables were calculated as follows: percentage of the population who are white (2011 census), percentage of the population who are overweight or obese (2013e15), people per square kilometre (based on mid-2018 estimates), median index of multiple deprivation (imd) for 2019 and annual mean concentration of particulate matter (pm2.5 mg m à3 ) for 2018. data on all of these variables were available for 310 of 317 english local authorities for which the covid-19 mortality rates have been published. 9 although it is widely reported that older people and men are at increased risk, these variables are not included in this analysis (because the mortality rates are age standardised and because we would not expect to see sufficient variation in the percentage of local authority populations who are men). scatter plots and correlations between the outcome of interest and all potential predictors were assessed. spearman rank correlation coefficients are given in table 1 . these exploratory analyses q3 confirm the strong associations of each of the variables considered and covid-19 mortality rates when they are considered in turn, and significant correlations between these potential predictors of covid-19 mortality. the highest correlations with mortality rates were a positive association with population density (r ¼ 0.6) and a negative association with the proportion of the population who are white (r ¼ à0.6). there was a moderate positive association with pm2.5 (r ¼ 0.4) and a weaker positive association with the median imd score (r ¼ 0.2). finally, there was a weak but unexpected negative correlation with the percentage of the population who are overweight or obese (r ¼ à0.2). these correlation coefficients suggest that each of these variables, taken in isolation, appears to predict the rate of deaths involving covid-19. univariate linear regression models were fitted, along with a multiple linear regression model which estimates independent effects of the variables of interest on covid-19 mortality rates adjusted for the other variables in the model (table 2 ). in line with our hypothesis that deprivation underlies other risk factors, a univariate model predicts an increase in mortality rate of 0.9 per 100,000 for each unit increase in the median imd score. however, the multivariate model suggests that this effect is mediated by other variables. when ethnicity, overweight/obesity, population density and pm2.5 are included in the model, then the relationship between deprivation and covid-19 mortality rate is no longer significant. the multivariate model suggests strong positive associations between both population density and overweight/ obesity and mortality rate. interestingly, adjusting for the other variables in the model has reversed the direction of the relationship for overweight/obesity in the univariate analyses, and the multivariate model predicts a 0.7 per 100,000 increase in mortality rate for each percentage point increase in overweight/obesity. there is also a strong association between ethnicity and the rate of deaths involving covid-19 e the model predicts a decrease of 1.2 per 100,000 for every percentage point increase in the proportion of the population who are white. this model provided strong evidence that ethnicity and population density are associated with the rate of deaths involving covid-19 at the local authority level and also suggests that areas with higher rates of overweight/obesity have a higher rate of deaths involving covid-19. of the variables considered, we found that the strongest predictors of the rate of deaths involving covid-19 at the local authority level were population density and ethnicity. while the spread of the infection in more densely populated areas is unsurprising, it is less clear why people from ethnic minorities appear to be at increased risk, and this is the topic of urgent research. 4 it has been suggested q4 that it may because they are more exposed to covid-19 by their over-representation in the caring professions and other 'public-facing' employment or in urban populations where covid-19 is more prevalent, or that it is due to other factors including deprivation. it is clear that ethnic minorities are overrepresented in the nhs , where white people make up 79% of the workforce, compared with 86% of the entire working age population. 8 although we have not been able to take occupation into account, we have controlled for deprivation and population density in this ecological analysis and found that the effect of ethnicity persisted. similarly, the previously reported effect of obesity on covid-19 complications was supported by the multivariate analysis and does not appear to be due to confounding by deprivation. data on comorbidities such as diabetes would be useful to determine whether they explain this relationship. while we confirmed a positive association between pm2.5 and covid-19 mortality in univariate analyses (in agreement with a similar analysis of case fatality rates in london boroughs 6 ), there was no evidence of a significant association after controlling for other variables in the model. there are several possible reasons for this. firstly, the outcomes considered in the earlier analysis were the number of 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 reported cases per borough and case fatality rate per borough. 6 secondly, the analysis of air pollution and covid-19 mortality in london boroughs did not control for any other variables and may therefore be confounded (an analysis of pollution levels in england found that concentrations were higher in areas with more nonwhite residents 11 ). finally, previous research on neighbourhood pollution levels has concluded that air pollution inequalities are mainly an urban problem 11 ; it is therefore possible that the association reported within london is diluted when studying local authorities across england. despite our initial hypothesis, our findings suggest that individual factors, such as ethnicity, and structural factors, such as population density, are stronger predictors of covid-19 mortality than deprivation. however, an important limitation of this analysis is that it is conducted at the local authority level, and the associations observed do not necessarily hold at the individual level. we note that data on risk factors were not available for seven local authorities. another important limitation relates to the measures included in the analysis. we used a very crude measure of ethnicity, so we did not estimate the risks for different non-white ethnicities; this estimate was based on 2011 census data which is likely to underestimate the proportion of non-white ethnicities; the use of median imd masks inequalities within local authorities; and of the two pollutants identified as being linked to covid-19, 6 we used only one of these that was readily available for each local authority. nevertheless, our analysis provides some useful insights while detailed analyses of individual-level epidemiological data are conducted to provide more reliable evidence. the contribution of working q6 in keyworker roles such as on public transport, as well as working in health and social care, to covid-19 complications and mortality rates amongst ethnic minority staff should be investigated further. we support the call for mixed methods research to explore the complex interplay between the various biological, social and cultural factors underlying the observed increase in risk for ethnic minorities. 2 given the apparent importance of population density in our analysis, we recommend that future research should include individual-level data on residential arrangements, such as multioccupancy dwellings and multigenerational households, as well as neighbourhood-level data on population density. as alluded to the earlier fact with respect to pollution, we note that associations between each of these risk factors and covid-19 are likely to differ between urban and rural areas, and subanalyses may reveal different patterns according to geography. our findings highlight the importance of multivariate analyses to understand the factors that increase risk of covid-19 mortality. amidst concerns that it is the most vulnerable who are most at risk during the current pandemic, it is crucial to understand the complex causal pathways between different vulnerabilities, including socio-economic disadvantage, and covid-19 infection, complications and mortality to tackle these inequalities. this research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors. nothing to declare. data are available for sharing. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 covid-19 and obesity is ethnicity linked to incidence or outcomes of covid-19? are some ethnic groups more vulnerable to covid-19 than other? the insitute for fiscal studies disparities in the risk and outcomes of covid-19 interpreting covid-19 and virtual care trends: cohort study a vulnerability-based approach to human-mobility reduction for countering covid-19 transmission in london while considering local air quality inequalities in health: the black report. harmondsworth: penguin strategic review of health inequalities in england post-2010. fair society, healthier lives: the marmot review deaths involving covid-19 by local area and socioeconomic deprivation: deaths occurring between 1 including supplementary analysis on pay by ethnicity) associations between air pollution and socioeconomic characteristics, ethnicity and age profile of neighbourhoods in england and the netherlands key: cord-281241-k1adcls8 authors: döhla, m.; boesecke, c.; schulte, b.; diegmann, c.; sib, e.; richter, e.; eschbach-bludau, m.; aldabbagh, s.; marx, b.; eis-hübinger, a.-m.; schmithausen, r.m.; streeck, h. title: rapid point-of-care testing for sars-cov-2 in a community screening setting shows low sensitivity date: 2020-04-18 journal: public health doi: 10.1016/j.puhe.2020.04.009 sha: doc_id: 281241 cord_uid: k1adcls8 objective: with the current sars-cov2 outbreak, countless tests need to be performed on potential symptomatic individuals, contacts and travellers. the gold standard is a quantitative polymerase chain reaction (qpcr)–based system taking several hours to confirm positivity. for effective public health containment measures, this time span is too long. we therefore evaluated a rapid test in a high-prevalence community setting. study design: thirty-nine randomly selected individuals at a covid-19 screening centre were simultaneously tested via qpcr and a rapid test. ten previously diagnosed individuals with known sars-cov-2 infection were also analysed. methods: the evaluated rapid test is an igg/igm–based test for sars-cov-2 with a time to result of 20 min. two drops of blood are needed for the test performance. results: of 49 individuals, 22 tested positive by repeated qpcr. in contrast, the rapid test detected only eight of those positive correctly (sensitivity: 36.4%). of the 27 qpcr-negative individuals, 24 were detected correctly (specificity: 88.9%). conclusion: given the low sensitivity, we recommend not to rely on an antibody-based rapid test for public health measures such as community screenings. objective: with the current sars-cov2 outbreak, countless tests need to be performed on potential symptomatic individuals, contacts and travellers. the gold standard is a quantitative polymerase chain reaction (qpcr)ebased system taking several hours to confirm positivity. for effective public health containment measures, this time span is too long. we therefore evaluated a rapid test in a highprevalence community setting. study design: thirty-nine randomly selected individuals at a covid-19 screening centre were simultaneously tested via qpcr and a rapid test. ten previously diagnosed individuals with known sars-cov-2 infection were also analysed. methods: the evaluated rapid test is an igg/igmebased test for sars-cov-2 with a time to result of 20 min. two drops of blood are needed for the test performance. results: of 49 individuals, 22 tested positive by repeated qpcr. in contrast, the rapid test detected only eight of those positive correctly (sensitivity: 36.4%). of the 27 qpcr-negative individuals, 24 were detected correctly (specificity: 88.9%). conclusion: given the low sensitivity, we recommend not to rely on an antibody-based rapid test for public health measures such as community screenings. © 2020 the royal society for public health. published by elsevier ltd. all rights reserved. covid-19 is rapidly spreading worldwide, and the number of cases in europe is rising with increasing pace in several affected regions. 1 while there is an urgent need to contain the pandemic to protect the elderly and vulnerable population, there are several obstacles to control the spread of new infections. the vast majority of sars-cov-2einfected individuals appear to have only mild to moderate symptoms similar to the flu or other flu-like infections, 2e6 lacking defining symptoms. thus, while we start losing the ability to trace all sars-cov-2einfected contacts, identification of potentially infected individuals becomes increasingly hard ( table 1 , fig. 1 ). to protect the vulnerable population, it is necessary to assess the infection status of potential contacts to patients with covid-19 rapidly but also to approve employees to work with at-risk individuals in the hospital or nursing homes. the current gold standard for sars-cov-2 detection is a sars-cov-2especific, quantitative real-time polymerase chain reaction (rt-qpcr) testing from a nasal or pharyngeal swab, sputum or broncoalveolar lavage. 7, 8 following standard protocols, rna needs to be extracted and the presence of viral rna confirmed by rt-qpcr. this requires several potentially erroneous steps and several hours for sampling and evaluation. even high-throughput laboratories require a minimum of 3e4 h from sampling to evaluation, and final information of the infection status may take up to 24 h. this bears the risk of a potential further spread of sars-cov-2 in the meantime and hinders widespread testing of all potential contacts. there is currently 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 no rapid method to detect potentially sars-cov-2epositive individuals that would allow an assessment of their infection status in a reliable manner. there is an urgent need for immediate targeted detection of infected individuals to slow the pandemic. we therefore evaluated a rapid antibody igg/igmebased testing system in the community setting for its ability, specificity and sensitivity to reliably identify infected individuals. the german red cross had established a covid-19 screening centre in a high-prevalence area with more than 300 confirmed cases among 12,000 inhabitants. the cluster outbreak occurred after a carnival celebration and secondary transmissions in the families and rural community. the medical personnel at the screening site perform 150e200 throat swabs for sars-cov-2 diagnostics every day on symptomatic individuals. thirty-nine randomly selected individuals at the centre were tested simultaneously using the sars-cov-2 rapid test and the gold standard rt-qpcr method (altona diagnostics). in addition, collected and stored serum samples of 10 previously diagnosed individuals with known sars-cov-2 infection were analysed. all individuals accepted testing via written informed consent. the rapid test used for evaluation is a qualitative igg/igm detection system to test for a current or past infection of sars-cov-2. the chemical coupling pad contains gold-labelled sars-cov-2 weak and strong is superior; the manufacturer's recommendation is also to interpret weak results as positive. lrþ: positive likelihood ratio; lr-: negative likelihood ratio; roc: receiver operating characteristics; ci: confidence interval. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 antigens and mouse igg controls. there are two detection bands (t1 ¼ igm and t2 ¼ igg) on the test strip, which are coated with mouse anti-human igm and igg antibodies, respectively. the control band (c) is coated with a goat anti-mouse igg antibody. after discarding the first drop of blood from a fingertip prick, two drops of blood are applied onto the rapid test chip. in addition, two drops of a provided solution are added. the test indicates positivity for igg after 15 min and for igm after 20 min. when a test sample is added to the sample-loading area, the antigen forms an immune conjugate with the gold-labelled antibodies and then move to the detection zone by a capillary action. the negative conformity rate has been described to be 100% for 68 negative controls. the positive conformity rate has been described to be 70% at early stages of infection (day 4e10) and 100% at late stages of infection (day 11e24). the study population was well balanced in terms of age (median: 46 years, interquartile range [iqr]: 28e72) and gender (24/49 female [49.0%]). the majority described symptoms including dry coughing (70.8%), fatigue (64.6%) and a runny nose (45.8%). only five individuals had no symptoms. twenty-two individuals were tested positive by repeated rt-qpcr, while 27 were tested negative. positive individuals reported five symptoms in median (iqr: 3e7), while negative individuals reported only 4 (iqr: 2e5) symptoms. we were able to identify the probable date of exposure of 22 individuals (44.9%). median time between exposure and test was 18.5 days (iqr: 15e24). all used rapid tests were valid; 38 of 49 (77.6%) tests were negative. we saw a weak response in 7 cases and a strong response in 4 cases. there was no case of a singular igm response indicating acute or recent sars-cov-2 infection. the manufacturer recommends to classify weak responses as positive which was supported via receiver operating characteristics (roc) curve analysis. therefore, we defined 11 tests as positive in our study. considering the pcr results, we found eight tests to be true-positive and 3 to be false-positive, whereas 24 tests were true-negative and 14 tests were false-negative (table) there was no statistically significant correlation between rapid test results and time from potential exposure (exact test, p ¼ 0.636), presence of symptoms (exact test, p ¼ 0.689), age (exact test, p ¼ 0.145) or gender (exact test, p ¼ 0.531). the sars-cov-2 outbreak in 2019/2020 followed an unprecedented international response to contain the pandemic. high transmission rates and the vast majority presenting with only mild to moderate unspecific symptoms complicate the ability to contain the virus. 9 moreover, laboratory methods to detect sars-cov-2 infection rely on rt-qpcr testing that require longer time for sample handling, preparation and diagnosis. while rapid point-ofcare testing is critically needed, the current evaluation of an antibody-based system demonstrates only low sensitivity and is therefore not recommendable to detect potential infections as a stand-alone test. indeed, studies demonstrated that seroconversion occurred sequentially for igm and then igg with a median time of 11 and 14 days, respectively. the presence of antibodies was <40% among patients in the first 7 days of illness and then rapidly increased to 100% at day 15 after onset of symptoms, which appear to be too late from a public health perspective. 10 in this real-life study setting at a community sars-cov-2 testing site after a cluster outbreak, we investigated the superiority of an antibody-based rapid test in comparison with the current sars-cov-2 rt-qpcr gold standard. we tested screened persons of an official screening centre that we had selected by chance. this is a scenario that already occurs and will more often occur in all european union (eu) member states within the next months. the rapid test was substantially inferior to the rt-qpcr testing and should therefore neither be used for individual risk assessment nor for decisions on public health measures. as there is an urgent need for a sufficient rapid testing system for sars-cov-2, an antigen-based system may therefore be more appropriate. we recommend accelerating the development and evaluation of effective point-of-care testing systems. the study has been approved by the local institutional review board in march 2020 (085/20). none declared . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 european centre for disease prevention and control (ecdc) clinical characteristics of coronavirus disease 2019 in china scientists are sprinting to outpace the novel coronavirus imaging and clinical features of patients with 2019 novel coronavirus sarscov-2 evidence of sars-cov-2 infection in returning travelers from wuhan, china improved molecular diagnosis of covid-19 by the novel, highly sensitive and specific covid-19-rdrp/hel real-time reverse transcription-polymerase chain reaction assay validated in vitro and with clinical specimens diagnosis of sars-cov-2 infection based on ct scan vs. rt-pcr: reflecting on experience from mers-cov epidemiology and transmission of covid-19 in shenzhen china: analysis of 391 cases and 1,286 of their close contacts antibody responses to sars-cov-2 in patients of novel coronavirus disease none q3 declared. key: cord-257325-pvf0uon3 authors: zeitoun, jean-david; faron, matthieu; lefèvre, jérémie h. title: impact of local care environment and social characteristics on aggregated hospital-fatality rate from covid-19 in france: nationwide observational study date: 2020-10-10 journal: public health doi: 10.1016/j.puhe.2020.09.015 sha: doc_id: 257325 cord_uid: pvf0uon3 objectives we aimed to investigate possible differences in aggregated hospital-fatality rate from covid-19 in france at the early phase of the outbreak, and to determine whether factors related to population or healthcare supply before the pandemic could be associated with outcome differences. study design nationwide observational study including all french hospitals from january 24, 2020 to april 11, 2020. methods we analysed aggregated hospital-fatality rate. a poisson regression was performed to investigate associations between characteristics pertaining to populational health, socioeconomic context and local healthcare supply at baseline, and the chosen outcome. results on april 11, 2020, a total number of 30 960 patients were hospitalized among the 3 046 french healthcare facilities, including 6 832 patients in intensive care unit (icu). a total of 8 581 deaths due to covid-19 had been recorded, with a median mortality rate per 10 000 people per department of 0.53 (iqr: 0.29-1.90). there were significant variations between the 95 french departments even after adjusting on outbreak inception (p<0.001). after multivariable analysis, four factors were independently associated with a significantly higher aggregated hospital-fatality rate: a higher icu capacity at baseline (estimate=1.47; p=0.00791), a lower density of general practitioners (estimate=0.95; p=0.0205), a higher fraction of activity from the for-profit private sector (estimate=0.99; p<0.001), and the ratio of people over 75 (estimate=0.91; p=0.0023). conclusions aggregated hospital-fatality rate from covid-19 in france seems to vary among geographic areas, with some factors pertaining to local healthcare supply being associated with outcome. first cases of coronavirus disease 19 , the viral pneumonia related to severe acute respiratory syndrome coronavirus 2 (sars-cov-2), were officially identified in december 2019 in china and were notified to the world health organization (who) on december 31, 2020. 1 since then, the epidemic has expanded well beyond china and the pandemic has officially been declared by the who on march 11, 2020. 2 while italy has been the earliest disease cluster in europe 3 , france has rapidly followed. on february 23, 2020, the french ministry of health issued the phase i of the national epidemic. phases ii and iii were respectively announced on february 29, 2020 and march 14, 2020. 4 fatality rate, defined as the number of deaths of patients in whom covid-19 was confirmed, divided by the total number of covid-19 cases, seems to vary among countries. italian reports have shown a casefatality rate ranging from approximately 7% to 10% 5 , while other countries such as south korea have observed much lower figures. 6 even if there is uncertainty due to variations in case recording, we lack definitive explanations for possible differences in case-fatality rates between countries. the number of tests that could be made to screen and insulate patients has been raised as a possible factor contributing to differences. also, it is not known whether this outcome varies within a country. several factors can likely explain differences such as affected population profile, healthcare environment and quality of care. there has been concern in france regarding critical care capacity with respect to the probable high number of simultaneous severe cases during the outbreak peak. 7 it has been estimated by the french ministry of health that there were approximately 5,000 intensive care unit (icu) beds in france yet with differences between regions. estimates forecasted that this capacity would be exceeded. 7 j o u r n a l p r e -p r o o f therefore, we sought to measure aggregated hospital-fatality rate from covid-19 in france, and to examine the association between populational and local healthcare supply characteristics, and this outcome. we used official and publicly available sources to retrieve and gather the needed data: we also retrieved the number of hospital beds per 10 000 people, including surgery beds, medicine beds, obstetrical beds, physical medicine beds, psychiatry beds and those in long-term care facilities (2017) according to a 2019 report from the french ministry of health, 9 and the total number of adult intensive care beds in each department at baseline, i.e. before the outbreak (2020). last, the fraction of hospital care activity as measured by hospital-days, performed by the for-profit private sector was collected (2017). for each department, the following health indicators were retrieved: overall mortality aggregated hospital-fatality rate was chosen as study outcome (i.e. for each day of the study period, the number of hospital deaths divided by the number of admitted patients). we chose not to analyze case-fatality rate since it would be unreliable in the french case. indeed, france has not performed systematic or large sars-cov-2 testing, and the number of recorded cases has repeatedly been recognized as being orders of magnitude below actual frequency. conversely, all serious cases of suspected covid-19 were required to be tested for confirmation. hospitalized cases, whether in regular wards or intensive care units (icus), therefore represent a reliable denominator for calculation. for each day of study period and in each of the 95 french departments, the number of hospitalized covid-19 patients and the number of covid-19 patients in icus were collected. also, for each day of study sample, the j o u r n a l p r e -p r o o f cumulative number of covid-19-related in-hospital deaths over study period was collected. to account for gaps in outbreak start between areas, the time origin for each department was set to the first day where at least 10 deaths due to covid-19 had been recorded in total. to investigate the relationship between our covariates and the selected outcome, a mixed-effects poisson generalized linear regression was used. models were adjusted for the number of people living in the department and the corrected day since the beginning coded as a third order polynomial as fixed effects. to account for the hierarchical structure of our data, the department (grouping variable) was used as a random effect. both a random intercept and random slope (for the corrected days since the beginning) were used. any variable achieving a pvalue < 0.2 in the univariable analysis was proposed in the multivariable model. in there were a total number of 3046 healthcare facilities (including public hospitals, table 1 . the median area of the 95 departments was 5 880 km 2 (iqr: 4 977-6 817 km 2 ). the study included data from january 24, 2020 (first french case) to april 11, 2020. the details of univariate and multivariable analyses are given in table 1 . following univariate analysis, eleven factors were included in the multivariable analysis. apart from the population, four factors were independently associated with a significantly higher aggregated hospital-fatality rate from covid-19: a higher icu capacity at baseline (estimate=1.47; p=0.00791), a lower density of general practitioners (estimate=0.95; p=0.0205), a higher fraction of activity from the for-profit private sector (estimate=0.99; p<0.001) and the ratio of people over 75 (estimate=0.91; p=0.0023). no health indicator was associated with our outcome in the multivariable analysis. in this nationwide observational study regarding covid-19 in france, we found significant differences between areas in terms of aggregated hospital-fatality rate. four factors were associated with our study outcome: a higher density of icu beds at baseline, a lower fraction of hospital care activity from the for-profit private sector, a j o u r n a l p r e -p r o o f lower density of general practitioners, and a greater proportion of people over 75 were all predictors of higher aggregated hospital-fatality rate in the current model. our study has several strengths. first, it is a nationwide analysis gathering exhaustive data from reliable sources. for most of covariates, year of availability was very recent, thereby limiting timeliness issues. in addition, the variables of interest are unlikely to significantly change across a relatively short period of time. second, we collected a very diverse set of data regarding demographics, populational health, wealth, and also characteristics of care supply and local healthcare ecosystems. populational health data were in particular critical to incorporate in the model since they are factors likely to influence disease outcome. we had very fine health data beyond age, namely prevalence of chronic conditions that have already been recognized as risk factors for covid-19 outcome. 3, 11, 12 third, we used a robust statistical model to analyse the data, namely a poisson linear model as the variables were daily counts and a mixed model as the observed data were not independent (repeated measures within a department), which allows separate intercept and slopes for each department. also, time-adjustment was made so as to align all departments on a similar basis and take into account timeliness issues. our findings have implications. critical care capacity has been a matter of concern regarding covid-19 outbreak. it has been predicted that france did not have enough icu beds to absorb all of the patients in need along several days or weeks. yet we found no evidence that less icu beds at baseline in a given area were associated with a worst outcome. conversely, we found that areas with an initial higher density of icu beds were associated with a higher aggregated hospital-fatality rate. we do not have any certain explanation for those unexpected findings. it may be that critically ill patients were more often transferred from rural areas or smaller facilities to more j o u r n a l p r e -p r o o f comprehensive facilities. it also should be underlined that hospitals have anticipated the outbreak progression by resetting their organization and creating new icu capacity in other wards. we could not measure actual icu beds at a given time since those data were not consistently reported. this will need further investigation. we also found that areas in which the density of general practitioners was higher were associated with a better outcome. even though this should be interpreted with caution, one may hypothesize that general practitioners played a critical role in the epidemic, through adequate orientation of covid-19 patients to hospitals while maintaining others at home. last, it is remarkable that social and wealth factors were not associated with the chosen outcome. the relationship between wealth and health has been consistently documented by a huge body of literature. again, we cannot certainly explain why herein departments with more deprivation were not associated with a higher aggregated hospital-fatality rate yet it should be recalled that france has a very protective social system with a great safety net. perhaps it helped to attenuate the social risk in the case of the epidemic. this study has limitations. firstly, as an observational study, it cannot establish definitive causality. we cannot exclude the possibility that our results might be confounded by factors that were not measured. in particular, we cannot rule out that criteria for admitting patients were different among areas and that some hospitals had more serious cases than others, whether in regular wards or icus. also, we did not have access to age-and gender-structure of hospitalized patients. last, we did not take into account control measures implemented in the different departments even though those measures were thought to be very similar. secondly, the follow-up was intentionally limited. however, given the high urgency that many healthcare systems are currently facing worldwide, we aimed at rapidly providing a first evaluation of j o u r n a l p r e -p r o o f hospital-fatality rates from covid-19 in a markedly affected country. subsequent work over the outbreak course will say whether local differences and their associated factors persist. thirdly, we did not have access to hospital data or patient data. thus, we could not calculate individual hospital-fatality rate and had to deal with aggregate measures which have been updated on a daily basis at the department level over the study period. fourth, we intentionally excluded nursing home since the related data were not available across the whole study period. this represents a selection bias. last, as of march 28, 2020, the french government decided to implement targeted transfers of seriously ill patients by medicalized trains or helicopters in order to improve resource allocation within the whole territory. those transfers may have interfered with our results even though we believe it is unlikely. indeed, reported counts of those transfers showed it involved very few patients as compared to the magnitude of the epidemic. it seems implausible that it significantly influenced the findings from the regression analysis, which were otherwise consistent over time. in conclusion, we found significant differences in aggregated hospital-fatality rate across french areas over the early period of the covid-19 outbreak. several factors pertaining to local healthcare supply were associated with a worst outcome, such as a higher icu capacity at baseline and a lower involvement from the private sector as well as a lower density of general practitioners. those findings clearly deserve further investigation with hospital-or patient-level data and over a longer follow-up. those departments have been chosen to illustrate the heterogeneity of situations across the whole french territory (see figure 1 ). world health organization. who director-general's opening remarks at the media briefing on covid-19 -11 critical care utilization for the covid-19 early experience and forecast during an emergency response arrêté du 14 mars 2020 portant diverses mesures relatives à la lutte contre la propagation du virus covid-19 2020 case-fatality rate and characteristics of patients dying in relation to covid-19 in italy transmission potential and severity of covid-19 in south korea coronavirus : les simulations alarmantes des épidémiologistes pour la france health as an independent predictor of the 2017 french presidential voting behaviour: a crosssectional analysis les établissements de santé -édition the association between income and life expectancy in the united states clinical characteristics of coronavirus disease 2019 in china characteristics of and important lessons from the covid-19) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention key: cord-276394-s9y11oep authors: liang, w.; mclaws, m.-l.; liu, m.; mi, j.; chan, d.k.y. title: hindsight: a re-analysis of the severe acute respiratory syndrome outbreak in beijing date: 2007-10-31 journal: public health doi: 10.1016/j.puhe.2007.02.023 sha: doc_id: 276394 cord_uid: s9y11oep summary objective to review the severe acute respiratory syndrome (sars) epidemic in beijing using basic epidemiological principles omitted from the original analysis. study design analysis of prospective surveillance data for beijing collected during the outbreak. methods surveillance data were reclassified according to world health organization criteria. cases previously excluded without date of onset of illness were included in the epidemic curve from estimates using the average time between date of onset and date of hospitalization for cases with both dates. cases who failed to give a contact history were now included; 7% ( n = 5 ) of cases during the import phase and 61% ( n = 365 ) during the peak phase. previously excluded cases were included for plotting on an epidemic curve, and basic spot mapping for distribution of cases was used from attack rates recalculated for age, gender, occupation, residential location, date of onset of illness and demographics. results the spot map effectively illustrated clusters by residency, with the inner-city sustaining the highest attack rate (33.42 per 100,000), followed by an easterly distribution 5–30km away (21.62 per 10,000), and lowest in districts 60–160km away (9.21 per 100,000). the new epidemic curve shows the outbreak commencing 10 days earlier than initially reported, with a three-fold greater increase in cases during the escalation phase than previously estimated. conclusion in hindsight, the investigation of the beijing sars would have benefited from the use of spot maping as an essential outbreak tool for early identification of specific geographical area(s) for quarantining. if a spot map of incidence density rates was used during the early phase of the outbreak, the inner city might have been identified as a major risk factor requiring rapid quarantining. contact history became uncommon as the outbreak progressed, suggesting that hospitals were over-burdened or pathogenesis and environment risk factors changed, strengthening the usefulness of early spot mapping and the need to modify risk factors included as contact history as the epidemic progresses. the origin of the novel coronavirus (sars cov) 1 responsible for severe acute respiratory syndrome (sars) infection was traced to the guangdong province of mainland china. 2 it spread within china and from guangdong to the hong kong special administration region of china (hong kong-sar) in february 2003 and on to five continents, infecting more than 8000 residents from more than 30 countries. 3 not surprisingly, the densely populated mainland of the people's republic of china sustained the largest burden of sars cases, an estimated 5327 cases, followed by china's hong kong-sar, with 1755 confirmed cases. 3 within the mainland, the case burden was the greatest in its capital, beijing, with 2521 probable cases, representing 31% of cases globally and 25% of all deaths. retrospective examination of reports from the three regions in china most affected, beijing, 4 guangdong 2 and hong kong-sar, 3 suggested regional deficiencies in epidemiological data. post-epidemic analysis using spatial diffusion process provides a powerful understanding of the geographic relationship between populations and their environment. 5 however, it does not provide preliminary assistance that would identify potential hot spots of exposure as the outbreak unfolds. we carried out simple re-analysis of the beijing data to determine which data could have provided information that would have resulting in early containment. the original epidemic curve excluded those cases without a history for date of onset of illness, whereas re-analysis included these cases and plotted cases on an epidemic curve substituting the date of presentation to hospital for date of onset of illness. during the early phase (import and escalation phases) of the outbreak, case definition was in accordance with the ministry of health criteria 6 in the absence of world health organization (who) criteria and a serology test. re-analysis, therefore, also included cases initially excluded if they did not fulfil the ministry of health diagnostic criteria of sars 6 requiring cases with contact history of either direct case contact or contact with an endemic area. these cases were now reclassified according to who criteria, 7 with cases classified as 'probable' cases only where their signs and symptoms were in accordance with criteria for one of three who definitions for 'probable' sars. all 5327 cases available from the sars epidemic database, collated by the disease control and prevention centre, beijing, 6 were now included in the epidemic curve. cases were categorized into 15 occupational groups, with restaurants combined with hospitality services and the military and police services combined. 8 re-analysis included an epidemic curve for 'probable' sars cases only and calculations of the beijing population-based rate, stratified by age and sex, using the fifth general census of china (version 2000). the original analysis did not include a spot map. re-analysis included cases plotted for 18 geographic areas with rates calculated per 100,000 residents and then regrouped into three geographic areas according to distance from the city centre: inner city, 5-10 km, and more than 10 km from the inner city. denominator data were not available to calculate specific exposure rates, such as number of hospitalized patients for a healthcare-acquired infection rate, number of healthcare workers for an occupationally acquired rate or healthcare worker hours for occupationally acquired rate per hours of exposure. the epidemiologic curves were developed using microsoft excel 2000, and spss version 10 was used to calculate case fatality rates (cfr), odds ratios, 95% confidence intervals for proportions, rates, odds and rates, and tests for significance. of the 5327 cases on mainland china, 3 after adjusting for onset of illness for 574 cases admitted early in the epidemic, the commencement of the epidemic was actually 10 days earlier (1 march) than the unadjusted curve (fig. 1) . the import phase continued until 24 march, with an average daily incidence of three, and contributed 3.1% of all cases. the corrected index case in the beijing epidemic was a visitor from shanxi province to beijing hospitalized on the 1 march 2003 and transferred for treatment 2 days later to a second hospital. nineteen secondary cases were subsequently traced to this index case; five relatives, 10 patients with healthcare-acquired sars and four healthcare workers with occupationally acquired sars. after adjustment, the escalation phase commenced earlier (on 25 march), during which time (table 1) . during the import phase with few cases, 75, it was most common (88.0%) for a contact history to be given. reporting contact history significantly changed with each phase (w 2 ¼ 892:57, po0.0001), finally dropping to 10% for cases presenting during the termination phase. during the crisis phases of the epidemic (import and peak), cases were 24.6 times (95% ci 17.7-34.2) more likely to give a contact history compared with cases during the period when there was no growth in the epidemic (the decline and termination phases). between 20 march and 24 june, 125 of the 192 total deaths attributed to 'probable' sars had a recorded date and time of death (table 1) . as deaths lagged the epidemic curve, most (72.8%) occurred during the decline phase. the average daily death rate was less than one from the import phase until 30 april when there were, on average, five deaths daily; thereafter, the daily rate dropped to 1.2. the incidence rate of sars in beijing was 18.6 per 100,000 residents and sustained a mortality rate of 1.4 per 100,000. the revised cfr was 7.6 per 100 clinically diagnosed 'probable' sars, not 8.4% as originally reported. 4 as the original and adjusted epidemic curves shifted by 10 days, the revised cfr at the beginning of the termination phase had reached 3.6%. the revised cfr identified that just over one-quarter (27.2%) occurred between the import phase and end of the peak (between 1 march and 25 april), when the cfr was 1.4%. by 20 april, one death occurred on average per day. the daily average number of deaths accelerated between 21 april and 30 april to five and, by 2 may, 50% of fatalities occurred; thereafter, during the decline and termination phase, the daily average for deaths fell to 1.2. the age-specific mortality rate was greatest (4.5 per 100,000) in older residents aged between 50 and 80 years and older, compared with 0.03 and 0.80 per 100,000 for young and younger adult groupings aged 0-19 years and 20-49 years of age (po0.00001). although the male to female ratio of cases was close (1.09 : 1.00), the population-based attack rate was significantly higher for females (19.1 per 100,000) compared with males (18.0 per 100,000) (p ¼ 0:027) ( table 2 ). the age of cases ranged from 1 to 93 years, with a median age 37.1 years (sd 15.8), 4 years older than the original estimate. regardless of gender, the population-based attack rate was significantly (po0.0001) higher for those aged 20-29 years, 30.8 per 100,000, whereas the lowest attack rate was sustained by the youngest, 2.5 cases per 100,000. most infections, 72.3% (1822/2518), were sustained by people aged between 20 and 49 years, with significantly (p ¼ 0:0001) more female cases, 26.3 per 100,000, than male, 21.9 per 100,000, within this grouping. within this age group, the mortality rates for females, 0.82 per 100,000, did not differ significantly compared with males 0.79 per 100,000 (p ¼ 0:59). when the attack rates were examined by three age groupings (young, 0-19 years; younger adult, 20-49 years; older, 50280þ), adults and elderly people constituted higher rates of sars cases (6.1, 24.0 and 17.5, respectively) (po0.00001). just over half (51.3%) of all cases were contributed by four occupation groups: healthcare workers (17.3%, revised from 16.2%); 4 government officials (12.9%); retired people (11.4%); and factory workers (9.7%). these four occupational groups contributed more than half (66.3%) of all deaths, with retired people having sustained the highest death rate (24.5%), followed by factory worker cases (8.8%), government officials (5.3%), and healthcare workers (2.5%). those whose socio-economic status would seems to be low (e.g. retired people, farmers and unemployed people), sustained the greatest proportion of deaths (24.5%, 11.7% and 10.6%, respectively). for the 2447 cases with place of residence, a plot of 18 beijing districts identified significant increases in rates associated with geographic location (po0.00001), with the epicentre located in the inner-city where the incidence rates ranged from 9.8 to 44.1, averaging 33.4 per 100,000 (fig. 2) ( table 3) . districts 5-10 km away from the innercity sustained rates between 16.7 and 23.5, and averaged 21.6 per 100,000. moving 11 or more kilometres from the inner-city rates were lower still, ranging from 0.5 to 35.3 and averaging 9.2 per 100,000. of specific interest was the tongzhou district (60-160 km from the city), with a rate as high as that for the inner-city, at 35.3 per 100,000. the cfr increased from 6.2% for cases located further from the city to 9.2% in the inner-city (w 2 for slope 4.09, slope ¼ 20:02, p ¼ 0:04). the import phase of the beijing epidemic occurred rapidly, between 1 and 10 march, with 14 cases admitted with an acute pneumonia of unknown cause without history taken for exposure to a case of respiratory illness or environmental contact. although the first case was admitted on 1 march, this case was transferred to a second hospital and was not to be recognized as sars until contact tracing identified this case as the index case for five family members, four healthcare workers and 10 patients at two hospitals. on re-analysis of the import phase, 88% of patients had a known contact history (table 1) . by 16 april, most patients fulfilled the clinical requirements of a case, but a known contact history could not be elicited in more than 36.2% of cases. the spot map developed by john snow 9 remains a rudimentary epidemiological tool in outbreak investigation. our analysis for spot mapping clearly illustrates that the highest attack rate was sustained by residents living in a most densely populated area, within 30 km of the city centre, concurring with the post-epidemic sophisticated analysis of spatial diffusion process. 5 during the 89day epidemic, similar durations were experienced elsewhere in china; 10,11 although our database could not identify community-acquired from occupationally acquired risk, an early spot map would have identified clustering of cases, indicating a likely community exposure. the decline in contact history should have raised suspicion that the definition of 'contact' in the initial phase could have benefited from a re-definition throughout the epidemic. contact history during an outbreak involving progressive transmission should list exposure to animals, environmental contact (i.e. a hospital or geographic contact by virtue of residential location), as potential contacts. such redefining, along with spot maps for place of residency or occupation, would have still revealed the heavy case loads in the inner city areas. although this is not always suggestive of a causative agent, it would be strongly supportive of the usefulness of geographical quarantining. even though more contacts acquired sars from spouses (15.4%), the proportion was greater with non-household contact (11.6%) 12 than household contact (8.8%), or friend (10.0%), suggesting that environmental exposure is a causal factor and supported by the clustering on our spot map and the high attack rate in those of working age. daily commuting to work across densely populated cities assists the dissemination of airborne or droplet spread diseases even when infectivity may be low. 13 excellent control measures were instigated during the early phase, including quarantining contacts and closing public social and education venues. 12 however, basic spot mapping could support a policy for rapid and severe restriction of population movement within 30 km circumference from the city centre. the who diagnostic criteria was not available during the initial phase of the outbreak. as a result, during the first 24 days into the epidemic, the magnitude was under-estimated by close to onethird by excluding cases without contact history or date of onset of illness. this resulted in a delay of 10 days in which an epidemic could have been recognized for containment. with any outbreak of unknown origin, there will be a paucity of crucial epidemiological data, including the significance of asymptomatic infection, an accurate incubation period, the infectivity and likelihood of person-toperson spread and changes in clinical presentation. the rapid decline in reports of contact history should strongly suggest that strict application of a current case definition could under-estimate the magnitude of the epidemic and efficacy of interventions. to fulfil the criteria of 'contact history', such contact would have had to occur between 1 and 16 days previously. 14 the dramatic decline in contact history may be caused by: (1) failure by healthcare workers to elicit contact history; (2) burden of recall of a protracted incubation period (up to 2 weeks); (3) infectivity of the agent improving enabling spread via asymptomatic cases; and (4) spread through casual environmental contamination. in china, 32% of our 1.3 billion population live in cities, with movement of both susceptible and infected people within and outside of china inevitably making public health hygiene of paramount importance. for management of future possible airborne outbreaks, we would recommend the development of a colour-coded public warning system, similar to the three tiered numerical typhoon warning system. 'yellow' warning would be given to the public to heed specific hygiene practices, reduce public gathering (cinema, dining out etc.), or both, with the understanding that this level could be a false-alarm or upgraded to 'orange', indicating further cases fulfilling a firmer case definition, finishing with 'red' to indicate a definite outbreak. all levels could be down-graded or up-graded with continuous analysis of data. containment of an outbreak requires interpretation of data analysis using the three public health tenets, 'time, place and person'. these analyses carried out early may be flawed; however epidemiologists must be able to issue early warning with support from both government and non-government bodies and withstand pressure from economic lobby groups when warnings are false alarms or require geographic quarantining. post-epidemic population movement analysis is crucial to our understanding of disease dynamics, which identified that population density was more significant than population size for the spread of sars. 5 however, although continuous basic outbreak analysis is more primitive than statistical modelling, it would have immediately illustrated the effect of the population density. although the use of a consistent definition is sound practice, periodic analysis, including cases that do not strictly fit a given criterion (close contact or date of illness) common during our peak phase, may have illustrated a different curve, enabling earlier recognition of a potential control opportunity: quarantining large areas of a city. sars working group. a novel coronavirus associated with severe respiratory syndrome epidemiology and cause of severe acute respiratory syndrome (sars) in guangdong, people's republic of china who summary of probable sars cases with onset of illness from 1 schuchat a for the beijing joint sars expert group. severe acute respiratory syndrome understanding the spatial diffusion process of severe acute respiratory syndrome in beijing document and supplement. sars and occupation statistics who case definition for sars document. sars and occupation statistics the cholera near golden-square, and at deptford a preliminary study on sars epidemics, and evaluation of its prevention and control in guangzhou city transmission dynamics of the etiological agent of sars in hong kong: impact of public health interventions evaluation of control measures implemented in the severe acute respiratory syndrome outbreak in beijing transmission dynamics and control of severe acute respiratory syndrome epidemiological determinants of spread of causal agent of severe acute respiratory syndrome in hong kong key: cord-303861-qn8yifcd authors: wang, chongjian; wei, sheng; xiang, hao; xu, yihua; han, shenghong; mkangara, ommari baaliy; nie, shaofa title: evaluating the effectiveness of an emergency preparedness training programme for public health staff in china date: 2008-05-31 journal: public health doi: 10.1016/j.puhe.2007.08.006 sha: doc_id: 303861 cord_uid: qn8yifcd summary background the severe acute respiratory syndrome (sars) crisis of 2003 provided a new urgency in china in terms of preparing public health staff to respond effectively to public health emergencies. although the chinese government has already carried out a series of emergency education and training programmes to improve public health staff's capability of emergency preparedness, it remains unclear if these training programmes are effective and feasible. the purpose of this research was to evaluate an emergency preparedness training programme and to develop a participatory training approach for emergency response. methods seventy-six public health staff completed the emergency preparedness training programme. the effectiveness of the training was evaluated by questionnaire before training, immediately after training and 12 months after training (follow-up). additionally, semi-structured interviews were conducted throughout the training period. results the emergency preparedness training improved the knowledge levels and increased attitudinal and behavioural intention scores for emergency preparedness (p<0.01). the results at follow-up showed that the knowledge levels and attitudinal/behavioural intention scores of participants decreased slightly (p>0.05) compared with levels immediately after training (p<0.01). however, there was a significant increase compared with before training (p<0.01). moreover, more than 80% of participants reported that the training process and resources were scientific and feasible. conclusions the emergency preparedness training programme met its aims and objectives satisfactorily, and resulted in positive shifts in knowledge and attitudinal/behavioural intentions for public health staff. this suggests that this emergency training strategy was effective and feasible in improving the capability of emergency preparedness. summary background: the severe acute respiratory syndrome (sars) crisis of 2003 provided a new urgency in china in terms of preparing public health staff to respond effectively to public health emergencies. although the chinese government has already carried out a series of emergency education and training programmes to improve public health staff's capability of emergency preparedness, it remains unclear if these training programmes are effective and feasible. the purpose of this research was to evaluate an emergency preparedness training programme and to develop a participatory training approach for emergency response. methods: seventy-six public health staff completed the emergency preparedness training programme. the effectiveness of the training was evaluated by questionnaire before training, immediately after training and 12 months after training (follow-up). additionally, semi-structured interviews were conducted throughout the training period. results: the emergency preparedness training improved the knowledge levels and increased attitudinal and behavioural intention scores for emergency preparedness (po0.01). the results at follow-up showed that the knowledge levels and attitudinal/behavioural intention scores of participants decreased slightly (p40.05) compared with levels immediately after training (po0.01). however, there was a significant increase compared with before training (po0.01). moreover, more than 80% of participants reported that the training process and resources were scientific and feasible. since the 9/11 disaster, anthrax bioterrorism, 'mad cow' disease, severe acute respiratory syndrome (sars) and avian influenza outbreaks, public health emergencies have become an important threat to communities worldwide. managing these emergencies and the threats they pose is part of the longterm government development plans in many countries, and expensive resources are being invested into preventing and responding to public health emergencies. 1 in china, surge capacity is one of the most urgent problems regarding public health emergency response at the present time, 2 along with the lack of equipment and the low efficiency of the public health emergency information system. recognizing this, the chinese government carried out a series of emergency preparedness education and training programmes to improve the capability of public health staff to respond to emergencies nationwide. however, it remains unclear if these training programmes are feasible and effective in improving emergency preparedness. investigation has revealed that the emergency response of the public health sector was insufficient, especially the emergency preparedness of public health staff, such as not knowing the emergency response protocols and management procedures, and how to collect and analyse the relevant data during the sars outbreak. 2, 3 therefore, in order to change the current situation and improve the capability of public health staff in china to respond to emergencies, a pilot study was developed and supported by the ministry of health of the people's republic of china (moh) and the world health organization (who). the study was carried out by tongji medical college in hubei province from 2004 to 2006. the training was completed in 2005, and the follow-up survey was conducted 12 months later. like any other successful health education programme, the emergency preparedness training programme should be subjected to a process of continuous monitoring, control, evaluation and, if needed, relevant modifications. [4] [5] [6] [7] [8] the comprehensive evaluation of an emergency training preparedness programme should include its various aspects (contents, aims and objectives, training resources, methods, effects and impact), and it should also answer questions about the efficiency and impact of training on the participants. [9] [10] [11] this study highlighted the procedures used in the evaluation of an emergency preparedness training programme, and focused on its most important aspects: training resources; training process; and effectiveness of training (before training, immediately after training and 12 months later). seventy-eight trainees from the centers for disease control and prevention (cdc) in 18 cities in hubei participated in the emergency preparedness training programme in 2005. two participants did not complete their training and were not part of the evaluation (n ¼ 76). trainers were selected based on their expertise in the field of public health emergency response, related training programmes and their involvement in continuous consultations on health service programmes, both educational and promotional. trainers came from the moh, who, chinese cdc, health department of hubei province, fudan university, wuhan university and huazhong university of science and technology. the aims and objectives of training were designed carefully by educational and training experts with an intimate knowledge of the public health emergency response plan and the training programme, in consultation with public health personnel who did not participate in the training. the training programme was based on the us cdc's emergency preparedness core competencies for all public health workers. [12] [13] [14] in brief, the training consisted of: (1) the definition of public health emergency; (2) the public health workers' role during emergencies; (3) the responsibilities of local, province and government agencies during emergencies; (4) the role of the cdc during emergencies; (5) the cdc emergency response chain of command; (6) emergency communication strategies and use of special equipment; (7) emergency response protocols; and (8) management procedures, including the management of necessary supplies and equipment. the training contents and objectives were subjected to continuous monitoring and evaluation throughout the training period. various training methods were used, including case studies, workshops, tutorials, seminars, group discussions, role playing, drilling and fieldwork. formal lecturing was the least used method. the training centre was equipped with modern audiovisual aids designed for training purposes. as well as the training logistics, other facilities and general services, such as transportation and accommodation, were provided free of charge to the participants. individual basic information, knowledge levels, attitudes and behaviours regarding emergency preparedness were investigated by questionnaire, which was designed by experts in the field of training programmes and continuous consultation on emergency management. in order to assess the questionnaire, a pilot test was undertaken among other public health personnel who did not participate in the training, and modifications were made by experts based on the feedback. thirty questions assessed the participants' knowledge of public health emergency competencies, which consisted of basic public health science knowledge, emergency management knowledge and emergency analytical/assessment skills (10 questions). if the correct answer was given to these questions, the participant received one point, whereas incorrect answers received no points. eight items were designed to assess the staff's attitudinal and behavioural intentions related to the 'eight core competencies for public health services'. 15 each of the eight items asked respondents to rate their attitudinal and behavioural intentions, as well as the frequency of their use of each of the competencies. responses were rated on an ordinal scale (1 ¼ very low, 2 ¼ low, 3 ¼ middle, 4 ¼ high, 5 ¼ very high). participants completed the first measurement (pre-test, baseline) on the first day of training. the post-training measurement (post-test) was conducted at the end of the last day of training. for the follow-up test, the participants were mailed a copy of the survey, with a self-addressed return envelope, 12 months after the training had been completed. the training process and resources were subjected to continuous monitoring and evaluation by semi-structured interviews. the inclusion of the trainees in the evaluation process was extremely helpful in updating and modifying the programme. the items addressed in the semi-structured interviews were as follows: (1) the scientific methods offered; (2) the technical material presented; (3) the performance of the trainer; (4) the benefits derived by the participant; (5) the use of the audiovisual aids; (6) the strengths and weaknesses of the session; and (7) final critical comments and remarks. the forms were distributed at the end of each session to be completed anonymously by each participant. the forms were analysed immediately and the results were shown to the trainer who had conducted the session. if any defects were revealed, the necessary rectifications were made immediately. evaluation of workshops and fieldwork was carried out in a similar fashion. feedback of the results of the evaluation was given to the participants. most data were reported as scores. frequency and confidence scores were derived for each domain by participants' responses to the frequency questions and the self-efficacy questions. repeated-measures analysis of variance was used to test differences between pre-test, post-test and follow-up test. the data from semi-structured interviews were categorized independently by three authors using the triangulation method, and the individual results of the analysis were compared and discussed until consensus was reached. all results were expressed as mean7standard deviation. data were analysed by one-way analysis of variance using statistical package for the social sciences for windows, version 12.0 (spss. inc., chicago, il, usa). seventy-six of the study participants completed the entire training programme and represented public health staff from the cdc of 18 cities (97.44% response). most respondents were male (n ¼ 57, 75%) and over half (n ¼ 42, 55.26%) had earned a bachelor's or master's degree, of which one-sixth possessed masters of public health degrees. additionally, most participants (n ¼ 62, 81.58%) had more than 5 years of experience as public health staff. some trainees (n ¼ 50, 65.79%) had participated in inter-related training approximately 12-24 months previously. the results of reliability assessment showed that test-retest reliability and the internal consistency of questionnaires was accredited to some extent (test-retest reliability of pretraining ¼ 0.83, cronbach's alpha 40.61). the results of related analysis indicated that the construct validity of the questionnaire was of high quality (related coefficient fluctuated between 0.35 and 0.79, po0.05). 16, 17 knowledge levels the investigation revealed that knowledge levels of public health emergency preparedness were relatively low before training. after training, a significant increase in the mean knowledge scores was observed (pre-test: 19.7972.41; post-test: 24.4970.86; followup test: 24.2471.58) (po0.01). basic public health science knowledge and emergency management knowledge scores decreased slightly (p40.05), but the mean scores for emergency analytical/assessment skills were increased dramatically in the follow-up test compared with the post-test (po0.01). furthermore, there was a significant increase in overall knowledge scores between the follow-up test and the pre-test (po0.01) (fig. 1 ). descriptive statistics on attitudinal and behavioural intentions at pre-test, post-test and follow-up test are presented in table 1 . as mentioned above, the responses ranged from high (5) to low (1) . the results showed that participants reported a significant improvement in their attitudinal and behavioural intentions in all eight core competencies in the post-test compared with the pre-test. twelve months later, there were slight decreases in participants' attitudinal and behavioural intentions in some core competencies, but the mean score for emergency analytical/assessment skills was significantly increased compared with the post-test (4.35 vs 3.69), and mean scores for policy development/programme planning skills (2.94 vs 3.95) and financial planning and management skills (2.66 vs 3.47) were decreased compared with the posttest (po0.05). the results of the semi-structured interviews showed that most participants (n ¼ 73, 96.05%) thought that the training methods were excellent/very good, and the training contents were clear and easy to understand. the remaining participants (n ¼ 3, 3.95%) indicated that the training methods needed to be improved/further developed. however, all of the participants recognized that the training was innovative. analysis showed that 80.26% (n ¼ 61) of participants were satisfied with the trainers' performance, and 19.74% (n ¼ 15) of participants thought that the trainers' performance needed to improve. however, no participants indicated that resource personnel were incompetent. additionally, most participants (n ¼ 72, 94.74%) were very satisfied with the venue, training logistics and services, and only four participants (n ¼ 4, 5.26%) thought that logistics and services needed improvement. continuous medical education and training is a process of updating knowledge, developing skills, bringing about attitudinal and behavioural changes, and improving the capability of participants to perform their tasks efficiently and effectively. 18 effective training methods are key to the success of an emergency training programme. a number of studies have shown that the training methods recommended by the present study educators were effective because different participants learn by different training methods, and methods of active training are especially helpful for adult learning. [19] [20] [21] formal lecturing was the least used training method because trainees do not participate actively in the learning process and the outcome is inferior to methods of active learning. the results of the evaluation suggested that up-todate training of public health staff should focus on the development of effective training methods, and interactive training methods may help to increase the quality of training and improve retention of knowledge through immediate reinforcement of learning. 22, 23 furthermore, comprehensive evaluation and feedback about the training programme were of vital importance for the participants and trainers as it helped participants to identify their limitations while monitoring their performance during the training period. also, trainers tended to improve their performance as they were aware that it was being monitored and evaluated. feedback of the results of evaluation of the training sessions to the trainers was found to be helpful in rectifying the weaknesses of sessions. 24 in addition, the mean scores of emergency analytical/assessment skills increased rather than decreased by 12-month follow-up. this is similar to results found by qureshi et al. 14 for this type of phenomenon, one must consider the experience of the public health staff at the end of 2005. before the follow-up survey, the majority of trainees had participated in avian influenza emergency response activities, thus providing practice and increasing perceived relevance of the training. as such, this probably had a positive effect on the effectiveness of training. nevertheless, the increased overall knowledge score and the positive change in attitudinal and behavioural parameters suggested that training programmes on emergency preparedness resulted in gaining knowledge and shifts in attitude and behaviour. this study had a few potential limitations. the analysis was limited to staff who were primarily engaged in disease monitoring and control, and epidemiological investigations in the cdc. in addition, evaluations were based on changes over time without the use of a horizontal comparison group. thus, it was not possible to fully determine which changes were due to the emergency preparedness training programme and which were the result of other factors. these results, however, remained constant throughout, which provides support that these changes were due to the training programme. the effectiveness of any educational training programme depends on its continuous monitoring and evaluation, which should include appropriate and varied methods. moreover, trainers and trainees should be actively subjected to the process of monitoring and evaluation, which was helpful in monitoring their overall performance. immediate feedback with results analysis of the continuous monitoring and evaluation should be available to those involved so that necessary improvements can be made. the results of the evaluation suggested that the emergency training strategy was effective and feasible in improving the capability of public health staff to respond to an emergency. a preliminary framework to measure public health emergency response capacity evaluation of the performance of responding to public health emergency for the workforce in cdc in hubei report of the system construction on disease control and prevention. hubei measuring effectiveness of tqm training: an indian study emergency preparedness: one community's response the road map to preparedness: a competency-based approach to all-hazards emergency readiness training for the public health workforce primary health workers in northeast brazil evaluation of health impact assessment workshop. criteria for use in the evaluation of health impact assessments business and public health collaboration for emergency preparedness in georgia: a case study responsive evaluation of competencybased public health preparedness training programs emergency preparedness training for public health nurses: a pilot study emergency preparedness core competencies for all public health workers public health worker competencies for emergency response council on linkages between academia and public health practice. core competencies for public health professionals psychometric considerations in evaluating health-related quality of life measures psychometric theory training objectives, transfer, validation and evaluation: a srilankan study what matters most? predictors of student satisfaction in public health educational courses applying educational gaming to public health workforce emergency preparedness relative effectiveness of worker safety and health training methods emergency preparedness and bioterrorism response: development of an educational program for public health personnel evaluating health impact assessment evaluation study of the training programs for health personnel in al-qassim, saudi arabia the authors thank all of the participants and trainers for their hard work, and all of the coordinators for their support and help. in addition, the authors would like to thank c.k. lee for his critical reading of the manuscript. not required. world health organization. none declared. key: cord-269575-hdqa12es authors: wei, b.; lu, l.; zhang, z.y.; ma, z.y. title: bridging the gap between education and practice in public health, with particular reference to less-developed provinces in china date: 2010-12-17 journal: public health doi: 10.1016/j.puhe.2010.10.006 sha: doc_id: 269575 cord_uid: hdqa12es ongoing healthcare system reform is one of the most important issues in china. there is an increasing awareness that public health education should be reformed to meet the demands of public health practice. this paper summarizes the current status of increasing public healthcare demand and public health service capacity in china, especially in less-developed provinces, and introduces the current public health educational system and public health administration structure. the paper also provides evidence for a considerable gap between public health education and practice, and suggests possible measures to bridge the gap. china is confronting many new challenges in public health, such as the increasing burden of chronic non-communicable diseases, responding to public health emergencies, mental health problems, injury, an ageing population and environmental pollution. alongside this, infectious disease remains a serious problem, especially in the less-developed provinces of china, such as guangxi and yunnan. both provinces are located in southern china, have a warm climate, many ethnic minority groups and a lower level of social and economic development. for example, the prevalence rates of human immunodeficiency virus/acquired immunodeficiency syndrome (hiv/aids) in yunnan and guangxi provinces are highest and second highest in china. the incidence rates of some infectious diseases, such as hiv and tuberculosis, are much higher than those in more-developed provinces, and pose a serious threat to the health and social stability of these areas. additionally, both provinces are bordered by other countries of south-east asia including vietnam, laos and burma. co-operation with these countries in order to prevent and control new and re-emerging infectious diseases, such as avian flu, h1n1 flu and hiv/aids, is an important part of the health strategies of the two provinces. 1, 2 additionally, an inverse care law is in operation. the lessdeveloped provinces in china face much greater public health problems than the more-developed provinces, but there are fewer public health professionals available to respond. demand for services is high and this is likely to increase as increasing health awareness (known in china as the 'healthoriented principle') is being increasingly filtered into the population mindset. this, in turn, will increase demand for public health professionals. it has been recognized that there are insufficient qualified, capable public health workers in the centres for disease control and prevention (cdcs) and other public health organizations, 3 particularly in less-developed provinces. this is partly a result of the gap between education and practice in public health, 3, 4 with a need to develop capacity in the public health workforce for disease control and health protection, and also to ensure that health systems deliver effective healthcare. 5 china is currently reforming its healthcare system. the latest iteration of the direction for the reform has emphasized the importance of the public health system as one of the four essential elements of a basic universal healthcare system. alongside this, in 2002, the institute for international medical education proposed the global minimum essential requirements in medical education, which includes seven core competencies for medical students. 6 consequently, the public health education system in china faces challenges from both recent internal healthcare reform and international public health trends for education and workforce development. the current system and structure of public health education in china remain largely based on the soviet model, which has been in operation since the 1950s. 5, 7, 8 schools of public health, which were mainly developed from the former departments of preventive medicine, are an integral part of medical colleges or medical universities. public health is a medical degree. students who pursue bachelors degrees with a major in preventive medicine or public health need to study at university for 5 years. they need to complete courses in natural science, basic biomedical sciences and clinical medicine in the first 3 years, before moving to study public health professional curricula. public health curricula include epidemiology, health statistics, social medicine and health management, nutrition and food hygiene, occupational hygiene, environmental hygiene, childeadolescent and maternal hygiene, health chemistry and health toxicology. placements, practicums and exercises are conducted in hospitals (clinical training) and cdcs (public health) in the last year of study. a typical school of public health has the following departments: epidemiology and health statistics, social medicine and health management, occupational and environmental health, childeadolescent and maternal health, health toxicology, health chemistry and a teaching laboratory. 8e10 the number of staff in schools of public health varies from 30 to 200, and is generally lower in schools in less-developed areas than those in more-developed areas. for example, there are only 80 staff at the school of public health of guangxi medical university, including 54 teachers, 15 technicians and nine administrative staff. each year, it recruits 100 students majoring in public health and 50 students majoring in health management. over 1600 undergraduates and postgraduates have graduated from the school in the past 30 years, most of whom are working in county-level, prefectural-level and provincial-level public health organizations. 1 these statistics are similar to those of the school of public health of kunming medical college. in contrast, peking university school of public health currently has over 150 staff and recruits a total of some 60 undergraduate students each year, which represents 40% of the number recruited by either the school of public health of guangxi medical university or the school of public health of kunming medical college. peking university school of public health, however, places more emphasis on longer education programmes and postgraduate education, and has more research postgraduate students than the other schools. schools of public health offer a range of academic programmes, which include diploma programmes, certificate programmes and short courses, as well as undergraduate and postgraduate programmes. the 5-year bachelors degree, masters degree and master of public health (mph) programmes are the most important of these courses. 11e13 the masters degree is a science degree that focuses on academic research ability, whereas the mph is a professional degree with a focus on professional knowledge, practice and skills needed in the current practice of public health and health management. 13 public health structures an emphasis on public health and prevention has characterized the health policies in china since the beginning of the 1950s. 13e15 since 1949, the ministry of health was established to take responsibility for healthcare policies and activities, including both medical and public health services. healthcare in both rural and urban areas in china is organized through a four-tired service system consisting of national, provincial, municipal (formerly prefectural) and district (in cities) or county (in rural areas) organizations and facilities under the management and supervision of the department of health. at each level of the system, there are hospitals and a cdc. hospitals provide clinical care and cdcs offer preventive and public health services. more recently, in many cities and rural areas, community health centres and clinics have been established to re-inforce primary care, enabling the co-location of primary clinical and public health services. the responsibilities of cdcs include disease surveillance and control, public health emergency response, laboratory analysis and evaluation. a higher-level cdc is also responsible for the public health agenda in its entire region, has an advisory and consultant role for lower-level cdcs in its region, and will provide fieldwork experience and internships for the public health education sector. a cdc must prioritize the scientific research and public health services in the region to achieve measurable health impact for the public, and emphasize prevention of disease by targeting early risk factors and supporting healthy lifestyle behaviours. 16 the role of the cdc in providing leadership to strengthen the health impact of the state and local public health systems is crucial to realizing the vision of optimizing life expectancy and health experience, addressing health p u b l i c h e a l t h 1 2 5 ( 2 0 1 1 ) 2 5 e2 9 disparities and supporting equitable health outcomes across the population and life course. one of the duties of the provincial cdc is to provide fieldwork experience and internships for the public health education sector. a typical cdc has functional departments including occupational safety and health, nutrition and food health, infectious diseases surveillance, injury prevention and control, emergency response, health information services, health promotion and vaccination. the number of staff at a cdc varies from 50 to 500, depending on its tier. there are approximately 50 staff in county centres, 100e200 staff in municipal centres and 400e500 staff in provincial centres, with various educational and professional qualifications. workers in public health organizations at the district/county level are, in general, a practice-oriented workforce, with a typical qualification being a 3-year higher diploma. at municipal/prefectural level, most staff have a 5-year bachelors degree, whilst at the provincial level, a large number of staff have education above bachelors degree, such as a master of science, mph, master of philosophy or doctor of philosophy. in summary, the national cdc and provincial cdcs have many qualified public health professionals, whereas those working in the rural areas tend to have the minimal education necessary to practice. there is a considerable gap between education and practice in public health that has been hindering the further development of public health in china. the most prominent problem is the disconnection between theory and practice. there are several contributory factors. first, schools of public health seem to have an educational goal which is different to that expected by the service sector, and thus the educational objectives may not reflect the needs of public health practice. many schools of public health place more emphasis on producing research-oriented graduates, and pay less attention to the knowledge and skills required in public health practice. 14 it is true that some public health graduates will choose a research career, but most will end up working as a public health practitioner. more diversified educational programmes may be required, and different programmes, such as 7-, 5-and 3-year programmes, master of science programmes and mph programmes, would help to meet different needs but must set clearly different educational objectives. secondly, there is very limited communication between cdcs and the education sector around curriculum development. as a result, many of the basic and essential skills and knowledge required in the cdc, such as the sterilization and disinfection process, are missing in public health curricula. thirdly, many staff move to work in a university immediately after graduation from the university, and fewer and fewer university teachers have first-hand practice experience themselves. 4 as universities are increasingly emphasizing research and paying less attention to teaching, many teachers lack sufficient field experience and practical skills to support their teaching. 1, 4 for example, in kunming medical college, only seven out of 60 teachers have experience of working in a public health service organization, and have had any practical disease control experience. many teachers responsible for teaching infectious disease have little or no direct experience in the taught areas. few have ever seen a bubonic plague or cholera patient, or participated in dealing with serious public health emergencies such as severe acute respiratory syndrome, h1n1 influenza or avian flu. most of the teachers do not understand the latest national health policies, nor know the requirements of potential employers of their students. many schools place more emphasis on laboratory research than population research, having limited content in the curriculum that can be applied to practical situations, as the former is more likely to produce high-impact publications. fourthly, the number of practice and internship placements for students of schools of public health is limited. the relationship between cdcs and schools of public health is not as close as that between medical schools and affiliated hospitals. in clinical education, students can practice and apply the knowledge and skills immediately after they are taught, whereas such opportunities do not exist for public health students. student learning in schools of public health is further hindered by the old didactic teaching methods which are still the main methods of teaching, and limited opportunities are available for practice, discussion and application. 14 a number of strategies and methods can be applied to bridge the gap between education and practice in public health. these strategies would require greater changes in the education sector than in the service sector, and only the department of education can make most of the changes in the education sector. however, in china, schools of public health are financially and administratively under the department of education, which is independent of the department of health under which cdcs work. communication and collaboration between the education and service sectors in public health would be crucial for any such efforts to succeed. the department of education needs to continuously investigate the new needs and requirements in public health practice, and ensures that education and training in most undergraduate public health education programmes is serviceand practice-oriented and its graduates can gain experience working in grassroots public health institutions. to make this happen, the central and local governments have a role in co-ordinating the education and health departments, and facilitating the exchange of ideas, communication and crosssector collaborations on public health education and practice. ideally, schools of public health and cdcs could be placed under the same department of administration. however, this is unlikely to become possible in the foreseeable future. alternatively, schools of public health and cdcs can be brought together to work more closely in other creative ways. a promising model has emerged in yunnan. the director of yunnan cdc was concurrently appointed as the dean of the school of public health of kunming medical college in 2008. this was the first appointment of its type in china. as p u b l i c h e a l t h 1 2 5 ( 2 0 1 1 ) 2 5 e2 9 a result, good communication, fruitful collaborations and a reduction in the educationepractice gap have occurred in the region. for example, senior experienced staff at the provincial cdc have been appointed as adjunct professors to teach at the school, and are able to participate in both teaching and research. conversely, teachers at the school are also appointed as adjunct staff of the provincial cdc, so that they can participate in and observe the service work on the one hand and help with training programmes for the cdc on the other. staff of the two organizations are frequently invited to give lectures and seminars at the opposite institution, and they can also attend each others' lectures and seminars of interest. furthermore, municipal and county cdcs have become members of the teaching base of the school, and 18 municipal and county cdcs have opened their laboratory facilities to the school. these arrangements have extensively widened the opportunities for exposure to real public health work for both teachers and students, and also opened up many new opportunities for collaboration in public health activities across the two sectors. 17 the model for public health education in china needs to be reshaped to reflect the needs and implications of the new biopsychosocial medical model and the ecological model for the determinants of health, 18, 19 which would entail the development of a multidisciplinary public health workforce, rather than hygiene and disease control technicians. the guiding principle for public health education should be to strengthen students' on-site working capacity, including professional, social and learning capacity. 20 theoretical teaching should adopt the five-in-one method, incorporating lectures, tutorials, self-directed learning, question and answer sessions, and open discussions, alongside a practical aspect, which supports social practice, on-site teaching, seminars and undergraduate mentorship programmes. 21, 22 today, the term 'public health' is used with a much wider connotation than the old term 'preventive medicine'. most schools in china and worldwide are now called 'schools of public health'. however, in official communications and policy documentations in china, 'preventive medicine' is still used to represent all aspects and areas of public health. this may negatively affect the development of some new public health areas in the schools of public health. at the same time as maintaining public health as a medical degree, efforts should be made to develop multidisciplinary public health, which recognize the contribution to public health from many other disciplines. alongside this, sustaining existing learning opportunities, such as the 3-year higher diploma and 5-year bachelors degree, is essential, especially for the less-developed areas in china such as guangxi and yunnan provinces, where there is a need to develop capacity and capability to work at multiple levels of the system, including at grassroots levels. further development of the mph programme, and 5-and 3-year courses should be considered to ensure the training of an application-oriented workforce. finally, health education and health promotion courses must be strengthened, to include a practicum in addition to the 30 class hours taught. firsthand experience of epidemiological investigations, health education and health promotion courses are an important tool for cdcs to carry out their routine work. there is a considerable gap between education and practice, particularly in less-developed areas in china. largely due to the administrative disjuncture between the service and education sectors, the major gap is that education is aimed more at theories and research, while the service sector lacks updated knowledge and skills to solve practical problems. creative ways of bringing schools of public health and cdcs together to work more closely are needed to bridge the educationepractice gap. current status, challenges, opportunities and prospect of public health education in yunnan province the origin and prevention of pandemics eight suggestions on public health reform the challenges and opportunities of public health and public health education we are facing today global minimum essential requirements in medical education. institute for 15 international medical education (iime) opinions of contemporary public health education implications of the development of modern public health discussion of public health system and public health education implications of modern public health contents for reforms in public health education in china reflections of public health education reform in china the current state of public health in china discussion on the changes of public health personnel training model in higher education reforming education of preventive medicine and culturing new-type talents of public health the challenges and opportunities in public health education of china centres for disease control and prevention cultivate public health professionals with comprehensive quality at the moment of internship teaching health departments: meeting the challenge of public health education applied topics in the essentials of public health: a skills-based course in a public health certificate program developed to enhance the competency of working health professionals the role of the faculty of public health (medicine) in developing a multidisciplinary public health profession in the uk reform trends of teaching methods on public health education analysis on the reform of public health education methods in china none declared. r e f e r e n c e s key: cord-354318-gzdy25vv authors: cénat, jude mary title: us deportation policies in the time of covid-19: a public health threat to the americas date: 2020-05-22 journal: public health doi: 10.1016/j.puhe.2020.05.017 sha: doc_id: 354318 cord_uid: gzdy25vv nan in an open letter to the u.s. government, 164 organizations called for the end of the deportations, highlighting the threat they represent. since then, in less than a week, 62 new deportations have been carried out to jamaica and 128 to haiti. by failing to promptly putting an end to deportations, the u.s administration risks becoming the most influential factor in the spread of covid-19 in some vulnerable countries in the americas. in this time of pandemic, international solidarity, one of the strong pillars of global health, is more than necessary. its absence may quickly become a threat to both lmics in the face of covid-19. in the present situation, it is important that the world health organization and the paho remain vigilant to lmics in the americas' needs, and support them in better managing deportations in an effort to contain this new threat. covid-19 and us deportation threat for the americas 3 the vulnerability of low-and middle-income countries facing the covid-19 pandemic: the case of haiti hospital bed density -country comparison the coronavirus crisis: the dread of responsibility' -paul farmer on the pandemic and poor countries paho to deploy extra covid-19 support to weaker regional health systems | devex paho prepares 8 caribbean countries for laboratory diagnosis of new coronavirus [internet]. panamerican health organization coronavirus en guatemala: los contagios de covid-19 entre migrantes que llevaron al país a suspender los vuelos de deportados desde ee.uu. . bbc news mundo covid-19 and us deportation threat for the americas 4 covid-19: un rapatrié testé positif quitte le centre de quarantaine, un malade à l'agonie et un cadavre échappent aux autorités . le nouvelliste global network against food crises, food security information network global report on food crises key: cord-312646-hfv7ce3f authors: pfützner, andreas title: comment to döhla et al., rapid point-of-care testing for sars-cov2 in a community screening setting shows low sensitivity date: 2020-06-02 journal: public health doi: 10.1016/j.puhe.2020.05.048 sha: doc_id: 312646 cord_uid: hfv7ce3f nan dear editors, we have read with interest the manuscript by döhla et al., which has been recently published by your journal [1] . in this manuscript, a point-of-care rapid test for assessment of anti-sars-cov-2 virus antibodies (igg/igm) is evaluated for sensitivity and specificity to detect the viral infection. the authors use a specific real-time polymerase chain reaction test (rt-pcr) as standard laboratory reference method. they found that the antibody rapid test only detects 36.4 % of the samples identified as positive by means of rt-pcr, and conclude that this poct is not recommendable for community screenings. basically, the authors compare a test with moderate sensitivity (~70 %) to detect the viral rna from a nasal or pharyngeal swab sample [2] with a blood test that measures the immune response of a host to the viral exposure. it is textbook knowledge that it takes about 5 to 10 days for igm antibodies to become prevalent. so it is predictable from the chosen methodology that a substantial number of pcr-positive samples have to be negative in the antibody test. it is also predictable that an antibody test is not really suitable to identify newly infected subjects. and this is not how it should be used! a point-of-care antibody test can e.g. be used to differentiate people with past infections (and potential immunity) from people that have not had the infection yet. in case that recent reports are confirmed that people with past infections may become asymptomatic carriers of the sars-cov-2 virus [3] , the antibody tests may be the only way to differentiate pcr-positive subjects into two groups: i.) patients who are freshly infected and may soon develop clinical symptoms (negative igg result) and ii.) patients who have developed antibodies and may now be asymptomatic virus spreaders (positive igg result). performance evaluations for an antibody rapid test should only be done in a proper way and using a standard reference methods (e.g. a chemiluminescence method) that measures the same analyte. it would have been fair and scientific standard, if the authors would have pointed to the limitations of their study. in any case our conclusion with respect to antibody testing is that the antibody detection offers vital clinical information during the course of the sars-cov-2 pandemic, and community testing will be warranted and necessary in the near-term future to reinstall normal life in our communities. yours sincerely rapid point-of-care testing for sars-cov-2 in a community screening setting shows low sensitivity antibody responses to sars-cov-2 in patients of novel coronavirus disease 2019 virological assessment of hospitalized patients with covid-2019 key: cord-290173-r3ikazrt authors: acharya, yogesh title: re: letter to the editor of public health in response to 'nipah virus infection: gaps in evidence and its public health importance' date: 2020-03-02 journal: public health doi: 10.1016/j.puhe.2020.01.007 sha: doc_id: 290173 cord_uid: r3ikazrt nan re: letter to the editor of public health in response to 'nipah virus infection: gaps in evidence and its public health importance' i agree; emerging infectious diseases remain the most suitable candidates to warrant the search for novel agents against them. unfortunately, year 2018 witnessed six outbreaks of the world health organization (who) priority pathogens. 1,2 nipah virus, complicated by the lack of treatment strategies, has the potential to cause an epidemic crisis in the near future. recent ebola crisis has highlighted the need for coordinated and better preparedness to tackle these possible and inevitable public health 'tsunamis.' pandemic emergency finance facilityà2017, 3 world bank initiative for expediting funds to the crisis hit countries acknowledge rapid mobilization of resources for effective containment of these outbreaks. coalition for epidemic preparedness innovations (cepi) is another international initiative worth mentioning here. 4 it is a collective and colligative effort in the field of expedited vaccine development and distribution. after its formal beginning in 2017 (world economic forum meeting, davos), cepi has been able to secure significant funding toward its objectives. their commitment is shown by the fact that they have already invited the proposal for vaccine development pertaining to the who priority list, starting with three pathogens: nipah virus, mers-cov, and lassa virus. beyond doubt, a lack of effective vaccination, antiviral agent, and treatment strategies are a public health emergency. ribavirin tried in kerala outbreak in 2018 was not able to show statistical benefit. 5 although there are some promising results from antiviral drugs such as remsdesivir 6 in the non-human trial against nipah virus, it is yet early to speculate its efficacy and safety in humans. it is pertinent that we prepare ourselves at this moment by consolidating public health awareness, mobilizing stakeholders, and strengthening multidisciplinary collaboration. above all, if we are to win this race, we need to respect 'one health' 7 and honor the intricate relationship between humans, animals, and the surrounding environment. more dangerous outbreaks are happening. why aren't we worried about the next epidemic pandemic emergency financing facility cepi j new vaccines for a safer world [internet]. cepi clinical manifestations of nipah virus-infected patients who presented to the emergency department during an outbreak in kerala state in india gs-5734) protects african green monkeys from nipah virus challenge from four-way linking to a one health platform in egypt: institutionalisation of a multidisciplinary and multisectoral one health system e-mail address: dryogeshach@gmail.com all rights reserved. please cite this article as: acharya y, re: letter to the editor of public health in response to 'nipah virus infection: gaps in evidence and its public health importance key: cord-333532-vrfduv5a authors: patel, kishan pravin; patel, puja a.; vunnam, srinivas r.; jain, rohit; vunnam, rama r. title: covid-19 patients: are current isolation guidelines effective enough? date: 2020-05-11 journal: public health doi: 10.1016/j.puhe.2020.04.048 sha: doc_id: 333532 cord_uid: vrfduv5a nan as the coronavirus disease 2019 (covid-19) pandemic continues to evolve, the number of cases and the death toll continue to rise, posing a substantial threat to global public health. as of april 23, 2020, the united states has the highest number of covid-19 cases (31.5%) and deaths (22.8%) in the world 1 . both clinicians and hospitalized patients are facing complications including limited resources, workforce and information, thus, making infection control an even higher priority. the median basic reproduction number (r0) of severe acute respiratory syndrome coronavirus-2 (sars-cov-2) is estimated to be 5.7 (95% ci, 3.8 to 8.9) 2 ; this value holds great significance as, theoretically, an infection will continue to spread as long as r0 >1. with growing concern, the focus needs to shift towards strategies to mitigate the spread of infection in both hospital and community settings alike. we believe the current isolation guidelines need to be revisited and clinicians should counsel covid-19 patients to practice contact precautions for longer durations given new evidence suggesting the possibility of a fecaloral route of transmission. according to current center for disease control (cdc) recommendations, discontinuation of transmission-based precautions per the test-based strategy in covid-19 patients is warranted after all of the following: (1) resolution of fever without the use of fever-reducing medications; (2) improvement in respiratory symptoms; and (3) two consecutive negative reverse transcriptase polymerase chain reaction (rrt-pcr) results obtained at least 24 hours apart by nasopharyngeal swabs 3 . for asymptomatic individuals, contact precautions can be discontinued seven days following diagnosis, should they remain asymptomatic -three days following the 2 discontinuation, individuals should still practice social distancing and nasal/oral barrier protection 3 . to date, covid-19 has been thought to be transmitted via respiratory droplets with most patients commonly presenting with fever, cough, or dyspnea. however, studies have also versus 16.7 ± 6.7) 6 . in a case series conducted examining the first 12 covid-19 patients in the us, sars-cov-2 rna was detected in the stool of 7/10 patients 7 . furthermore, a recent case reported an asymptomatic covid-19 patient who retested positive for sars-cov-2 despite being discharged after two negative consecutive respiratory nucleic acid tests at least 24 hours apart, raising concern for inadequate discharge protocol. notably, he was found to have a weakly positive stool sample test during his observation. should these patients remain contagious and prematurely discontinue self-isolation, they may disrupt current infection control 8 . moreover, one study to date has successfully cultured live sars-cov-2 from a fecal specimen, with implications that stool samples may contaminate hands, food, water, etc 9 . the resilience of sars-cov-2 plays a role in its virulence and pathogenesis. due to its hard outer shell, the virus can remain active for extended periods of time and may be more resistant to antimicrobial and digestive enzymes in body fluids 10 . additionally, per nucleocapsid and membrane protein analysis, sars-cov-2 has been classified as category b, which means it has intermediate grades of both respiratory and fecal-oral transmission potentials 10 . a study suggested that the half-life of the aerosolized form of sars-cov-2 is approximated to be 1.1-1.2 hours. however, it was found to remain viable on wooden and metal surfaces for up to 72 hours, supporting a concern for indirect transmission beyond respiratory particles 11 . given the possibility of fecal-oral transmission, evidence noting the occurrence of viral rna shedding in feces for up to a month, and the current state of the pandemic, we believe it is reasonable to extend the duration of contact isolation precautions as currently outlined by the practicing respiratory hygiene, and maintaining social distance 12 . currently, time and resources are limited but our efforts should not be. the covid-19 pandemic is a public health emergency, and clinicians need to act accordingly. with consideration of its high virulence, high infectivity, and the concern for a fecal-oral route of transmission, we suggest modifying guidelines to extend isolation and/or contact precautions in the best interest of patients, healthcare workers, and the global community as a whole. key words: covid 19; sars cov-2; gastrointestinal; isolation; fecal-oral; transmission; precautions world health organization high contagiousness and rapid spread of severe acute respiratory syndrome coronavirus 2. emerging infectious diseases disposition of non-hospitalized patients with covid-19 covid-19: gastrointestinal manifestations and potential fecal-oral transmission the presence of sars-cov-2 rna in feces of covid-19 patients prolonged presence of sars-cov-2 viral rna in faecal samples first 12 patients with coronavirus disease 2019 (covid-19) in the united states sars-cov-2 turned positive in a discharged patient with covid-19 arouses concern regarding the present standard for discharge chinese) shell disorder analysis predicts greater resilience of the sars-cov-2 (covid-19) outside the body and in body fluids aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 rational use of personal protective equipment for coronavirus disease ( covid-19) and considerations during severe shortages: interim guidance key: cord-328662-kpx73ki2 authors: van hout, marie claire title: "covid-19, health rights of prison staff and the bridge between prison and public health in africa " date: 2020-06-25 journal: public health doi: 10.1016/j.puhe.2020.06.037 sha: doc_id: 328662 cord_uid: kpx73ki2 nan title: "covid-19, health rights of prison staff and the bridge between prison and public health in africa ". despite a range of international instruments designed to protect human and health rights of people deprived of their liberty, many african prisons are still not meeting minimum conditions and standards of care [1] . human rights violations, systemic abuse and deplorable environmental determinants of health continue. african prisons are generally operating over capacity and are characterized by old physical infrastructure, insufficient sanitation, ventilation and hygiene, severe congestion caused by high pre-trial detention rates, and fragile prison health systems [1] [2] [3] . prison health research in africa is historically of low priority and remains underdeveloped [4] . this letter is intended to draw attention to the concerning lack of academic activity in this field and the particular lack of representation of the voices of people who work in prisons and their occupational health situation. the wellbeing, working conditions, health and safety concerns and experiences of prison staff in the african prison environment is understudied and ill understood. extant empirical literature has generally focused on stakeholder perspectives on the situation of incarcerated people, and not that of prison staff. where prison staff have been consulted on the environmental determinants of health in prisons, they voice a deep concern for their health and that of their families, and anxiety around bio-hazard risks (particularly airborne diseases such as tb) [5] . given the current covid-19 pandemic, and its devastating impact on african prisons and local communities, it is imperative that greater investment in occupational health research occurs. the academic discourse on prison staff and their health situation in africa is inadequate. this letter advocates not only for research into prison health determinants, but also for greater academic research into existing prison health policies related to prison staff to assess gaps and inform policymaking efforts. prison staff and prisoners are exposed to the same pathogens, the same hygiene and sanitation; the same congested space; air for breathing; and water for washing, drinking and cooking. they are also exposed to generally research is warranted to enhance our understanding of the prison determinants of health and cultures which shape prison staff responsiveness to threat of contagious and infectious diseases, the impact of prison conditions in terms of congestion, hygiene, ventilation and sanitation, navigation of health risks and work-related stress [2] [3] [4] [5] . information garnered can help to reduce future risks, tackle occupational health deficits, and identify what policies, practices, interventions and mechanisms could be best employed by authorities to improve prison occupational health standards, outbreak preparedness and ensure safe working conditions in african prisons. this focused attention on the health and well-being of prison staff through research could also contribute to greater social accountability and buy-in from government and prison officials, and fuel the upscaling of holistic prison health initiatives. such a concerted and strategic research effort can support a positive shift to reforming african prison health operations and systems. marie claire van hout, professor of public health policy and practice, hiv and tuberculosis in prisons in sub-saharan africa prison health situation and rights of juveniles incarcerated in sub saharan african prisons contemporary female prisoners health experiences, unique prison health care needs and health care outcomes in sub saharan africa: a scoping review of extant literature challenges in ensuring robust and ethical health research and the reporting of health outcomes and standards in sub-saharan african prisons prison facilities were not built with a woman in mind': an exploratory multi-stakeholder study on women's situation when incarcerated in contemporary malawi prisons key: cord-285928-gl4jfb3z authors: armitage, richard title: substance misuse during covid-19: protecting people who use drugs date: 2020-05-13 journal: public health doi: 10.1016/j.puhe.2020.05.010 sha: doc_id: 285928 cord_uid: gl4jfb3z nan people who use drugs (pwud) face additional risks from covid-19, linked to drug use behaviours, settings where drug use takes place, and related healthcare needs. these marginalised groups are present in countries of all incomes, 1 meaning they must be included in global public health strategies to safeguard them, their healthcare workers, and the wider public. pwud suffer significant acute and long-term health consequences due to direct and indirect effects of drug misuse, including acute intoxication, mental ill-health, and reduced access to healthcare through stigmatisation and discrimination. 2 the high prevalence of chronic conditions among pwud, including respiratory diseases like asthma and copd, 3 may put them at increased risk of covid-19 infection and severe disease. 4 in addition, public health measures may exacerbate poor outcomes for pwud, as social isolation is associated with increased substance misuse. 5 covid-19 is primarily transmitted by respiratory droplets and contact routes, 6 which informs public health mitigation measures including social distancing and hand hygiene. pwud who share drugs or paraphernalia are consequently at increased risk of transmission between drug users. in addition, drug use often takes place in crowded or substandard living conditions, threatening social distancing and hand hygiene adherence, and placing both pwud and the wider public at risk. pwud are also disproportionately represented in homeless, vulnerably housed, and incarcerated populations, which face additional risks from covid-19 infection. 7, 8 surges in demand for emergency care during covid-19 are forcing health systems to scale down routine services, risking discontinuity of care across many domains of health, including substance misuse services. this threatens pwud with reduced access to vital medications, psychological support, and clean drug equipment. in addition, physical distancing and self-isolation public health measures raise further barriers to accessing health and social services within this already-disadvantaged group. there is urgent need to protect pwud against the direct impacts of covid-19 infection, and to secure the continuity of care provided by substance misuse services. public health messaging should sensitively target this group to discourage drug and paraphernalia sharing, promote social distancing and hand hygiene, and empower pwud to appropriately seek medical attention, while safeguarding provision of drug misuse services, and protecting the health workers delivering them. this will require re-imagining services, such as telemedicine and online care, and maintaining infrastructure vital to treating addiction, including housing and welfare. prevalence of common chronic respiratory diseases in drug misusers: a cohort study do chronic respiratory diseases or their treatment affect the risk of sars-cov-2 infection? the lancet respiratory medicine the association between social isolation and dsm-iv mood, anxiety, and substance use disorders: wave 2 of the national epidemiologic survey on alcohol and related conditions world health organization. modes of transmission of virus causing covid-19: implications for ipc precaution recommendations covid-19: a potential public health problem for homeless populations. the lancet public health prisons and custodial settings are part of a comprehensive response to covid-19. the lancet public health key: cord-279032-plj9kg42 authors: jin, kaifeng; min, jinjin; jin, xiuming title: re: can the summer temperature drop covid-19 cases? date: 2020-08-15 journal: public health doi: 10.1016/j.puhe.2020.07.041 sha: doc_id: 279032 cord_uid: plj9kg42 abstract the temperatures may have influence on the spread of covid-19, however, we believe that government regulation and cooperation of public play a more important role. the temperatures may have influence on the spread of covid-19, however, we believe that 2 government regulation and cooperation of public play a more important role. key words： 5 covid-19, coronavirus, temperature 6 7 8 re: can the summer temperature drop covid-19 cases? 9 we are very happy to see that chandi et al. raised a speculation about temperature and covid-19 10 spread [1] . they obtained a meaningful conclusion that there may be a negative correlation between 11 environment temperature of a country and covid-19 cases. indeed, temperature can influence 12 immune system and virus activity to a certain extent. low temperature of environment can 13 suppression the immune response, people in low temperature are more susceptible to be infected. 14 warm and moister environment can suppression the spread in early stage, but there are too many 15 susceptible populations, the pandemic will not decrease in summer, the warm temperature cannot 16 stop the spread of virus. the government regulation and cooperation of public can be a more 17 important role in a modern society. in countries where government control is laxer, the cooperation of public is the key point. take japanese seemed be more cautious in reducing unnecessary going out and wearing masks. 27 according to a report, during the golden week of 2020, a noticeable decrease was found in the 28 year-over-year of the average number of passenger flow of jr line. compared to previous year, 29 the average number of passenger flow of jr line declined substantially (95%), as the number of 30 jr east japan's "narita express" (99%). reducing travel can be an effective way to control the 31 outbreak [3] . also, japanese have a "cough etiquette", that people who get cold should wear mask 32 lest infect others. besides, takata suzuki, a professor of aichi medical university found that 33 about 94% japanese wore masks regularly or at all times this year. however, in american the culture is totally different, a survey of longwoods international found 36 that 86% of americans want to travel within american once social isolation and other measures 37 are relieve. even the situation in american is still worse, more young people do not want stay at 38 home anymore, data from the american cdc shows that the average age of covid-19 infection 39 in the united states was significantly reduced. in arizona, the average age reduced from 48 in 40 march to 39 in june, and in florida, the average age is only 34. moreover, axios reported only 50% 41 vaccine. the virus may still out of control even the vaccine developed. except for japan, covid-19 in some other asian countries with different temperature, like 45 singapore, south korea and china, in these countries, the government regulation is much more 46 powerful, the pandemic is almost under control, which showed environment temperature may not 47 be a vital factor for virus transmission. in summary, we believe environment temperature may 48 affect viral activity (the source of infection), but government regulation and cooperation of public 49 play a more important role in blocking route of transmission and protecting susceptible population 50 [4] . 51 52 53 54 55 56 can the summer temperatures reduce covid-19 cases? susceptible supply limits the role 70 of climate in the early sars-cov-2 pandemic the effect of travel restrictions on the spread of the 2019 74 novel coronavirus (covid-19) outbreak transmission dynamics of the covid-19 outbreak and effectiveness 78 of government interventions: a data-driven analysis we declare that we have no financial and personal relationships with other people or organizations 58 that can inappropriately influence our work, there is no professional or other personal interest of 59 any nature or kind in any product, service and/or company that could be construed as influencing 60 the position presented in, or the review of, the manuscript entitled 61 62 63 64 key: cord-263719-a9mnjr3s authors: lee, a. title: wuhan novel coronavirus (covid-19): why global control is challenging? date: 2020-02-29 journal: public health doi: 10.1016/j.puhe.2020.02.001 sha: doc_id: 263719 cord_uid: a9mnjr3s nan wuhan novel coronavirus : why global control is challenging? on 31 december 2019, the world health organization (who) was alerted to the emergence of cases of pneumonia of unknown etiology detected in wuhan city, china. within days, chinese health authorities identified 44 more cases. a novel coronavirus (covid-19) was subsequently isolated from patients. a putative epidemiological link was made with exposures in a seafood market in wuhan city. 1 by the end of january 2020, 9720 cases of 2019-ncov were confirmed throughout china, with further 15,238 suspected cases and 213 deaths. 2 more worryingly, 106 cases were also confirmed abroad in 19 countries, from neighboring countries such as japan and vietnam to more distant countries such as finland, canada, and australia. on 30 january 2020, the emergency committee of the who, under the 2005 international health regulations, declared covid-19 acute respiratory disease a public health emergency of international concern. at this stage, the global spread of covid-19 acute respiratory disease continues to grow, and the full extent and severity of this outbreak remains to be seen. that said, global disease control of covid-19 is likely to be challenging. experience from the 2003 severe acute respiratory syndrome (sars) and 2015 middle east respiratory syndrome (mers) outbreaks, both also caused by emerging novel coronaviruses, may be informative. firstly, the rapid spread of covid-19 is likely to be driven by the phenomenon of 'superspreading'. superspreading describes heightened transmission of the disease to at least eight contacts and has been observed for several infectious diseases including sars, mers, and influenza. 3, 4 any delay in recognition of the disease and implementation of effective control measures increases the likelihood of greater spread of the pathogen. another feature of covid-19 common to sars and mers is the rapidity of global spread due to commercial air travel. the 1918 spanish influenza pandemic took months to spread from europe to australia or south america as ship-borne travel took time. modern air travel allows passengers to traverse the globe in less than a day. this allows the viruses to rapidly spread across continents, and efforts at airport screening to halt them have been fairly ineffective and costly. 5, 6 this is in addition to the potential for in-flight transmission of the virus among passengers that was observed with sars. 7 once the pathogen has landed in a new country, the likelihood of contagion and spread is dependent on local transmission pathways and the strength of local health protection systems. experience from mers suggests the transmissibility of the virus is not just due to its inherent infectivity but also due to influence by local contextual variables such as hygiene practices, crowding, and infection control standards. 8 high-income countries such as the united states and united kingdom have well-developed health protection systems to detect and respond to communicable disease threats. they have the ability to robustly trace contacts, assess suspected cases, and have them tested rapidly to get timely laboratory confirmation of infectious status to guide the management of these individuals. infected individuals identified can then be isolated until the risk of disease transmission has abated. this containment strategy, however, is resource intensive and may be more difficult to enforce in liberal democracies. the other component of well-developed health protection systems are strong infectious disease surveillance systems. surveillance enables the disease to be detected, outbreaks to be tracked, and the efficacy of interventions to be monitored. it also can provide vital information on the characteristics of the pathogen and help identify vulnerable population groups. during an outbreak of this significance, active surveillance is likely to be instituted, often with daily monitoring of disease trends demanded by health authorities. once again, this is laborious and resource intensive. the current concerns then regarding the 2019-ncov outbreak must be for low-and middle-income countries where health protection systems tend to be weaker. in these settings, laboratory resources may be lacking, notification of infectious diseases are often not timely or complete, and their public health infrastructure is often weak. 9 their surveillance systems may be more rudimentary, lacking in coverage and analytical strength. 10, 11 surveillance systems are the eyes of the health system e without them the health system would be blind. you cannot tackle what you cannot see. unfortunately, in resource-constrained settings, investment in this critical health protection infrastructure is a low priority compared with other health priorities. health protection investment is analogous to an insurance policy e in good times when it is infrequently called upon it may be deemed unnecessary by policymakers. but this is a dangerous misperception. furthermore, compared with other public health interventions, health protection interventions are highly cost-effective. 12 disinvestment in health protection is risky as it is not easy to build up health protection infrastructure, skills, and workforce rapidly. consequently, the risk of covid-19 is most likely to be greatest in developing countries that are most likely to lack the means and health protection systems to protect themselves. the burden of infection may, therefore, be heaviest in these countries. undoubtedly, most developed countries would be focused on preparing their health systems to protect their own health security. however, without adequate intervention in the developing countries, covid-19 could take root and become endemic in these countries, in effect becoming human population reservoirs for the virus that can and will reinfect other populations worldwide. there is therefore both a self-preservation and a moral imperative for richer public health jo u rn a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / p u h e countries to offer and provide assistance to developing countries to help them bolster their defenses against this global threat. what is clear is that global health threats such as covid-19 will require collaborative solutions by the international community. the global covid-19 outbreak story could have several different endings. with a degree of luck, the best-case scenario may be covid-19 spontaneously petering out as was the case with sars in 2003. or it may continue to sporadically pop up over many years with the occasional outbreak as mers has done. or, more worryingly, it may follow a more sinister path such as the 1918 spanish influenza and take root in populations worldwide, exacting a heavy toll in morbidity and mortality over decades to come. the initial signs are worrying e early estimates put its reproductive number at 3.11 with a case fatality rate around 3%, 13, 14 not too dissimilar to the 1918 pandemic flu strain. 15 only time will tell. 2019-ncov) situation report -1 (website). who; 2020. 21 2019-ncov) situation report -11 (website). who; 2020. 31 superspreading sars events the role of superspreading in middle east respiratory syndrome coronavirus (mers-cov) transmission border screening for sars evaluation of border entry screening for infectious diseases in humans transmission of the severe acute respiratory syndrome on aircraft middle east respiratory syndrome coronavirus: risk factors and determinants of primary, household, and nosocomial transmission beyond traditional surveillance: applying syndromic surveillance to developing settingseopportunities and challenges global infectious disease surveillance and health intelligence communicable diseases surveillance lessons learned from developed and developing countries: literature review return on investment of public health in-terventions: a systematic review novel coronavirus 2019-ncov: early estimation of epidemiological parameters and epidemic predictions clinical features of patients infected with 2019 novel coronavirus in wuhan transmissibility of 1918 pandemic influenza key: cord-283553-n06og3cw authors: de coninck, david; d'haenens, leen; matthijs, koen title: nan date: 2020-05-13 journal: public health doi: 10.1016/j.puhe.2020.05.011 sha: doc_id: 283553 cord_uid: n06og3cw nan recently, the coronavirus disease 2019 (covid-19) has been rapidly expanding across the globe. in order to respond to this pandemic, many countries are combining suppression and mitigation activities aimed at delaying major surges of patients and leveling the demand for hospital beds, while protecting the most vulnerable from infection. bedford et al. state that 'national response strategies include varying levels of contact tracing and self-isolation or quarantine; promotion of public health measures, including hand washing, respiratory etiquette, and social distancing; and closing all nonessential establishments' 1 . it is crucial for the public's health that information about these measures is accurately and quickly disseminated throughout the population. currently, legacy news media (e.g. television, radio, newspapers) and social media are the main platforms through which this dissemination takes place 2,3 . however, there are several aspects related to the journalistic infrastructure on the one hand and on the reliance on news media as agents of information on the other that may (in)directly and inadvertently endanger the public's health in several ways. although the corona crisis is the biggest journalistic story in times, that same crisis is also directly crippling media companies. this is a paradoxical situation: news consumption, viewing and reading figures, visits and likes are sky-high 9 , but contrary to what happens in 'normal' times, media turnover is dropping. as non-essential establishments are closed and (mass) events are cancelled, the demand for ads has dropped. consequently, many news outlets are suffering from falling advertisement revenues. this loss may cause structural damage to many traditional news media and may signal a rapid shift to a more digitized media environment. especially the need for local information provision and local connections is greater than ever, but the revenue model for local and 2 regional news provision has completely collapsed as it is heavily dependent on advertising revenues from local small and medium-sized enterprises. the public's reliance on news media coverage to convey accurate information (i.e. more than statistics) increases during times of uncertainty and crisis -especially in the current context with large shares of the population working or locked down in their homes 4 . the social distancing leads to increased anxiety or stress, which in turn has a detrimental impact on the public's physical and mental health over time, as evidenced by longitudinal studies following other health or societal crises 4, 5 . the amount of news media exposure and the content of the news media coverage are related to public anxieties: overly sensationalized coverage (e.g., graphic imagery) is related to higher stress levels 6 . not all media types frame stories the same way, are equally trusted or have an equal impact on fears among the public 7, 8 . given the large presence of fake news and the growing distrust of the public in social media, legacy media remain important platforms for informing the public. the damage that legacy media are currently sustaining threatens journalists' positions, particularly the self-employed journalists and the freelancers, in their ability to accurately report the news. governments must take these problems into account and take measures. we urge policy makers to follow the example of the netherlands, where a subsidy of €11 million has been made available to support local information provision. readers are also invited to donate or to subscribe. governmental support is imperative to sustain and uphold the journalistic infrastructure, maintain integrity and quality in news media, given their importance in the dissemination of information to the public. this, in turn, will have a major impact on public health in the context of the covid-19 crisis. a weakened journalistic infrastructure, during times where people heavily lean on news media to provide them with facts and opinions, bringing expertise and explanations to the table, will potentially lead to increased reporting of 'alternative' or dubious content, which may result in the dissemination of 3 potentially 'dangerous' views that jeopardize public health (e.g., faux covid-19 treatments) 1 . by ensuring that public information media remain strong and properly financed, governments also indirectly make an investment in the public's short-and long-term physical and mental health. policy makers face several challenges as they look ahead to loosening some of the restrictive public health measures that have been installed over the past weeks. some european countries are cautiously looking ahead to what lies beyond the crisis and begin to make plans to lift some of the restrictions: steering legacy media will play a significant role in influencing people's behaviour, for instance on how and when to wear respirator masks. preliminary covid-19 research on representative samples of the flemish (belgian) public teaches us that news media consumptionparticularly on (public) television -is strongly related to support for public health measures. a clear communication strategy by the government will therefore be vital in ensuring that the public is wellinformed about when and how restrictions are lifted in order to avoid another wave of covid-19 10 . minimizing sensationalized coverage, while at the same time actively engaging in debunking fake news, will be necessary to limit public anxiety and stress, and facilitate a 'normalization' of societal life. the authors report no conflict of interest, and no funding was obtained. covid-19: towards controlling of a pandemic social media and emergency preparedness in response to novel coronavirus the novel coronavirus (covid-2019) outbreak: amplification of public health consequences by media exposure. health psychology a dependency model of mass-media effects distress, worry, and functioning following a global health crisis: a national study of americans' responses to ebola media exposure to collective trauma, mental health, and functioning: does it matter what you see? lessons learned from public health mass media campaigns: marketing health in a crowded media world the relationship between media use and public opinion on immigrants and refugees: a belgian perspective nieuwsconsumptie in tijden van covid-19: meer bezoekers, meer likes, meer engagement [news consumption in times of covid-19: more visitors, more likes beware of the second wave of covid-19 key: cord-258842-vuxzv6eu authors: bennett, b. title: legal rights during pandemics: federalism, rights and public health laws – a view from australia date: 2009-02-26 journal: public health doi: 10.1016/j.puhe.2008.12.019 sha: doc_id: 258842 cord_uid: vuxzv6eu pandemic influenza will cause significant social and economic disruption. legal frameworks can play an important role in clarifying the rights and duties of individuals, communities and governments for times of crisis. in addressing legal frameworks, there is a need for jurisdictional clarity between different levels of government in responding to public health emergencies. public health laws are also informed by our understandings of rights and responsibilities for individuals and communities, and the balancing of public health and public freedoms. consideration of these issues is an essential part of planning for pandemic influenza. s u m m a r y pandemic influenza will cause significant social and economic disruption. legal frameworks can play an important role in clarifying the rights and duties of individuals, communities and governments for times of crisis. in addressing legal frameworks, there is a need for jurisdictional clarity between different levels of government in responding to public health emergencies. public health laws are also informed by our understandings of rights and responsibilities for individuals and communities, and the balancing of public health and public freedoms. consideration of these issues is an essential part of planning for pandemic influenza. ó 2009 the royal society for public health. published by elsevier ltd. all rights reserved. in his book 'blindness', josé saramago tells the story of a city struck by an epidemic of 'white blindness'. this is not the darkness or blackness that most of us associate with blindness. instead, in this blindness, everything is white, as if, according to one man in the early pages of the book, 'i were caught in a mist or had fallen into a milky sea'. 1 those who are blind are placed in quarantine in a disused mental hospital, with food delivered to the main entrance three times daily. inside the hospital, the ugly side of humanity is revealed as the strong take control of the food supplies and assault the women. beyond the hospital walls, the epidemic, initially a trickle of baffling cases, spreads to affect the whole city until, finally, soldiers no longer maintain the quarantine and the blind leave the hospital. the story follows a small band of people as they venture back into the city, led by one woman who still has her sight. through their experiences, we see the chaos of a city where all social infrastructures have broken down and people do their best to survive in their new grim reality. our ability to respond to the social and economic disruption that may be caused by an outbreak of a serious infectious disease may be tested should the world experience another influenza pandemic. following an outbreak in 2004 of a highly pathogenic avian influenza caused by the h5n1 virus, the world health organization noted in 2005 that 'the world has moved closer to a pandemic than at any time since 1968'. 2 more recently, dr margaret chan, director-general of the world health organization, has noted that 'for the first time in history, the world has been watching the conditions that might start an influenza pandemic unfold in real-time'. 3 while human-to-human transmission of the virus has yet to be established, by 19 june 2008, there had been 385 cases of human infection with the h5n1 virus, including 243 deaths, primarily in south east asian countries. the world health assembly has called on its member states to develop national preparedness plans, 4 and the world health organization has provided recommendations 5 and checklists 6 for national plans. while many countries have taken steps to develop preparedness plans for an influenza pandemic, variations between countries and gaps in the plans are still evident. 7 in the uk, a 2005 house of lords science and technology committee report noted that government figures estimated that illness-related absenteeism from work during a pandemic could cut gross domestic product (gdp) by £3-7 billion, while pandemicrelated excess mortality could cut gdp by an additional £1-7 billion (0.37-2.5% mortality). 8 in australia, the impact of pandemic influenza in the absence of an effective vaccine and if containment fails has been estimated at 13,000-44,000 deaths, 57,900-148,000 hospitalizations and 1-7.5 million outpatient visits. 9 at global level, 'even in one of the more conservative scenarios, it has been calculated that the world will face up to 233 outpatient visits, 5.2 million hospital admissions and 7.4 million deaths globally, within a very short period'. 10 the sudden and dramatic increase in demands upon the health system during a pandemic would challenge already-stretched health resources and personnel, highlighting the need for health systems to have in place plans for surge capacity to respond to disasters and health emergencies. 11 in addition, absenteeism in the community more generally could challenge the continuity of critical infrastructures, such as power, telecommunications and water, upon which hospitals rely. 12 while the social disruption arising from pandemic influenza would be considerably less than the total social breakdown portrayed in saramago's story, 'blindness' reminds us of the fragility of our current lives and the speed with which our worlds can be turned upside down. it reminds us of how selfish and uncaring people can be when they are scared and feel threatened, and how quickly order can descend into chaos. it also tells of the courage and strength of the human spirit when faced with danger. this paper talks about the role that law can play in providing some certainty for times of chaos. legal frameworks can clarify the rights and duties of individuals, communities and governments for times of crisis, and public discussions around these issues can themselves help to alleviate community anxiety. in thinking about the legal framework, there are two main issues to be addressed. first, there is a need for an understanding of the role of law in public health at state, national and international levels, and the need for jurisdictional clarity when differing levels of law and government intersect. these legal frameworks are important, for they define the scope of government responses to public health emergencies at local, national and international level. secondly, our understandings of the role of law in responding to pandemics are necessarily informed by relational bonds between individuals in society, and by the meanings of rights and responsibilities for public health laws when dealing with infectious disease. gostin has defined public health law as 'the study of the legal powers and duties of the state to assure the conditions for people to be healthy . and the limitations on the power of the state to constrain the autonomy, privacy, liberty, proprietary, or other legally protected interests of individuals for the protection or promotion of community health'. 13 reynolds points out that 'public health law is a disparate collection of laws and government responses, with its common feature a focus on the population rather than the individual'. 14 while law plays an important part in shaping the role of state action and intervention in the health of individuals and communities, the scope of these state powers is shaped by a range of factors including: the nature and traditions of the legal system in the country in question; cultural understandings of the individual, the community and the state and of the relationships between them; and the wealth or poverty of the country and its people. as magnusson points out, in the context of liberal democracies, debates about the boundaries and meanings of public health law reflect 'competing claims about the boundaries for the legitimate exercise of political and administrative power'. 15 our understandings of law and ethics, and indeed of health itself, are culturally and historically specific, requiring dialogue and cooperation for effective global responses to issues of common concern. the legal framework for public health in australia is made up of a mixture of federal and state legislation, with quarantine powers reserved to the federal government in the australian constitution, 16 and the states having control over other public health matters. the reality is somewhat more complex than this suggests, as the federal government can achieve public health objectives through the use of its other constitutional powers, such as the grants power in section 96 of the constitution which allows the federal government to make financial grants to the states, and the spending power in section 81 which allows the federal government to fund health programs. 17, 19 however, while the federal government can seek to use its other constitutional powers to achieve health-related objectives, it is important to realize that the power under section 51(ix) of the constitution to make laws 'with respect to quarantine' is the only power relating to communicable diseases directly given to the federal government in the constitution, and that this, in turn, shapes australian debates about government responses to public health issues and emergencies. while the absence of comprehensive health-related powers for the federal government in the constitution may seem surprising given our contemporary reliance on a national public health insurance system (medicare), and the general trend in australia away from federalism and towards centralization, 18 it is important to remember that these are more contemporary features of the australian political landscape and were not in existence at the time of federation and the drafting of the constitution in the opening years of the 20th century. 19 australia's geographic location and the fact that it is an island continent have influenced australia's historic approach to quarantine. maglen has argued that while england increasingly relied upon sanitary measures in the 19th century for protection against disease, quarantine remained an important tool against imported disease in the australian colonies of the time. 20 new south wales introduced australia's first quarantine legislation with the quarantine act 1832, and federal quarantine legislation was adopted in 1908. australia's quarantine act 1908 (cth) sets out the powers and procedures for the administration of quarantine in australia. under the act, the scope of quarantine is quite broad and covers a range of measures which aim to prevent or control 'the introduction, establishment or spread of diseases or pests that will or could cause significant damage to human beings, animals, plants, other aspects of the environment or economic activities'. 21 the act defines a quarantinable disease as 'any disease, declared by the governor-general, by proclamation to be a quarantinable disease'. 22 masters of vessels are required to make a notification to a quarantine officer if prescribed symptoms or a prescribed disease is present on board, or if the master 'has reason to believe or suspect' that a quarantinable disease or pest is on board. 23 individuals or vessels can be ordered into quarantine if they have a quarantinable or communicable disease, 24 and there are also powers to subject individuals to quarantine surveillance in certain circumstances. 25 the governor-general can declare, by proclamation, that an epidemic exists or that there is the danger of an epidemic, and while the proclamation exists the minister may give directions and take actions necessary to control, eradicate or remove the danger of the epidemic by way of quarantine or measures incidental to quarantine. 26, 27 the quarantine act 1908 is focused on preventing quarantinable diseases at ports of entry into australia. while there is still benefit in this focus, it is inadequate for a world where international travel is now primarily by aircraft, and passengers can travel from one country to another before they even realize that they are sick. 33 as a canadian report on severe acute respiratory syndrome (sars) noted, 'sars has illustrated that we are constantly a short flight away from serious epidemics'. 28 while previous outbreaks of pandemic influenza have traditionally taken 6-8 months to spread globally, 29 aided by international air travel, pandemic influenza could spread globally within 3 months. 30 this potential for quarantinable diseases to emerge within domestic populations raises questions about the scope and applicability of quarantine laws in these circumstances. however, it has been argued that the broad scope of quarantine under the act, the fact that quarantine powers are not restricted to ports of entry, and the ability for state laws to be over-ridden in emergencies suggests that the federal quarantine power could also have domestic application. 31 domestically, state public health laws are also relevant to the notification and control of communicable diseases. in new south wales, for example, sars and avian influenza in humans are both notifiable diseases under the public health act 1991. 32 state public health laws also contain a range of measures to enable health authorities to restrict the spread of disease, including powers to require medical testing and, in some cases, powers to restrict movement or to specify treatment of individuals who are regarded as posing a risk to public health. a the intersections between federal and state laws are relevant to australia's responses to public health threats. as howse has noted, 'in a public health emergency caused by the spread of an emerging infectious disease, australia could need to rely on a patchwork of legislative measures to assist it to cope'. 34 in australia and elsewhere, cross-jurisdictional and interagency cooperation are essential components in effective emergency responses. 35, 36 at an international level, the international health regulations (ihr) provide a framework for notification and response to infectious diseases. first introduced in 1951 as the international sanitary regulations, and renamed in 1969, the ihr required member states to notify the world health organization of cases of plague, cholera and yellow fever. prior to 1981, smallpox was also on the list of notifiable diseases. however, the ihr became increasingly irrelevant during the 20th century with the re-emergence of old diseases such as tuberculosis, the emergence of new diseases such as sars, and the threat of biological weapons. 37, 38 a revised version of the ihr was adopted in 2005 and took effect from 2007. the ihr (2005) seek to balance public health responses to disease against the needs of international traffic and trade, and rest on the principle that public health responses should not unnecessarily interfere with international traffic and trade. while the ihr (2005) has a list of specified diseases, including sars and smallpox, which must be notified to the world health organization, the ihr (2005) also move beyond the specified-diseases approach and adopt a broader approach with focus on events which could constitute a public health emergency of international concern. using a decision algorithm, countries are required to assess public health events in order to determine whether the event is a public health emergency of international concern. if the event is of international significance, notification to the world health organization is required. the new ihr focus on risks to health, and provide a more flexible and relevant approach to identification of those risks. 39, 40 the ihr (2005) focus on the development, strengthening and maintenance of capacities at national level to respond to public health emergencies of international concern. as outlined above, the legislative frameworks in australia for public health responses to infectious diseases are shaped by australia's federal legal system, and will also be relevant to the responses in other countries with a federal structure. in becoming a signatory to the ihr (2005), the usa submitted a reservation to the ihr on the basis of federalism, noting: 'the government of the united states of america reserves the right to assume obligations under these regulations in a manner consistent with its fundamental principles of federalism. with respect to obligations concerning the development, strengthening and maintenance of the core capacity requirements,.these regulations shall be implemented by the federal government or the state governments, as appropriate and in accordance with our constitution, to the extent that the implementation of these obligations comes under the legal jurisdiction of the federal government. to the extent that such obligations come under the legal jurisdiction of the state governments, the federal government shall bring such obligations with a favourable recommendation to the notice of the appropriate state authorities.' b in australia, the pandemic influenza planning process has taken a whole of government approach, with the planning process involving both federal and state levels of government. in 2007, the national health security act 2007 (cth) was passed. part 2 of the act deals with public health surveillance and has as its objects: provision of a national public health surveillance system to enhance the ability of commonwealth, states and territories in identifying and responding to 'public health events of national significance'; information sharing with the world health organization and 'countries affected by an event relating to public health or an overseas mass casualty'; and 'to support the commonwealth, and the states and territories in giving effect to the international health regulations'. 41 in april 2008, the commonwealth, state and territory governments signed the national health security agreement to support the national health security act and to ensure a coordinated approach between the different levels of government in the event of a public health event of national significance. in 2006, the national pandemic influenza exercise, exercise cumpston 06 enabled the testing and assessment of australia's pandemic preparedness through the use of a comprehensive simulation exercise. 42 quarantine laws and public health laws do give governments some fairly broad powers to declare quarantine and to restrict the movement of individuals. there is a very real sense in which these powers may well be needed in order to ensure an effective public health response to pandemic influenza. however, these laws are also clearly situated within a broader social context. our perceptions of individual liberty and individual rights have undergone considerable evolution since most of our public health laws were originally introduced. today, the public is likely to have high expectations about the preservation of individual liberty and freedom of movement. these expectations underpin the political context for the development and application of public health laws in australia. appropriate responses to these expectations will also play an important role in addressing community unease and potential disobedience to the implementation of response measures. when seeking to clarify public health laws, it is important that we take this broader social context into account. as gostin notes in his definition of public health law outlined above, public health laws are not only about articulating the coercive powers of the state for enforcement of public health measures, but also about the limits of state power and the rights of individuals and communities. the language of human rights is increasingly part of the landscape for health law in australia and a see, for example, public health act 1991 (nsw) s 23. internationally. [43] [44] [45] given the potential for public health laws to impact upon the freedom of individuals, and the need for public health laws to balance the interests of individuals and society, public health laws will ideally have a transparent ethical framework, articulating the principles upon which state intervention will be premised. 46 the world health organization has acknowledged the importance of legal and ethical considerations to pandemic preparedness, noting that public health measures such as quarantine, compulsory vaccination and off-licence use of medicines 'need a legal framework to ensure transparent assessment and justification of the measures that are being considered, and to ensure coherence with international legislation (international health regulations)'. 47 consideration of ethical issues is also essential for, as the world health organization has noted, ethical issues 'are part of the normative framework that is needed to assess the cultural acceptability of measures such as quarantine or selective vaccination of predefined risk groups'. 48 the exercise of state powers in terms of quarantine, isolation and detention during a public health emergency is likely to be particularly controversial in western liberal democracies such as australia. the extent to which the state can and should exercise its powers in this area has become increasingly relevant in public health, as is clear from debates over detention of tuberculosis patients, 49, 50 and from the use of quarantine during the sars crisis. 51 although comparable countries to australia in europe, the usa and canada all have human rights charters or equivalents, which could provide procedural protections and safeguards for citizens in relation to quarantine and detention, australia has yet to develop a bill of rights at the federal level. while australian state and territory governments have begun enacting human rights legislation, 52 there is no comprehensive inclusion of human rights safeguards in the federal quarantine act, which raises issues about the mechanisms for ensuring procedural safeguards in the event of a pandemic. 53 public health measures directed at implementing social distancing, quarantine or travel restrictions will not only infringe on individual liberties that are often taken for granted in western societies, but are also likely to have a profound economic impact. as outlined above, estimates indicate that pandemic influenza will have a significant impact on the global economy. at local level, businesses may be closed or experience a reduction in their cash flow as public health measures are introduced or people stay home voluntarily. in such an environment, the economic cost to individuals and businesses may be significant, which in turn demands consideration of development of support systems and compensation systems for those affected. 54 in the usa, a great deal of work has been done on strengthening the public health laws, both generally and specifically for public health emergencies. the turning point public health statute modernization national collaborative developed the turning point model state public health act. 55 in 2001, the centre for law and the public's health at georgetown and johns hopkins universities prepared a model state emergency health powers act, setting out the powers for a state of public health emergency. the provisions of the earlier model state emergency health powers act were adapted and included in the turning point model act. 56 article v of the turning point model act deals with the powers of public health authorities, including the powers of quarantine and isolation. the model act provides that the principles to be applied in relation to quarantine and isolation include that they should be by the least restrictive means necessary to prevent the spread of disease (s 5-108[b](1)). in addition, there is a provision that: 'the needs of individuals who are isolated or quarantined shall be addressed in a systematic and competent fashion, including but not limited to, providing adequate food, clothing, shelter, means of communication with those in isolation or quarantine and outside these settings, and competent medical care.' (s 5-108[b](6)) article vi of the turning point model act deals with public health emergencies, and contains provisions addressing: planning for a public health emergency; declaring a state of public health emergency; management of property, safe disposal of infectious waste and human remains, and control of healthcare supplies; protection of individuals; immunity from private liability; and payment of just compensation for the use or appropriation of facilities or materials. the turning point model act is intended as a tool to enable governments to assess their existing public health laws. the turning point model act not only sets out the rights of the state in terms of its coercive powers, but also the responsibilities of the state to care for those who are isolated or quarantined. these matters are important if we are to see public health laws as a matrix of both rights and responsibilities. if individual autonomy is to be constrained in the name of public health, we also need to ensure that individual dignity, and ultimately social dignity, is maintained. non-pharmaceutical measures may have a significant community impact. consideration may need to be given to support mechanisms if voluntary, stay-at-home forms of quarantine or isolation are used to limit the spread of influenza in the community. there is also a need to consider the flow-on effects of some of our public health measures. if schools are closed, for example, this may have an immediate impact on the broader workforce in a context, such as the contemporary australian one, where significant numbers of women with children are in the paid workforce. rights and responsibilities are multilayered. they arise at local, national and global levels and at the intersections between these levels. what is clear is that public health rights and responsibilities for infectious disease are global as well as national. if we are to assess the adequacy of our legal frameworks for pandemic preparedness, we also need to assess the adequacy of our laws in terms of their suitability for meeting our international obligations. while developed countries of the world already have sophisticated public health systems, the capacity to meet their obligations under the ihr (2005), and the financial resources to develop national vaccine stockpiles, the developing countries of the world face a very different outlook. 57 as we consider the intersections of law and public health in the context of the shared global risks of an influenza pandemic, it is important to realize that pandemic preparedness must necessarily involve improved international cooperation and the sharing of expertise to assist in capacity building for public health and the regulatory frameworks surrounding it, as well as a renewed dialogue around international obligations to help the world's poorest and least healthy people. 58 legal analysis must be a key part of our planning for pandemic influenza. it is essential that federal and state laws are harmonized so as to ensure their smooth functioning and to eliminate crossjurisdictional differences and uncertainties. public health laws also play a key role in setting out the rights and responsibilities of individuals, communities and governments, providing transparency and accountability to the frameworks for decision-making. in contemporary australian society where there are high expectations of individual rights and freedoms, and of the public health system, public health laws have an important role to play in ensuring that, as far as is possible, the public's health and the public's freedom are both balanced and protected. effective preparedness for pandemics does not end at national borders. pandemic influenza will affect all parts of the globe, leaving no country untouched. as we prepare for the next influenza pandemic, we must remember that global cooperation is also an essential part of effective preparedness. none sought. none declared. avian influenza: assessing the pandemic threat. geneva: world health organization pandemics: working together for an effective and equitable response strengthening pandemic-influenza preparedness and response. resolution wha58 world health organization. who global influenza preparedness plan: the role of who and recommendations for national measures before and during pandemics. geneva: world health organization world health organization. who checklist for influenza pandemic preparedness planning. geneva: world health organization how prepared is europe for pandemic influenza? analysis of national plans pandemic influenza: report with evidence department of health and ageing. australian health management plan for pandemic influenza. canberra: department of health and ageing world health organization. who checklist for influenza pandemic preparedness planning. geneva: world health organization disaster surge planning in australia: measuring the immeasureable pandemic influenza and critical infrastructure dependencies: possible impact on hospitals public health law: power, duty, restraint. berkeley: university of california press public health law in the new century mapping the scope and opportunities for public health law in liberal democracies the architecture of public health law reform: harmonisation of law in a federal system federalist paper 1: australia's federal future. a report for the council for the australian federation commonwealth and state powers in health: a constitutional diagnosis a world apart: geography, australian quarantine, and the mother country quarantine act 1908 (cth) s 4(1)(b) quarantine act 1908 (cth) ss quarantine act 1908 (cth) s 22 quarantine act 1908 (cth) ss quarantine act 1908 (cth) s 34 quarantine act 1908 (cth) s 2b for further discussion of australia's quarantine laws, see centre for public health law. emergency powers and cross-jurisdictional issues regarding outbreaks of communicable diseases avian influenza: assessing the pandemic threat. geneva: world health organization international monetary fund. the global economic and financial impact of an avian flu pandemic and the role of the imf public health law and regulation centre for public health law. emergency powers and cross-jurisdictional issues regarding outbreaks of communicable diseases managing emerging infectious diseases: is a federal system an impediment to effective laws? centre for public health law. emergency powers and cross-jurisdictional issues regarding outbreaks of communicable diseases assessing crosssectoral and cross-jurisdictional coordination for public health emergency legal preparedness from international sanitary conventions to global health security: the new international health regulations travel in a small world: sars, globalization and public health laws health law's kaleidoscope: health law rights in a global age the new international health regulations: an historic development for international law and public health office of health protection. national pandemic influenza exercise: exercise cumpston 06 report. canberra: australian government, department of health and ageing will international human rights subsume medical ethics? intersections in the unesco universal bioethics declaration health law's kaleidoscope: health law rights in a global age the proliferation of human rights in global health governance world health organization. ethical considerations in developing a public health response to pandemic influenza. geneva: world health organization world health organization. who checklist for influenza pandemic preparedness planning. geneva: world health organization world health organization. who checklist for influenza pandemic preparedness planning. geneva: world health organization detention and the evolving threat of tuberculosis: evidence, ethics and law through the quarantine looking glass: drugresistant tuberculosis, public health governance, law and ethics sars thrusts quarantine into the limelight for discussion, see williams g. the victorian charter of human rights and responsibilities: origins and scope times of pestilence: would a bill of rights assist australian citizens who are quarantined in the event of an avian influenza (bird flu) pandemic? pandemic and public health controls: toward an equitable compensation system public health statute modernization national excellence collaborative. turning point: collaborating for a new century in public health: model state public health act -a tool for assessing public health laws transforming public health law: the turning point model state public health act an exploration of conceptual and temporal fallacies in international health law and promotion of global public health preparedness the duty of states to assist other states in need: ethics, human rights and international law none declared. key: cord-324650-rsp72rx8 authors: teixeira da silva, jaime a.; tsigaris, panagiotis title: policy determinants of covid-19 pandemic-induced fatality rates across nations date: 2020-08-18 journal: public health doi: 10.1016/j.puhe.2020.08.008 sha: doc_id: 324650 cord_uid: rsp72rx8 abstract objectives covid-19 is the most devastating pandemic to affect humanity in a century. in this paper, we assessed tests as a policy instrument and policy enactment to contain covid-19 and potentially reduce mortalities. study design a model was devised to estimate the factors that influenced the death rate across 121 nations and by income group. results nations with a higher proportion of people age 65+ had a higher fatality rate (p = 0.00014). delaying policy enactment led to a higher case fatality rate (p = 0.0013). a 10% delay time to act resulted in a 3.7% higher case fatality rate. this study found that delaying policies for international travel restrictions, public information campaigns, and testing policies increased the fatality rate. tests also impacted the case fatality rate, and nations with 10% more cumulative tests per million people resulted in a 2.8% lower mortality rate. citizens of nations who can access more destinations without the need to have a prior visa have a significant higher mortality rate than those that need a visa to travel abroad (p = 0.0040). conclusion tests, as a surrogate of policy action and earlier policy enactment, matter for saving lives from pandemics as such policies reduce the transmission rate of the pandemic. million people, causing 658,861 mortalities globally. 1 the majority of deaths have occurred in the 65+ age 25 group, most having medical preconditions. 2,3 policies for social distancing, lockdowns, testing, isolating and 26 tracking are necessary to contain the spread of the virus, although they come with a cost of an economic 27 recession with its negative side effects. 4 here, we assessed tests as a policy instrument and the start of policy enactment to contain 29 and potentially reduce mortalities across 121 nations. to achieve this, a cross-sectional ecological study was 30 conducted for numerous nations around the world, and a model was estimated to explain the pattern of the 31 crude case fatality rate (cfr) 5 as of 21 july 2020. the objective was to estimate, using regression analysis, 32 the direction and strength of the association between the death rate, as the response variable, controlling for: high-income nations conducted significantly more tests per million people than the other two income 59 groups, (i.e., 3.87 and 9.9 times more than upper-middle income and low-income nations, respectively). in smoking prevalence and covid-19 in europe estimating case fatality rates of covid-19 key: cord-347261-d6012uem authors: hatefi, shahrokh; smith, farouk; abou-el-hossein, khaled; alizargar, javad title: covid-19 in south africa: lockdown strategy and its effects on public health and other contagious diseases date: 2020-06-19 journal: public health doi: 10.1016/j.puhe.2020.06.033 sha: doc_id: 347261 cord_uid: d6012uem nan the current global pandemic of the novel coronavirus (covid-19) is severely affecting the global health system. there is no treatment or vaccine available for covid-19 yet. since the world health organization (who) announced the pandemic of covid-19, many countries have announced new social distancing and lockdown rules to control the spread rate of the deadly covid-19 virus. according to the international health regulation (ihr) monitoring and evaluation framework, some african countries such as south africa, egypt, and algeria have demonstrated the highest risk of importation rate, and an average risk profile to fight against highly contagious diseases [1] . african countries, with previous experiences on the outbreaks of other infectious disease and pandemic situations, including hiv, malaria, and ebola, have limited financial, physical, and medical resources. in addition, there have been major problems related to the weak public healthcare and healthcare management systems in countries across africa [2] . in many low-and middle-income countries, the lockdown strategy were implemented to decrease the rate of the covid-19 outbreak. although lockdown strategies across many countries have been effective for decreasing the spread rate of contagious viruses, there have been other negative impacts reported globally; these concerns become worse in countries across africa, including south africa. for example, it has been reported that hiv care has been negatively affected by the current covid-19 pandemic. additionally, hiv transmission accelerated among poorer people and young women during lockdown [3] . there are also psychological problems associated with long-term lockdown strategies [4] . in south africa, the government announced a national-wide lockdown to manage the pandemic situation and decrease the spread rate of the covid-19 outbreak. however, due to limited available resources, as well as negative impacts of the lockdown strategy, the lockdown levels have been eased, twice. with regard to the current global situation during the covid-19 pandemic, different concerns in the public health system of south african people have been raised. the major concerns are summarized as follows: first, south africa's national lockdown started on the 15 th of march. due to various deficiencies, limited resources and financial means, the south african government has no other option but to ease the lockdown strategy and related rules. currently, the level of lockdown in south africa is at level three out of five levels of severity. however, according to the south africa national institute for communicable diseases (https://nicd.ac.za), the spread rate of the covid-19 outbreak is increasing. second, the lockdown strategy, social distancing rules, and community containment measures for covid-19 have negatively impacted the diagnosing and treatment of other contagious diseases, including hiv and malaria [5, 6] . in addition, in this pandemic situation, allocating resources for hiv care, including antiviral medication and allocating hospital beds for hiv patients, would be more limited. third, more than 1000 children under the age of 9 have tested covid-19 positive already. the covid-19 pandemic is severely affecting the young population of south africa, including maternal and infant children [4] . fourth, in south africa the winter season is starting. studies already undertaken reported the correlation between the sunlight and the rate of covid-19 recovery [7] ; the studies suggest that sunlight exposure increase the rate of recoveries in covid-19 patients. therefore, a longer recovery period for patients is anticipated. with regard to the concerns raised and the results of analyzed data, it can be predicted that the situation of south africa in fighting against covid-19 will become worse in the future. the daily fatality rate as well as the number of daily confirmed covid-19 cases is starting to increase dramatically. therefore, we urge a global collaboration in terms of providing essential resources and developing novel solutions to fight the covid-19 pandemic in south africa. we recommend that all governments and organizations start an international collaboration to maintain the healthcare plans across the world, in order to avoid disruption of the routine healthcare services. covid-19 is a global pandemic; the reaction to this situation should be at global levels. science and state-of-the-art technologies in all the scientific as well as social fields need to be combined to produce effective solutions to fight the covid-19 pandemic. many low-and middle-income countries, including african and middle eastern countries lack essential resources. in the covid-19 pandemic, increasing the outbreaks of viral infections in any country would affect the global health system negatively. therefore, measures, prevention solutions, resources, medical equipment, and medication should be developed and provided to people equally all across the world. the authors declare that there are no competing interests. limiting the spread of covid-19 in africa: one size mitigation strategies do not fit all countries. the lancet global health covid-19 response in the middle east and north africa: challenges and paths forward. the lancet global health three lessons for the covid-19 response from pandemic hiv. the lancet hiv early estimates of the indirect effects of the covid-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study. the lancet global health maintaining hiv care during the covid-19 pandemic. the lancet hiv diagnosing malaria and other febrile illnesses during the covid-19 pandemic. the lancet global health sunlight exposure increased covid-19 recovery rates: a study in the central pandemic area of indonesia key: cord-283467-bgxc3ti8 authors: wu, yan; song, shujuan; kao, qingjun; kong, qingxin; sun, zhou; wang, bing title: risk of sars-cov-2 infection among contacts of individuals with covid-19 in hangzhou, china date: 2020-06-12 journal: public health doi: 10.1016/j.puhe.2020.05.016 sha: doc_id: 283467 cord_uid: bgxc3ti8 abstract objectives this study determined the rate of secondary infection among contacts of individuals with confirmed covid-19 in hangzhou according to the type of contact, the intensity of the contact, and their relationship with the index patient. study design retrospective cohort study. methods the analysis used the data of 2,994 contacts of 144 individuals with confirmed sars-cov-2 infection. the contacts were categorized according to the information source, type of contact, location, intensity of contact, and relationship with the index patient. results the incidence of infection differed significantly according to contact type. of the contacts, 186 (6.2%) developed symptoms and 71 (2.4%) had confirmed infection with sars-cov-2. the main symptoms were cough and fever. compared to those who had brief contact with the index case, those who had dined with the index case had a 2.6 times greater risk of infection; those who had shared transport, visited, or had contact with the index case in a medical institution had a 3.6 times greater risk of infection; and household contacts had 41.7 times greater risk of infection. family members had a 31.6 times greater risk of infection than healthcare providers or other patients exposed to an index case. conclusions the form and frequency of contact are the main factors affecting the risk of infection among contacts of individuals with covid-19. centralized isolation and observation of close contacts of individuals with confirmed sars-cov-2 infection, in addition to population-based control measures, can reduce the risk of secondary infections and curb the spread of the infection. the incidence of infection differed significantly according to contact type. of the contacts, 186 (6.2%) developed symptoms and 71 (2.4%) had confirmed infection with sars-cov-2. the main symptoms were cough and fever. compared to those who had brief contact with the index case, those who had dined with the index case had a 2.6 times greater risk of infection; those who had shared transport, visited, or had contact with the index case in a medical institution had a 3.6 times greater risk of infection; and household contacts had 41.7 times greater risk of infection. family members had a 31.6 times greater risk of infection than healthcare providers or other patients exposed to an index case. january 23, 2020, zhejiang province was among the first provinces to declare a major public health emergency and introduced ten policies including vigorously promoting public 2 awareness on epidemic prevention, restricting public gatherings, and taking measures to prevent hospital-acquired infections to prevent the transmission of sars-cov-2 infection. 4, 5 after january 27, 2020, the number of imported cases in hangzhou declined rapidly, and the majority of the cases were local cases, indicating that the prevention and control measures taken had produced effective results. on continuous data were summarized as medians and interquartile ranges, and t-tests were used for intergroup comparisons. p-values <0.05 were considered to be statistically significant. the incidence rate of contacts with data collected by field investigation was significantly higher than that of contacts with data collected by big data (5.35% versus 0.07%, p<0.001). the geographical distribution of close contacts in the districts and counties of hangzhou is shown in supplementary figure s1 . during the observation period, 71 of the 186 (38%) individuals with symptoms were confirmed to have sars-cov-2 infection, of which 54 (76%) had a last exposure-onset interval of <7 days. the incidence rate of sars-cov-2 infection in the group with symptoms was significantly higher than that in the group with no symptoms 3 (38.17% versus 0.39%, p<0.05). the most frequently reported abnormal symptoms were cough (39.8%), fever (36.0%), sore throat and rhinorrhea (16.1%). an additional 11 contacts (0.4%) were infected with sars-cov-2 but remained asymptomatic. the overall incidence of infection among the contacts was 2.7%. there was no significant difference in covid-19 incidence among the close contacts according to age or sex, but significant differences were found according to the level of protection, type of contact, relationship with the index patient, and contact location. the results in table 1 show that the infection rate among those living in the same household as the index case was 41.7 times higher than that of individuals who had only had brief contact with the index case. compared to those who only had brief contact with the index case, those who had dined with the index case had a 2.6 times greater risk of infection, and those who has shared transport, visited, or had contact with the index case in a medical institution had a 3.6 times greater risk of infection. among the relationships of contacts, family members had the highest risk of infection, with 31.6 times greater risk of infection than healthcare providers or other patients who had been exposed to an index case. in terms of contact locations, the infection rate among those who had contact with the index case in or near his/her home was 17.2 times higher that among those who had contact with the index case in a medical institution; and the infection rate of those who had contact with the index case through work, study, or in a place of entertainment was 6.7 times that among those who had contact with the index case in a medical institution. this incidence of disease among contacts according to age and sex was consistent with the variation in disease incidence according to age and sex in the population as a whole. 7 the incidence rate among those who wore facemasks was significantly lower than that among those who did not use protective measures (0. in the process of case investigation, the hangzhou government took full advantage of the big data technology in combination with a grid management mechanism to trace cases, analyze transmission routes, and efficiently collect information of close contacts. of the contacts identified, 49.4% were identified using big data. this improved the screening efficiency of contacts and reduced the potential for recall bias or intentional concealment. in this way, contact screening was relatively complete. digitized epidemic prevention and control measures are likely to become more widely used in the future. not required (this research does not involve animals and human material and rights.) a novel coronavirus outbreak of global health concern a novel coronavirus from patients with pneumonia in china coronavirus disease (covid-19) situation report a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster epidemiological characteristics of coronavirus diseases 2019 in zhejiang province protocol for covid-19 monitoring, prevention and control in zhejiang province national health commission of the people's republic of china epidemiological investigation of the first reported case of coronavirus disease 2019 (covid-19) in zhejiang province the novel coronavirus originating in wuhan, china: challenges for global health governance special expert group for control of the epidemic of novel coronavirus pneumonia of the chinese preventive medicine association. an update on the epidemiological characteristics of novel coronavirus pneumonia (covid-19) none declared. key: cord-263659-9i5qws5h authors: zhao, y.; cui, s.; yang, j.; wang, w.; guo, a.; liu, y.; liang, w. title: basic public health services delivered in an urban community: a qualitative study date: 2010-12-08 journal: public health doi: 10.1016/j.puhe.2010.09.003 sha: doc_id: 263659 cord_uid: 9i5qws5h objectives: to understand the advancements in and barriers to the implementation of measures to improve basic public health services in an urban chinese community. study design: a qualitative study based on semi-structured interviews. interviews were audio-taped, transcribed and analysed using thematic content analysis. methods: in-depth interviews were undertaken with the directors of the management centres for community health services in 15 of the 18 districts in beijing from december 2008 to february 2009. content analysis of the data was completed in may 2009. results: fifteen types of free basic public health services had been delivered in beijing. some were supplied at a low level. an average of £2.38 per person per year was provided for inhabitants since 2008, but demand for funding far exceeded monies available. teams consisting of general practitioners, community nurses and public health specialists delivered these services. the number of practitioners and their low levels of skill were insufficient to provide adequate services for community residents. respondents gave recommendations of how to resolve the above problems. conclusions: in order to improve the delivery of basic public health services, it is necessary for beijing municipal government to supply clear and detailed protocols, increase funding and increase the number of skilled practitioners in the community health services. supplying free basic public health services (individual-based clinical preventive services and population-based public health services) in community settings is of great significance in improving quality of life and promoting social harmony. since 2005, the chinese government has promulgated a series of documents for developing basic public health services. 1e3 these reports mandated that basic public health services would be funded at all levels of governments and be delivered by the nationwide community health services (chs) organizations. 4 on 10 april 2009, the chinese government released a policy statement which enhanced the reforms of the medical and health systems, and which re-emphasized that governmental bodies will offer equitable access to basic public health services for both urban and rural residents. 3 as the centre of politics, economy and culture of china, beijing municipal government attaches extreme importance to and promotes advances in the development of basic public health services delivered in the community. over the past two decades, china has been undergoing a process of economic reform and has been relatively successful. the healthcare system, which had been reformed to suit the market economy, 5 faced multiple challenges: limited financial support from governments; high rates of catastrophic out-of-pocket spending and impoverishment through health expenses; inequalities in health and healthcare utilization; and limited financial protection even among those with insurance (a small minority of the population). 6 due to the above challenges, the old 'three-tiered' hospital system, which involved local neighbourhood hospitals, district-wide secondary hospitals and city-wide tertiary hospitals, was forced to rely on the sales of new drugs and technologies to boost income, which resulted in expensive and inefficient care and strained patientedoctor relationships. 7 the old public health system was the responsibility of dozens of disparate institutes, centres, agencies, bureaus and departments, which resulted in overlapping and sometimes conflicting mission statements and agency mandates. 8 with an increase in life expectancy, increased burden due to chronic diseases, and the challenges of emerging infectious diseases (e.g. severe acute respiratory syndrome in 2003), the chinese government re-examined the public health infrastructure and saw the need for a new public health system to address the many health issues associated with these changes. 5 to minimize overlapping of functions and to increase efficiency, the chinese government consolidated existing institutions into a new agency: the centres for disease control and prevention (cdc). the goal of the cdc is to provide a central public health organization with responsibility for both community and individual health needs. the development of the cdc strengthened the government's role in public health. 5 as public health and primary care share the common goal of improving the overall health of specific populations, it was decided to integrate the two systems by strengthening public health functions in primary healthcare settings. this approach could improve local public health surveillance and reinforce disease prevention and health promotion. 9 in order to resolve the problems of the increasing burden of healthcare expenses and limited access to health services, the chinese government initiated its chs programme in 1997. 4 the 'threetiered' hospital system was replaced by the current 'twotiered' chs centre system. the new system consists of ambulatory care in chs centres and inpatient care in referral hospitals. 7 the main roles of the chs centres are to provide high-quality, affordable, accessible primary health care and public health services to community residents. the scope of services of the chs centres is described symbolically by the chinese government as 'one body, six aspects'. the body is the chs centre. the six aspects consist of basic clinical services, prevention, health education, women and children's care, elderly care, immunizations and physical rehabilitation. 7 the centres integrate western and traditional chinese medicine. in the population-based public health services, there is collaboration between the community health centres and the local cdc. 7 local governments are the main sources of funding for the local cdc and chs centres. the core providers in the chs centres are general practitioners (family doctors), 10, 11 public health specialists and community nurses. these practitioners are responsible for the provision of basic clinical services and for maintaining the wellness of the residents, of all ages, in their communities. 4 in china, a general practitioner is a medical practitioner with recognized general training, experience and skills, who provides and co-ordinates comprehensive medical care for individuals, families and communities. 10, 11 two models are currently being used to train general practitioners in china. the first model is a 3-year general practice postgraduate residency training programme. the second model of education involves retraining the majority of the less-educated doctors currently working in local community health centres, and transforming them into general practitioners. completion certificates are awarded by different organizations, including the central ministry of health, provincial ministries of health and city-level health bureaus. 10, 11 general practitioners typically work in the clinics of chs organizations. when delivering population-based public health services, general practitioners often work in teams with public health specialists, community nurses and other providers. 10, 11 in 2007, in order to implement the chs more effectively, beijing management centre for community health services (mcchs) was established. it is affiliated administratively with beijing municipal health bureau. similarly, a district office of the mcchs is attached to each of the city's 18 district health bureaus. 12 the main responsibilities of beijing mcchs include writing regulations, establishing assessment standards, and organizing practices for the chs while, at the same time, supervising the work of the district mcchss. the district mcchss are responsible for planning, managing and assessing the work performed by all chs organizations in their respective districts. each director of a district mcchs must be familiar with the activities of the chs in his/her district. 12 fifteen types of free basic public health services have been delivered by the chs in beijing since 2006 13 (appendix 1). to date, no research has investigated the implementation of these services in beijing. due to an interest in understanding the status of and barriers to basic public health services in the beijing communities, the authors chose to design a study that would investigate the conceptual frameworks of these services. to that end, all 18 mcchs district directors were approached in order to ascertain their opinions of the quality of the delivery of basic public health services by providers in the chs. sampling consisted of all 18 directors from the 18 mcchs distributed in the 18 districts in beijing. after obtaining their numbers from the telephone book, initial contact was made with them. one director was away on business, one was too busy and declined to be interviewed, and one was unable to be reached, despite multiple calls. semi-structured, in-depth interviews were conducted with the remaining 15 mcchs district directors who were familiar with the work in the chs. interviews were usually carried out in the respondent's work offices. all participants were informed about the purpose of the study and were made aware that they could stop the interview at any point without giving a reason. written informed consent and an agreement for the use of anonymised quotes from the interviews were obtained from all participants. semi-structured, face-to-face, tape-recorded, qualitative interviews, lasting 60e90 mins, were conducted by trained professional interviewers from december 2008 to february 2009. interviewers took extensive notes, in addition to tape recording and transcribing the interviews. the transcripts were reviewed by the research team. analysis and interpretation were reached by consensus, using an iterative process in the research team meetings. the research team was a multidisciplinary group including two community-based medical researchers with qualitative and social research experience, one health administrator from a health bureau familiar with health policy, one family doctor familiar with the chs, two epidemiologists and one masters degree candidate with a family medicine degree. the variety of perspectives of the team ensured a depth of understanding critical to the design of the study and the validity of the results. an interview guide was developed on the basis of references and relevant government documents. the interview questions were open-ended and covered issues about basic public health services, the content of specific services being delivered, funding, types of providers, and general insights of the respondents. qualitative content analysis 14, 15 was used to analyse the data between march 2009 and may 2009. the data consisted of rich text files containing transcripts of the tape-recorded interviews. the team members read all the material through several times to obtain a sense of the whole, and then independently coded transcripts to identify themes by condensing and summarizing the contents. coding differences were resolved after thorough discussion in order to ensure that all perspectives on the themes were represented in the written results. the themes that emerged for the purposes of this report included the content of basic public health services, funding support, providers and recommendations. all of the interviews were included in the analysis; there were no disconfirming cases. the findings relate to three main themes: the content of basic public health services, funding support for basic public health services, and the providers who deliver basic public health services. fifteen types of basic public health services, including 78 specific services (appendix 1), were delivered at different levels in the various districts. among these services, most of the directors considered the establishment of health records, chronic disease management, childhood immunizations and care, maternal care, elderly care, disability and rehabilitation services, and health education to be supplied at high levels. however, the provision of mental health, ophthalmologic, oral health, pest control and endemic disease services were low and sporadic in some communities due to the low level of staff competency for these tasks. in community health information management, community needs assessments were one of the important jobs in the community. the 15 directors agreed that it was often necessary for community needs assessments to be undertaken with the assistance of a special research group due to practitioners' limited research skills in this area. the rates of creation of paper health records for all inhabitants were estimated to be high. at present, the governments have attached importance to the development of electronic health records, and the transformation from paper to electronic records is a slow, stepwise process in the communities: "paper health records have been established for 70% of people in our district, and we plan to complete this work for all our residents by 2010." "the municipal government required chs organizations to establish paper health records for all residents in beijing. a centre provides services to about 30,000e100,000 residents according to the size of a region. in fact, due to health workforce shortages and a small number of revisiting patients, only 30% of established paper records can be followed up and used continuously." "how to continuously and dynamically use these health records, especially those of healthy people, is a 'gordian knot'. a feasible method to resolve this problem may be by using an electronic health record information systems to reduce the time spent on paperwork. the first thing that the governments need to do is to establish the standards of electronic record systems and to make experiments in some districts." regarding the management of communicable diseases, most of the chs organizations' roles are limited to assisting the local cdcs with the completion of tasks such as finding, reporting and follow-up of cases: "however, for responses to emergent public health hazards, chs organizations are playing more and more important roles." the management of chronic, non-communicable diseases is an important job for chs organizations because of the high incidence and deleterious effects of these illnesses. providing optimal health care for persons with chronic conditions is a major concern in the community. beijing municipal health bureau has established a set of guidelines for the management of chronic diseases in community p u b l i c h e a l t h 1 2 5 ( 2 0 1 1 ) 3 7 e4 5 settings e including hypertension, diabetes, stroke and heart disease e and requires general practitioners to use these guidelines when managing chronic diseases. however, deficiencies in continuous professional development and a lack of evidence-based guidelines have created further problems in delivering cost-effective interventions for chronic disease prevention: "the rate of adherence to these guidelines is low due to poor understanding and co-operation. it is necessary to make recommendations for these diseases by means of a process of critical appraisal and consensus building." regarding maternal and child care, the interviewees said that chs organizations assisted local women's and children's health organizations in carrying out related programmes, such as health education and counselling, screening, followup and referral: "childhood immunizations were implemented at the highest rate. it is estimated to be 98e100%." "now, cost-free screenings for breast cancer and cervical cancer for adult women are delivered in some districts according to local government's regulations." when asked about geriatric care and care of persons with disabilities, all 15 directors replied that the instruction of self-care and the management of chronic diseases were emphasized for the elderly, and that exercise sites have been gradually upgraded by supplying physical rehabilitation equipment for disabled people. health education is delivered regularly in the context of supplying other health services. most of the respondents agreed that illness-oriented visits were the most important opportunities to deliver health habit counselling and education to patients, but that this was done less frequently during health maintenance visits. the directors agreed that tobacco cessation counselling and exercise advice were the most common health education topics covered by doctors and patients during illness visits. an average of £2.38 (at a conversion rate of 10.49 rmb to £1) per person per year was provided for basic public health services in beijing since 2008, and each district government supplied different amounts of money for basic public health services in its communities according to its economic level and population. however, basic public health services were often perceived as not being reimbursed proportionately to the amount of time expended, particularly when they were opportunistically added to illness visits. the 15 directors conveyed the opinion that funding for basic public health services was insufficient, and that most of the funds were spent on correlative public equipment and expendable items: "few financial incentives are paid to the individual health services.this may be an important reason why we can't motivate providers to deliver more and higher-quality basic public health services." "there is a higher percentage of migrants in some districts such as chaoyang, fengtai and haidian, but no exact budget support from beijing municipal government for migrants except immunizations. part of public health services, such as health education, communicable diseases management are delivered for migrants in some districts, financed only by local government. the municipal government needs to think over the problems brought by migrants." providers who deliver basic public health services teams consisting mainly of general practitioners, community nurses and public health specialists deliver basic public health services in the community. in addition to supplying medical care, general practitioners are required to delivery cost-free clinical preventive services for individuals and families, and population-based public health services (appendix 1). their roles include being exemplars for health; providing assessments; serving as educators, counsellors and evaluators; and making referrals when necessary. public health specialists, who serve as recorders of health data as well as health educators, are responsible for public health services for populations in their communities. community nurses mainly assist general practitioners and public health specialists. "basic public health services often were actually delivered by allied health professionals who may be more effective than physicians in initiating and carrying out many public interventions." due to the broad scope of basic public health services and limited financial incentives, providers felt that they were under great stress and harried by many competing demands for their time. it is unrealistic to expect that basic public health services would be improved by placing additional burdens on providers without removing other demands: "time constraints and the short supply of public health service providers are barriers to the delivery of prevention. furthermore, there are considerable gaps in knowledge and experience about public health among community providers. most of them don't realize the importance of delivering public health services for residents in community. individuals charged with making policy recommendations and increasing the delivery of basic public health services must acknowledge this fact." medical staff in community settings often complained that community members for whom they were responsible did not trust them as these clinicians had lower levels of knowledge and skill than specialists. as a result, community members are often reluctant to accept basic public health services: "young people especially, who seldom see general practitioners, do not know clearly which basic public health services are supplied by chs organizations. as a result, they often do not trust and refuse these community-based services, so patient noncompliance is one of the chief constraints to the improvement of basic public health services." the directors complained that some public health services, such as aspects of mental health care, pest control and endemic disease management, should have been supplied by other organizations but were passed off on the chs. as staff competency for these tasks is low, the quality of these services is low as a consequence. basic public health services delivered in the community should be creative, adaptive and responsive to local needs and expectations, including those of patients, community, local healthcare institutions, staff and doctors. 16 it is necessary for beijing municipal government to further elucidate the content of basic public health services and define the priorities in which services need to be delivered according to the needs of local practices, their patients and their communities: "certainly, it is difficult for medical staff in the community to deliver so many public health services with high levels of quality . the governments should prioritize the delivery of services according to patients' risk factors and preferences, practical considerations and financial budget." beijing municipal government is planning to increase funding for basic public health services to £4 per person in 2010. the 15 directors considered that this was still insufficient and advised that the municipal government should increase providers' salaries and subsidies. for example, an additional duty hour allowance scheme should be brought forward, under which health workers would be allowed to work extra hours and receive pay to augment their salaries: 17 "besides payment, of course, some changes in the process and organization of the providers' work are also part of the solution to the problem of the under-provision of basic public health services.a useful solution to attract more community residents to see general practitioners would be to increase the proportion of medical reimbursement for chs services." recruiting more competent medical staff there were 16.33 million residents and 5.55 million migrants in beijing in 2007. in 2008, the total number of medical staff in the entire beijing community was 24,740 (source: beijing statistical bureau, 2008). 33 of these, 3451 were general practitioners, 2299 were public health workers (including 765 public health specialists) and 4667 were nurses. staffing patterns differed from district to district. however, there was consensus among the directors that more medical staff need to be allocated to chs organizations. there is a large disparity between general practitioners and specialists in salary and opportunities for promotion. many doctors and nurses with better educational backgrounds or higher professional titles prefer to work in hospitals. 4 it is difficult to recruit competent medical staff in the community. the directors advised that the governments can attempt to attract better qualified doctors to work in the chs by raising salaries, providing more opportunities to participate in continuing medical education programmes and academic conferences, and shortening tenure periods for promotion to higher professional titles. in addition, emphasis was placed on the need to increase team work among chs workers or between chs providers and hospital-based specialists. china has made great efforts to improve the health of its huge population, and has had considerable success in this endeavour. for example, longevity has increased. compared with 35 years in 1949, life expectancy had increased to 73 years in both sexes in 2006 (source: ministry of health of china, world health organization, 2008). 34,35 however, excessive healthcare costs and inconvenient access to health care are still major healthcare problems in china. 4 in order to resolve these problems, china has initiated a new approach 3 which includes improving primary healthcare facilities and offering equitable access to basic public health services across the country. many provinces and cities have followed these regulations and are devoted to developing core communitybased public health services. accordingly, beijing municipal government has drawn up a series of protocols 18à20 to support basic public health services for its residents. as the tie that links district governments and chs organizations, the 18 district mcchss are at the front line of implementation of the plan to deliver basic public health services in community settings. this study found much valuable information by interviewing the directors of the mcchss. the chinese government is supplying nine types of basic public health services, including 21 specific services, at no cost for all people since 2009 according to its announcement. 3 since 2006, chs organizations in beijing have supplied more basic public health services for residents than those required by the national plan, and basic public health services are regarded as part of a core mission in general practice. however, the delivery of some of these basic public health services was at lower levels of quality than is desirable. this finding is consistent with the reports of other researchers about preventive services delivery in other countries. 16, 21 in general, locally tailored interventions are more likely to be adopted into the usual routines of practice than interventional approaches that are dependent on outside stimuli (such as financial incentives), 22 or which impose practice tools and approaches developed elsewhere. 23 it is imperative to undertake more research to find ways to make these improvements. 24 according to a 2009 policy statement, 3 the chinese government and local governments at all levels will provide financial outlays that are not less than £1.43 per person per year for basic public health services for all chinese people in 2009, and increase subsidies to achieve universal insurance coverage and to assure every citizen equal access to affordable basic health care. 25 year. the budget in beijing is £2.38 per person per year since 2008; however, beijing chs centres are required to deliver more basic public health services than their counterparts in other provinces. the deficiency in funding has become such a problem that some basic public health services cannot be implemented effectively in beijing. the municipal government is now assessing how much money should be devoted to basic public health services on the basis of its funding capability and the demands of stakeholders. in addition, migrants need to be recognized as a specific target group for health promotion, prevention and health care, 27 and the governments should provide additional funding for them. these findings are consistent with research 28 which points out that multidisciplinary practice teams are key to delivering basic public health services in community settings. successful teams are created through formulating inter-related goals, identifying measurable outcomes, systematizing routine tasks of care, defining provider tasks and roles explicitly, and providing appropriate training. 27 a document published by the state council of china in 2006 29 mandated that the allocation rate for medical staff working in the chs should reach the level of two to three general practitioners and nurses per 10,000 residents, and one public health specialist per 10,000 residents by 2010. in beijing, the allocation is one general practitioner per 3000 residents, one nurse per 25,000 residents and one public health specialist per 2000 residents. 20 in fact, the above allocation rates have not yet been met, especially since the demand for much of the scope and quality of public health services has increased. in addition, the low levels of chs providers' knowledge and skills 4 is a major problem. as a result, basic public health services are often only provided in response to patient requests or obvious needs in beijing; services thus tend to be reactive rather than proactive. it may simply be unrealistic to expect community providers to deliver a comprehensive package of basic public health services along with the many competing demands of providing direct clinical care. 21 in view of the reasons mentioned above, beijing municipal government is planning several programmes to improve the service capabilities of the chs providers. these include partial changes in the structure, roles and functions of the teams; incentives to attract more medical graduates to work in community settings; redistribution of tertiary hospital doctors to chs organizations; reemployment of retired doctors in the chs; and the provision of financial support and opportunities for younger doctors to get better continuing medical education. 4 the roles and experiences of both medical staff and their patients also impact on health promotion activities. the community resident/patient is not a passive participant in the process of receiving basic public health services, and many residents look to providers for guidance and direction in the prevention of diseases. 30 favourable interaction between providers and patients is critical to the effectiveness and efficiency of the delivery of basic public health services, because in some types of preventive services, the patient's contribution may ultimately be more significant than the provider's role (e.g. weight loss, smoking cessation, reduction of alcohol use, adherence to medical regimen). 30 people with insurance can access other services which are not free of charge in chs organizations. in fact, people with insurance prefer to visit doctors in hospitals to chs organizations. in order to attract more people to visit the chs, chs organizations are required to supply acceptable services by decreasing drug prices and increasing the proportion of medical reimbursement. 31 beijing municipal government is currently devoting significant funding to publicizing basic public health services in the community by means of various media, and is encouraging residents with common diseases to see general practitioners. this exploratory study provides in-depth examinations of the status and barriers of basic public health services provided in community practices. interviews were carried out and analyzed by a multidisciplinary group in order to maintain the validity and meaningfulness of the results. purposeful sampling was used to enhance external validity or transferability. 32 however, the findings must be interpreted in the context of the study's limitations. the data were crosssectional in nature. the possibility that the non-responding directors were different from the 15 interviewed directors can not be excluded. the study examined basic public health services from the perspective of supervisors, who do not themselves provide direct primary medical care. it did not examine the broader frame of basic public health services in the community and overall population levels. the fact that all the data for this study were collected in one city may call into question its generalizability to other locales. however, the choice of beijing as the site for data collection has particular significance to healthcare service delivery in china because the nation's capital was one of the first cities to comprehensively implement the chs reforms of 2006, and thus has had the longest experience with them. in addition, beijing has traditionally served as a national test site for reforms of the chs. accordingly, the authors recommend that further research should be undertaken on the delivery of basic public health services with larger sampling from community providers from other cities in china. this qualitative study suggests that the emphasis of beijing municipal government on the delivery of basic public health services in community settings is an important effort, but the specific parameters for these services should be clarified, the quantity and quality of staffing must be addressed, sufficient time for provision of services must be allowed, and sufficient funding must be provided. the authors believe that major reforms of the healthcare system in beijing and china are needed to address these problems. the state council of the people's republic of china. the guidelines of development of community health services in urban areas the state council of the people's republic of china. the suggestions of deepening reform of public health and medicine undertaking human resource staffing and service functions of community health services organizations in china public health in china: the shanghai cdc perspective china's health system and its reform: a review of recent studies primary care reform in the peoples' republic of china: implications for training family physicians for the world's largest country china's public health-care system: facing the challenges integrating public health and primary care north ryde nsw: mcgraw-hill australia pty ltd the quality and task of general physicians and their role in chs brief introduction about beijing management center for community health services and the functions beijing municipal commission and development and reform, beijing municipal commission of housing and urban-rural development, and beijing municipal commission of urban planning. the plans for establishing community health services organizations in beijing content analysis: an introduction to its methodology the content analysis guidebook online delivery of clinical preventive services in family medicine offices factors influencing resource allocation decisions and equity in the health system of ghana suggestions for promoting of community health services in beijing beijing municipal health bureau. the implementing suggestions of training the human resources in general practice the suggestions for strengthening human resource staffing in community health services organization direct observation of rates of preventive service delivery in community family practice a qualitative study in rural and urban areas on whether e and how e to consult during routine and out of hours sustainability of a practice-individualized preventive service delivery intervention public health in primary care trusts: a resource needs assessment china's health care reform: a tentative assessment department of the health care for women, children and communities, ministry of health of china challenges of change: a qualitative study of chronic care model implementation consequences of international migration: a qualitative study on stress among polish migrant workers in scotland ministry of health of the people's republic of china. the distribution standards of human resource staffing and community health services organization settings economic incentives and physicians' delivery of preventive care: a systematic review people's republic of china: ministry of labour and social security. the suggestions of encouraging people with health insurance to get chs services qualitative evaluation and research methods investigation reports of community health services in beijing 3 follow-up 10.4 intelligence, dental, hearing and vision screenings 10.5 growth and development assessment, monitoring and counselling 10.6 psychological development counselling 10.7 health status assessments 10.8 nutritional counselling 10.9 communicable diseases reporting and management in preschools 10.10 disinfection management in preschools 11. maternal care (women's care) 11.1 public awareness and professional education, providing health advice and support to young mothers 11.2 establishing records 11.3 examination of early pregnancy 11.4 perinatal high-risk management 11.5 follow-up of the prenatal and postpartum periods 11.6 prenatal/postpartum care 11.7 referrals 11.8 gynaecologic diseases, breast and cervical cancer screenings 12. family planning 12.1 education and consultation 12.2 provision of information on contraception 12.3 financing contraception 12.4 surgery for birth control 13 help people to develop their understanding and skills to improve their own health 15.2 raising public awareness of the early symptoms of diseases 15.3 reduction in inappropriate antibiotic use 15.4 multitopic health promotion campaigns 15 centre for disease control and prevention the authors wish to thank liguang sun for his help in coordinating work, gang liu for supplying some policy information for the interviews, min liu for sharing her expertise in the interview guide, qiongying wang for her help in organizing the data, and kenneth kushner and o. daniel smith for their astute editorial suggestions. the authors would also like to thank the participating directors for their contributions to this project and their commitments in the study. r e f e r e n c e s medical ethics committee of capital medical university. none declared. none declared. free basic public health services delivered in community health services organizations in 15 districts in beijing since 2006. key: cord-288616-7i1kukmn authors: wan, kelvin h.; huang, suber s.; ko, chung-nga; lam, dennis s.c. title: the end of cordon sanitaire in wuhan: the role of non-pharmaceutical interventions date: 2020-05-14 journal: public health doi: 10.1016/j.puhe.2020.05.007 sha: doc_id: 288616 cord_uid: 7i1kukmn abstract the effectiveness of the non-pharmaceutical interventions implemented in wuhan are described and discussed. in the absence of vaccine and proven specific safe and effective treatments, the experience and results achieved by wuhan could serve as a good reference for leaders and policymakers around the world in formulating their strategies and policies in fighting against covid-19. wuhan, the initial epicenter of coronavirus disease 2019 (covid-19), has lifted its cordon sanitaire on 8 april, 2020 after being in place for 76 days. however, epidemics are getting very serious in some countries such as america and italy. soon after the start of the outbreak, when the transmission dynamics and epidemiology had become a little bit clearer, the chinese government has reacted swiftly with liberal testing, immediate case isolation, rigorous contact tracing and quarantine, social distancing, community containment, and mass masking. "desperate times call for desperate measures", said by hippocrates, the famous ancient greek physician describes vividly the decision to lockdown the wuhan city on 23 january 2020. this was a major decision that needs much political will and wisdom. the report of the who-china joint mission on covid-19 concluded that "such an approach is warranted to save lives and to gain the weeks and months needed for the testing of therapeutics and vaccine development." 1 the effectiveness of these non-pharmaceutical interventions have now become evident and can serve as an important reference in managing covid-19 pandemic. temperature checking stations were set up across transportation hub, designated fever clinics and wards were established in hospitals for suspected cases. different tiers of healthcare facilities were established in anticipation of the overwhelming number of new cases. sports stadiums and convention halls were converted into makeshift hospitals to relieve the pressure in hospital for mild covid-19 cases. huoshenshan and leishenshan, the two dedicated hospitals with 2,600 beds for treating the seriously-or critically-ill patients were completed in 2 weeks. over 42,000 medical personnel from all over china were deployed to the epicenter soon after the outbreak. for isolation to be effective in preventing transmission, patients should be detected ideally before the onset of viral shedding. transmission from asymptomatic patients has made temperature and symptom-based screening less effective. 4 in china, testing for the coronavirus is free and easily accessible; 320,000 tests have been performed in the guangdong province alone in just over 2 weeks. 1 one reason that has attributed to the reduction of new cases in south korea has been its widespread testing together with a digital crowdsourced contact tracing strategy; they have performed over 608,000 tests as of 28 april, 2020. 5 testing must be widely available and hurdles to get tested must be reduced. rapid testing protocols also ensure the optimal use of isolation room and other facilities at the hospitals. through widely available testing and contact tracing, followed by isolation and quarantining, this will be a part of the strategy of breaking the transmission chains. companies across the world are developing and manufacturing diagnostic kit to increase the abundance of testing kits. the use of facemask as part of the respiratory hygiene is ubiquitous in southeast asian countries such as china, south korea, and japan. many provinces in china made it mandatory by law to wear a facemask in public during covid-19. in contrast, citizens are advised to wear facemask only when they are ill in most non-asian countries. some opposing parties believe that the limited supply of facemask should be reserved for healthcare workers. this has led to racial stigmatism and aggravation among mask wearers in some of the countries in the current pandemic. as a public health intervention, mass masking protects the wearer but also each 5 other, and would eliminate discrimination. there is limited evidence, but not evidence of absence, on whether mask masking is effective in protection against coronavirus infection. 6 an adequate supply of medical masks to the public is likely to be a key bottleneck that determines whether such a strategy could be implemented as one of the non-pharmaceutical interventions in a country. real-time information was broadcasted by the chinese government through popular instant messaging apps such as wechat and weibo. various it platforms have increased the accessibility to information, health services, and minimized fake news. video conferencing and telemedicine platforms reduced exposure to healthcare workers. wuhan wuchang smart field hospital, one of the makeshift hospitals, was staffed with robots. robots were equipped with infrared thermometry; they delivered meals and medications and disinfected areas. smart bracelets and rings worn by patients monitored their vitals with data fed to remote medical staffs. unmanned aerial drones transported supplies to those under quarantine; they also replaced police officers in patrolling areas to enforce quarantine restriction. these innovative technologies reshape how we can protect medical personnel and care for our patients during health emergencies. china enforced unprecedented public health efforts such as surveillance, prompt isolation of patients, quarantine close contacts, social distancing, and community quarantine. a modeling 6 study showed that changes to contact patterns via workplace and school closure significantly delayed the epidemic peak and flattened the curve of wuhan. 7 another model revealed that larger travel restriction of >90% together with a strong transmissibility reduction delays the epidemic growth such that the daily incidence does not exceed 1 case per 1000 in china. 8 the series of multifaceted public health measures led to a reduction in r t to less than 1.0 on 6 february and to below 0.3 on 1 march, 2020 in wuhan. 9 these encouraging results highlight the importance of the synergistic effect of all public health measures. such measures allow the healthcare system to better prepare their capacity to respond to an overwhelming influx of patients, minimize the morbidity and mortality, while hoping for an effective vaccine or antiviral to come. who director-general commented that the "chinese government is to be congratulated for the extraordinary measures it has taken to contain the outbreak." 10 report of the who-china joint mission on coronavirus disease early dynamics of transmission and control of covid-19: a mathematical modelling study impact of non-pharmaceutical interventions (npis) to reduce covid-19 mortality and healthcare demand transmission of 2019-ncov infection from an asymptomatic contact in germany the updates on covid-19 in korea as of respiratory virus shedding in exhaled breath and efficacy of face masks the effect of control strategies to reduce social mixing on outcomes of the covid-19 epidemic in 8 china: a modelling study. the lancet public health the effect of travel restrictions on the spread of the 2019 novel coronavirus (covid-19) outbreak association of public health interventions with the epidemiology of the covid-19 outbreak inwuhan, china who director-general's statement on ihr emergency committee on novel coronavirus patient and other consents: not applicable, not required acknowledgments: none key: cord-315217-sg6vnur0 authors: biana, hazel t.; joaquin, jeremiah joven b. title: the ethics of scare: covid-19 and the philippines’ fear appeals date: 2020-04-20 journal: public health doi: 10.1016/j.puhe.2020.04.017 sha: doc_id: 315217 cord_uid: sg6vnur0 nan the ethics of scare: covid-19 and the philippines' fear appeals covid-19 took the world by surprise; and, as of early april 2020, the virus has already claimed more than 80000 lives and infected more than a million people around the globe. 1 to combat the pandemic, most governments strongly enforced social-distancing, area-wide lockdowns and curfews, and contact-tracing of persons under investigation (puis). to motivate people to take preventive measures, some heads of states used what may be characterized as the "friendlier" strategies in the form of infographics, infomercials, and hashtags. 2 on top of this, other governments have resorted to rather extreme tactics, which play on people's fears to regulate behaviour. witness some cases in the philippines as examples. in the country's national capital region (ncr), which has the most covid-19 positive cases, most areas have an assigned town crier who, while on a recurida or a mobile audio truck, threatens residents with fines of up to php5,000 (us$100) and possible jail time for noncompliance with set curfew hours. 3 in cainta, rizal, a province north of manila, local officials signal the start of the curfew by sounding the alarm from the horror movie the purge (2013). 4 (the purge's story revolves around the "purging" or violent killing of people in a single night while emergency services are suspended.) even the philippine president, rodrigo duterte, dissuades the public from disobeying the enhanced community quarantine (ecq) with remarks like, "...if there is trouble or the situation arises that people fight and your lives are on the line, shoot them dead". 5 the psychology literature refers to these scare tactics as "fear appeals". fear appeals are nothing new. as a pioneer on the subject, howard leventhal explains, feararousing communication is a tool often used to persuade others to act and behave in a certain way. 6 parents use it to discipline children; bosses to drive staff productivity. even medical practitioners employ "fear-based medicine" in clinical encounters when they try to coax patients to follow a course of action by issuing "if you don't, then..." threats. 7 fear appeals have also permeated public health campaigns. visual health warnings on cigarette packaging, for example, are a case in point. 8 while some, like r.f. soames job, have argued that such campaigns are ineffective 9 , others, like kim witte and mike allen found that "strong fear appeals and highefficacy messages produce the greatest behavior change" 10 . the verdict is still out whether such campaigns are effective or not. 9 as irish olympian john treacy once said, "fear is a great motivator". it pushes our survival instincts into high gear. while fear appeals and scare tactics have been used in clear and present public health emergencies like covid-19, the ethics of such public health communication interventions needs to be scrutinized. 11 in particular, whether these appeals and tactics are morally acceptable and appropriate. 12 it might be argued that scare tactics are acceptable in times of crisis so long as they urge "large population segments, who are at moderate risk, to adopt risk-reducing practices... to influence those who are at high risk". 11 such a reason may perhaps be grounded on the utilitarian principle of doing what best promotes the greatest benefit for the greatest number. on the other hand, an argument premised on a kantian, rights-based moral philosophy might say that if these tactics violate certain moral and legal rights that people hold inviolable, then such appeals are morally inappropriate. to preserve the kantian ideal for appropriateness, it might be suggested that fear appeals "should exclusively be used when pilot studies indicate that an intervention successfully enhances efficacy". 13 in a time of the uncertainties of a global health crisis like covid-19, however, a utilitarian may question this suggestion's moral acceptability. on the whole, then, the rightness of fear-mongering might therefore be the balance of its moral acceptability and appropriateness. the editors of this journal have stated that the global health threat of covid-19 requires collaborative health actions from different sectors from around the world. and they called for a strong public health response to combat this pandemic. 14 whether this call extends to the use of scare tactics is something that the public should morally examine. one line that epitomizes a scary tactic is president duterte's fierce pronouncement on a live telecast that covid-19 is a "crisis with no solution in sight". 15 whether the statement is true, or whether it contributes to the well-being of the general public are beside the point. we just hope that that was a mere fear appeal as the very thought of it makes us shiver from sheer fright. world health organization. coronavirus disease department of health -philippines. infographics | department of health website six metro manila cities enact covid-19 curfew city in the philippines plays "the purge" announcement to enforce coronavirus curfew philippines president rodrigo duterte warns against violating coronavirus lockdown -abc news (australian broadcasting corporation fear appeals and persuasion: the differentiation of a motivational construct fear-based medicine: using scare tactics in the clinical encounter -the health care blog fear appeal arguments effective and ineffective use of fear in health promotion campaigns a meta-analysis of fear appeals: implications for effective public health campaigns. heal educ behav guilt, fear, stigma and knowledge gaps: ethical issues in public health communication interventions a method for evaluating the ethics of fear appeals threatening communication: a critical re-analysis and a revised meta-analytic test of fear appeal theory covid19 -the need for public health in a time of emergency duterte says there is 'no solution in sight' for covid-19 key: cord-280800-g25z8xzt authors: yang, m.; he, m.; gao, s. title: a joint infection control system is needed in mental health institutions during outbreaks of major respiratory infectious diseases date: 2020-10-22 journal: public health doi: 10.1016/j.puhe.2020.09.003 sha: doc_id: 280800 cord_uid: g25z8xzt nan letter to the editor a joint infection control system is needed in mental health institutions during outbreaks of major respiratory infectious diseases faced with the novel coronavirus disease (covid-19) pandemic, vulnerable populations including the aged, children, pregnant women, and psychiatric patients have been widely concerned. 1e3 to protect psychiatric patients, mental health institutions in china have established measures to prevent and control nosocomial infections. however, the capacity of one institution in the combat against such a pandemic is limited. effective prevention and treatment of covid-19 for psychiatric patients demand cooperation between multiple institutions within a region. here, we take, for example, the cooperative practice of covid-19 infection control in the regional mental health union in chengdu, china, to address the initiation of a joint infection control system across mental health institutions during outbreaks of major respiratory infectious diseases. during the covid-19 outbreak, effective protection for psychiatric patients in chengdu has been realized based on cooperation between member institutions of the chengdu mental health union. firstly, a system of covid-19 prevention and control measures was established by chengdu mental health center (cmhc), an acategory psychiatric hospital in china with the annual outpatient number of more than 350,000 and annual inpatient number of more than 10,000. based on this strategic system, cmhc has prevented its patients and staff from nosocomial infection and meanwhile provided instructions for member units, including 15 primary-level mental health institutions, 3 comprehensive hospitals with psychiatric inpatient wards, and 395 community health service centers/township hospitals, leading to effective infection control in the union with no suspected or confirmed cases of covid-19 infection due to hospital transmission. on the other hand, as a hospital designated for suspected and mild cases of covid-19einfected psychiatric patients in chengdu, cmhc has cooperated with member units and comprehensive hospitals designated for covid-19 treatment, covering procedures for consultation, referral, and joint treatment to achieve seamless connectivity and optimal and quickest control of both covid-19 and psychiatric symptoms. furthermore, under the guidance of cmhc, primary-level mental health institutions have advised and supported community health service centers/township hospitals on scattered management of home-based psychiatric patients to prevent clustered infection and social instability. while ensuring effective prevention and control of covid-19 transmission, cmhc and primary-level mental health institutions have provided onsite and online psychological intervention services for preclassified hospitals and populations in different districts of their community to develop a facilitative environment in the fight against the pandemic. the cooperative practice in the chengdu mental health union during the covid-19 outbreak has an important implication for regularization of joint infection control for major respiratory infectious diseases across mental health institutions. in a city or an equivalent administrative region, there should be a joint infection control network of three levels of institutions (fig. 1) . the top level is a large-scale psychiatric hospital, such as cmhc, integrating medical treatment, education, research, and prevention. the second level consists of small-and medium-sized psychiatric hospitals or comprehensive hospitals with psychiatric inpatient wards. the third level includes community or township health service centers. the first level plays the central role in the structure, with its strong specialty and a certain degree of comprehensiveness. it should be a hospital designated for suspected and confirmed cases of infected psychiatric patients in the region. therefore, an independent department of infectious diseases is necessary. the building layout and facilities of this department meet national requirements, e.g. requirements of environmental control for hospital negative pressure isolation ward (gb/t 35428-2017) 4 and technique standard for isolation in hospital (ws/t 311-2009). 5 medical staff in the department is mainly composed of specialists in epidemiology and psychiatry and also includes a multidisciplinary team of severe medicine, clinical pharmacist, nutrition, and so on. in nonepidemic periods, it admits hospital or community acquired infection patients with mental disorders. during outbreaks of major respiratory infectious diseases, it immediately functions as specialized area for suspected or infected cases of psychiatric patients. the establishment of such a department in the psychiatric hospital promotes 'one-stop' service for psychiatric infections. the second level is the intermediate hub connecting the top and bottom levels. in non-epidemic periods, institutions at this level admit or transfer patients mainly regarding their psychiatric phases. during epidemic outbreaks, they screen suspected cases in psychiatric patients to keep patients in hospital for observation or transfer them to designated treatment hospitals. these institutions also support and advise the third level on epidemic prevention under the guidance of the top level. community or township health service centers, the basic level in the network, are responsible for supervising rehabilitation and home management of non-acute psychiatric patients. during epidemic outbreaks, they take care of severe psychiatric patients at home and provide medicine delivery service and online treatment for those living in closed management areas. they conduct preliminary screening for psychiatric patients having a common fever and those having a fever caused by major respiratory infectious public health j o u r n a l h o me p a g e : w w w . e l s e v i e r . c o m/ l o ca t e / p u h e diseases and transfer patients with a common fever to the second level and suspected cases of the infectious diseases to the first level. to sum up, infection control practices in the covid pandemic provides mental health institutions a new insight in effective protection of vulnerable patients. in the future, professional experience can be combined with data modeling and machine learning to initiate a joint infection control system with high effectiveness and responsiveness. this study was supported by the national natural science foundation of china, china (grant numbers 61806042, 31600880) and the special research project for the novel coronavirus pneumonia funded by the chengdu science and technology bureau, china (grant number 2020-yf05-00171-sn). covid-19: active measures to support community-dwelling older adults clinical and ct imaging features of the covid-19 pneumonia: focus on pregnant women and children the risk and prevention of novel coronavirus pneumonia infections among inpatients in psychiatric hospitals requirements of environmental control for hospital negative pressure isolation ward: gb/t 35428-2017. general administration of quality supervision, inspection and quarantine of the people's republic of china. standardization administration of the people's republic of china technique standard for isolation in hospitals: ws/t 311-2009. ministry of health of the people's republic of china key: cord-303414-fwamdr08 authors: oztig, lacin idil; askin, oykum esra title: human mobility and covid-19: a negative binomial regression analysis date: 2020-07-10 journal: public health doi: 10.1016/j.puhe.2020.07.002 sha: doc_id: 303414 cord_uid: fwamdr08 abstract objectives this study aimed to examine the link between human mobility and the number of covid-19 infected people in countries. study design our dataset covers 144 countries for which complete data are available. in order to analyze the link between human mobility and covid-19 infected people, our study focused on the volume of air travel, the number of airports and the schengen system. methods in order to analyze the variation in covid-19 infected people in countries, we used negative binomial regression analysis. results our findings suggest a positive relationship between higher volume of airline passenger traffic carried in a country and higher numbers of covid-19 patients. we further found that countries which have a higher number of airports are associated with higher number of covid-19 cases. schengen countries, countries which have higher population density and higher percentage of elderly population are also found to be more likely to have more covid-19 cases than other countries. conclusions the paper brings a novel insight into the covid-19 pandemic from a human mobility perspective. future research should assess the impacts of the scale of sea/bus/car travel on the epidemic. the findings of this paper are relevant for public health authorities, community and health-service providers and policy-makers. the globalized world, in which the scale of the movement of people is at unprecedented scale 1 is susceptible to the spread of diseases on a global scale. with sophisticated transport networks that have increased reach, the speed of travel and the volume of passengers, "pathogens and their vectors can now move further, faster and in greater numbers than ever before". 2 the global spread of covid-19 that has led to the infection, and deaths, of thousands of people at a rapid scale, is indicative of how infectious diseases can become a global health problem that have the ability to reach more people, and at a faster rate, in an increasingly globalized world. throughout history, in addition to human migration, trade caravans, religious pilgrimages, and military manoeuvres played a central role in the spread of diseases. 3 during the middle ages, trade routes between europe and asia were instrumental in the spread of the plague into europe. 4 in the 1500s, the population of the new world suffered from infectious diseases brought by european explorers. the second voyage of christopher columbus to the caribbean in 1493 brought small pox to the region. in the 1518 small pox epidemic, thousands of indigenous inhabitants of the caribbean region died. 5 in the 16 th and 17 th centuries, ships from africa not only brought slaves, but also smallpox and fever-carrying mosquitoes to the new world. 6 overall, the pathogens carried by migrants had devastating consequences for native americans who had no immunity for them. the confluence of american troops with european and african troops in france, and the development of new virus strains, created a permissive environment for the 1918 influenza pandemic that resulted in the deaths of approximately 40 million people in a year. 7 the 1957 pandemic that erupted in china spread to the world within six months. 8 in 1972, a small pox epidemic erupted in the autonomous province of kosovo of (the then named) yugoslavia on april 11 th 1972. epidemiologic and serologic investigations revealed that small pox was imported to yugoslavia from a hajji pilgrim who had visited mecca and returned to the country by bus via iraq (where small pox cases were reported at the time). as a result of the smallpox outbreak, 175 people were infected, among which 35 people died. 9 global travel, given the unprecedented volume, speed, and reach, is an important factor in the rapid spread of current diseases. 10 the study by olsen et al. indicates that many sars-infected people traveled on commercial aircraft. 11 the study further revealed that after one flight carrying 120 people (among which one person was symptomatic), sars developed in 16 people. illness in passengers was related to the physical proximity to the symptomatic person. while sars spread to 37 countries (8000 cases) and mers spread to 27 countries (2494 cases), 12 covid-19 has spread to more than 200 countries and infected more than a million people in the world, initiating an unprecedented global crisis. wuhan, the epicenter of the pandemic, is central china's major air and train transportation hub. as of 2019, in wuhan, international outbound air travel constituted 13.5% of all outbound air travel, while the top 40 domestic outbound air routes constituted 81.3%. high air and train traffic across china due to the lunar new year spring festival, that started on january 10 th 2020, appeared to have played a facilitating role in the spread of covid-19 throughout the country and abroad. 13 the first covid-19 case outside china (a traveler from wuhan) was reported to the who by the thai government on january 13 th 2020. 14 three days later, the japanese government informed the who of its first confirmed infection in a traveler from wuhan. 15 strikingly, due to china's lockdown of the coronavirus-hit hubei province on january 23rd, many people left wuhan, which has resulted in the spreading of the diseases in and outside china. 16 soon afterwards, india, philippines, russia, spain, sweden, and the uk confirmed their first cases. based on the findings of the previous literature and the current trends in the spread of covid-19, we hypothesize that in countries in which there is a high mobility of people, the number of covid-19 infected people are correspondingly higher. we also hypothesize that there is a positive association between high numbers of airports in a country and high numbers of covid-19 infected patients, and that schengen countries are more likely to have higher numbers of covid-19 infected patients than non-schengen countries. the dependent variable of this study is the number of covid-19 infected people. the data on covid-19 cases is extracted from the official site of who published as of april 3 rd 2020. 17 we analyzed 144 countries for which the complete data on independent and control variables are available. it should be noted that our dependent variable consists of cases that are reported to the who. depending on the late development of/lack of testing equipments and the numbers of tests administered to individuals, the actual number of covid-19 infected people in countries might be much higher. lack of adequate testing, or some cases, any testing, in many countries might be affecting the availability and accuracy of data. for instance, the full impact of covid-19 on india (the world's second most populous nation), indonesia (the world's fourth most populous nation), african nations, and various smaller countries remains unknown. this constitutes a limitation to our study. as covid-19 is reported to have emerged in china and then spread to other countries, we do not include china in our analysis. we operationalize human mobility by looking at the number of airline passengers carried into the countries. the data are extracted from world development indicators. 18 airline passengers include both domestic and international aircraft passengers of air carriers registered in the country. we note that the most recent data on the airline passengers is from 2018. although the data does not correspond to actual human mobility as of 2020, we assume that the pattern of air travel is unchanged until the start of the pandemic. we measure airport numbers and the schengen system as factors that facilitate human mobility. the data on airport numbers are extracted from the world factbook of the central intelligence agency. 19 we code schengen countries as 1 and 0 otherwise. we control for population density in our analysis. in countries with high population density, people have contact with large numbers of people which facilitate person-to-person spread of many infectious diseases. 20 furthermore, the elderly people are more susceptible to infections "because of waning cell-mediated immunity and impaired host defenses but also because of chronic diseases and use of drugs and treatments that may be immunosuppressive". 21 by bearing in mind the fact that there is no scientifically established relationship between immunity and the risks of contracting covid-19 disease, we control for the percentage of elderly people in population our analysis. the data on population density and the percentage of elderly people (65 and above) are extracted from world development indicators. 22 in order to analyze the variation in covid-19 infected people across countries, we use negative binomial regression (nbr) model. nbr is based on the poisson-gamma mixture distribution. it is useful for predicting count-based data. we choose this method because our dependent variable (the number of covid-19 infected people) consists of only non-negative integer values and the variance of the dependent variable is greater than the mean. the dependent variable is substantially positively-skewed and kurtotic where is a vector of estimated coefficients of exploratory variables including the percentage of elderly people in population, the logarithm of the population density, the number of airline passengers, the number of airport and the schengen system. the vector of coefficients is then estimated by maximizing the logarithm of the likelihood function given below. one of the important properties of the poisson distribution is that the mean and the variance are equal to the parameter. however, the assumption of identical mean and variance was not satisfied for the data used in this study ( = 5,498.25 and + =21,577.85). the greater ratio of variance to mean leads to over-dispersion frequently caused by heterogeneity among observations. thus, we apply nbr to overcome this problem of over-dispersion. a gamma-distributed error term is added to the eq (2) in order to relax the pr assumption by including additional randomness. where , follows gamma distribution with mean 1 and variance -. the nbr distribution has a mean and variance + -. whereis the overdispersion parameter used as a measure of dispersion. in analyzing the variation in the dependent variable, the following model is considered: ln num. of. covid19 infected = > + ? * old + . * log _popdensity + e * log _airtransfer + h * log _airportnumber + j * schengen table 1 shows the estimates of model parameters ( m ), standard errors (std err of m ), 95% ci for the m by profiling the likelihood function, incident rate ratios (irrs) and goodness-of-fit statistics such as cragg-uhler pseudo-r², logarithmic likelihood and akaike information criteria (aic). the estimated coefficients of all variables used in this study are statistically significant (at least 95% confidence level) and in the positive direction. countries that have higher volume of airline passengers (irr=3.161, p<0.01); higher number of airports (irr=2.607, p<0.01); higher population density (irr=2.403, p<0.01); higher percentage of elderly population (irr=1.068, p<0.05), and schengen countries (irr=4.498, p<0.01) are found to be more likely to have higher numbers of covid-19 infected cases than other countries. table 1 . this study answers the question of why some countries have higher numbers of covid-19 infected people compared to others. analysis of the data suggests a link between the scale of human mobility and the number of covid-19 patients in countries. our results indicate a positive association between the magnitude of airline travel and high numbers of covid-19 infected patients. furthermore, we find that countries which have higher number of airports, schengen countries, countries which have higher population density and higher percentage of elderly population are found to be more likely to have more covid-19 cases than other countries. the quick spread of covid-19 appears to be propelled by "superspreading". superspreading refers to heightened transmission of the disease to at least eight contacts and has been observed for several infectious diseases including sars, mers, and influenza. 23 our study suggests that better connected areas are more likely to be infected first and have more infections initially (but it is still too early to report the potential consequences on less well-connected areas that may become infected in due course). there are a number of limitations in this article. while we measured human mobility by looking at the volume of air travel, future studies can provide a comprehensive analysis on the impact of sea/bus/train/car travels on the spread of covid-19. patients zero and their travel history will provide important insights into cross-country comparisons. in addition, when a virus arrives in a country, its contagion and spread hinges on local transmission pathways and public health provision. 24 efforts and (relative) successes of countries in handling the covid-19 crisis should be analyzed in a comparative manner. furthermore, we note that certain emerging trends might influence general applicability of the findings as we move into the future. for example, in addition to the reduced volume of travel, increased testing and future development of vaccines might also affect the applicability of the findings with passage of time. previous studies found that airport screening measures failed in halting the spread of viruses. 25 in the context of superspreading of covid-19, airports are more likely to be rearranged so as to minimize the risk of contagion. researchers should contemplate on new techniques and methods at airports for the maximum safety of passengers and staff against pandemical diseases. there are also issues that urgently need to be further studied, such as the link between public health provision and covid-19 mortality rates. our study indicates a positive relationship between the percentage of elderly population and covid-19 cases. recent developments reveal that the virus has the potential to affect all age cohorts. future studies can comparatively examine the spread and the mortality rate of covid-19 in countries with younger population and those with aging populations. psychological impacts of the covid-19 pandemic also need to be systematically studied. the long-term implications of the covid-19 pandemic on countries' health systems and global health policymaking and management strategies will also provide interesting avenues of research for further researchers. global transport networks and infectious disease spread geography of infectious diseases princes and peasants: smallpox in history the burdens of disease iberia and the americas: culture, politics, and history: a multidisciplinary encyclopedia the burdens of disease global transport networks and infectious disease spread the great influenza: the epic story of the 1918 pandemic global transport networks and infectious disease spread epidemiologic aspects of small pox in yugoslavia in 1972 travel and the emergence of infectious diseases transmission of the severe acute respiratory syndrome on aircraft nowcasting and forecasting the potential domestic and international spread of the 2019-ncov outbreak originating in wuhan, china: a modelling study nowcasting and forecasting the potential domestic and international spread of the 2019-ncov outbreak originating in wuhan, china: a modelling study world health organization. who statement on novel coronavirus in thailand world health organization. novel coronavirus -japan (ex-china) the novel coronavirus disease (covid-19) outbreak trends in mainland china: a joinpoint regression analysis of the outbreak data from nowcasting and forecasting the potential domestic and international spread of the 2019-ncov outbreak originating in wuhan, china: a modelling study coronavirus disease (covid-2019) situation reports 19 central intelligence agency, the world factbook population mobility and the geography of microbial threats population mobility and the geography of microbial threats population density (people per sq. km. of land area) wuhan novel coronavirus (covid-19): why global control is challenging? wuhan novel coronavirus (covid-19): why global control is challenging? border screening for sars evaluation of border entry screening for infectious diseases in humans key: cord-294884-6l25y6fw authors: lee, andrew; morling, jo title: covid19 the need for public health in a time of emergency date: 2020-04-08 journal: public health doi: 10.1016/j.puhe.2020.03.027 sha: doc_id: 294884 cord_uid: 6l25y6fw nan on 11 march 2020, the world health organization (who) declared covid19 a pandemic. three months on from when china first alerted the world to the emergence of this threat, there were more than half a million confirmed cases and 33,106 deaths reported worldwide. 1 large epidemics have sprung up in western europe and the united states. worryingly, the infection has also emerged in developing countries where the impact of the pandemic will probably be worst. infectious disease modellers at imperial college london estimate that without mitigation, covid19 could result in seven billion people infected and 40 million deaths globally this year. 2 consequently, the need for early and sustained suppression measures in these settings will be crucial in order to blunt the severity of the pandemic and save lives. in europe, italy was first to be most severely affected with numbers of cases exceeding china's tally, and a death toll already three times higher. in the worst affected areas, the outbreak was described as out of control and the response has been criticised for its "systematic failure to absorb and act upon existing information rapidly and effectively". 3 key ingredients for an effective response appear to be the need for extensive testing, proactive contact tracing, an emphasis on home diagnosis and care, and the monitoring and protection of health care and other essential staff. it is clear that the speed of response needed to keep pace with the epidemic spread is exponentially faster than bureaucratic processes in health systems. crucially, there is a need for learning in order to identify and understand which approaches work. the italian epidemic was 2 -3 weeks ahead of the rest of europe and certainly the uk. the uk adopted a graded contain-delay-mitigate-research response to the threat, moving from an initial containment phase characterised by rigorous contact tracing and testing, to a delay phase in mid-march. this approach was considerably less draconian than the lockdown measures introduced by the chinese government, possibly based on the concerns of wider socioeconomic and psychological impact of a full lockdown on society. it also did not align with the who approach and advice to "test, test, test" all suspected cases. what was not clearly articulated was the government's policy goal at the time, i.e. whether mitigation or suppression of the epidemic was the aim. what then emerged was an unverified narrative that the aim was to allow the infection to burn through the population in order to build up "herd immunity" which would have meant health services being overwhelmed and the deaths of many, predominantly elderly or with complex comorbidities, in the population. unsurprisingly, the uk government's approach was heavily criticised by academics who demanded the release of the evidence used to inform the government's approach. 4 the release of the evidence has been slow and it is clear that the lack of transparency has affected trust in the government's response from academics and other allied professionals. transparency is crucial to retain the cooperation and trust of the scientific community, health workforce and the wider public. the uk government belatedly introduced lockdown measures and adopted a new strategy to suppress-shield-treat-palliate. however, this intervention may have come a little late in the course of the outbreak and cases of infection have taken off exponentially. 5 compounded by supply issues for personal protective equipment for health staff and conflicting guidance on its use, this has further eroded trust in the government's approach. there was also a clear split in the public health community regarding the approach reflecting the uncertainties in what is known and not known about the virus and how best to tackle the pandemic. this has meant that the public health voice has been muddled and muted at a time when it needed to be crystal clear. another potential flaw to the uk's approach has been a strong focus on intensive care unit (icu) bed capacity as modelling predictions forecast demand for these beds far outstripping available supply. 6 this has led to frenzied planning and efforts to boost icu capacity. unfortunately, this fails to build on learning from italy: like previous outbreaks of mers cov, healthcare settings are possible sites of infection, "as they are rapidly populated by infected patients, facilitating transmission to uninfected patients". 7 the western health system paradigm is biased towards hospital modes of care delivery. however, in this epidemic scenario, what is becoming clear is that it is not just "an intensive care phenomenon, rather it is a public health and humanitarian crisis". 7 in common with other humanitarian crises, the consequences are pervasive, wide and varied, and therefore require a response beyond a hospital or healthcare response. as a public health emergency, it is concerning that there is not a stronger public health lead and response. the societal impact needs to be considered. it is predictable that the poor, the marginalised, those on insecure employment, those living with disabilities, and other vulnerable groups, are at greatest risk not just from infection but the indirect consequences. after a decade of austerity in many european countries, where health and social care funding has been curtailed, coupled with disinvestments in public health systems, there are less resilient health systems to cope with this pandemic. government fiscal ideology of running healthcare like an airline, with for example bed occupancy rates of over 90%, has been flawed as it has taken out vital surge capacity much required in emergency situations. the economic agenda has been prioritised over public health and we are now seeing the fallout from this. health and social care funding is an investment and a national insurance policy against disasters such as the covid19 pandemic. there have been some emerging positives from this crisis. scientific advice, public health and the evidence-based approach to decision making is valued once more. there has been rapid and considerable information sharing by clinicians and academics enabled by social media, and in keeping with many other leading journals public health has made its covid19 content freely accessible. innovation in ways of working by frontline teams is emerging. in the uk, primary care and community health care integration, as well as vertical integration between hospital and out-of-hospital care, is taking place where once it may not have been contemplated. indeed, integration and coordination will be essential in order to augment existing health and care capacity to absorb the rise in health need. novel coronavirus(2019-ncov) situation report -70 (website) the global impact of covid-19 and strategies for mitigation and suppression. who collaborating centre for infectious disease modelling, mrc centre for global infectious disease analysis, abdul latif jameel institute for disease and emergency analytics lessons from italy's response to coronavirus evidence informing the uk's covid-19 public health response must be transparent. the lancet offline: covid-19 and the nhs-"a national scandal". the lancet impact of nonpharmaceutical interventions (npis) to reduce covid19 mortality and healthcare demand. who collaborating centre for infectious disease modelling, mrc centre for global infectious disease analysis, abdul latif jameel institute for disease and emergency analytics at the epicenter of the covid-19 pandemic and humanitarian crises in italy: changing perspectives on preparation and mitigation. nejm catalyst innovations in care delivery on a final note, this pandemic is a global health threat and this will require collaborative action to tackle. whilst the focus of the response may very much be local at the present time, only through concerted public health action worldwide can it be successfully suppressed, and hopefully in time eliminated. key: cord-293316-kip8mrjo authors: de sa, j.; mounier-jack, s.; coker, r. title: risk communication and management in public health crises date: 2009-09-10 journal: public health doi: 10.1016/j.puhe.2009.07.017 sha: doc_id: 293316 cord_uid: kip8mrjo nan as the world faces its first influenza pandemic in 40 years, it has been argued that we have never been better prepared. concern about emerging infectious diseases has fuelled significant public health and political developments, such as the coming into force of the international health regulations (ihr). since the turn of the century, the world health organization (who) has documented a historically unprecedented number of emerging infectious disease outbreaks, and lessons drawn from their management have confirmed the critical importance of effective communications, specifically through formal channels such as who and in the public domain. in concert with novel emerging infectious diseases, the communication landscape itself has also changed radically. we now live in an era of real-time electronic communications; consequently, approaches to surveillance are being transformed. data sources, information messengers, mechanisms of data and information transfer and audiences are all changing. instant and global transmission of information has become a powerful ally, along with peer pressure, for who in ensuring that member states comply with new obligations to swiftly declare outbreaks considered to be of public health importance. there is now significant global attention and accompanying investment which should, the authors suggest, be used as an opportunity to improve strategic and operational communication capacity to respond not only to pandemic influenza but also to other public health threats. there are many concepts of communication in relation to risk associated with outbreaks. as these are relatively new concepts, this article will consider approaches relating to highlighting public health threats and supporting operational management, addressing these as the communication of risk and subsequent risk management. strategic considerations are critical to both, although information, messengers, communication tools and audiences may differ. the communication of risk refers to the process by which information regarding outbreaks is identified and shared with the purpose of increasing awareness amongst key stakeholders of the threat. key stakeholders for public health threats include who, national governments and the public. risk management, by contrast, refers to the management processes associated with response to the outbreak, for which communication is crucial at each stage. three examples are used to explore the challenges and demands of communicating effectively and coherently given this changing landscape. this brief paper will attempt to show the progress made, draw lessons to be learned and outline the ways forward. the outbreak of severe acute respiratory syndrome (sars) in 2002-2003 was an unprecedented public health emergency played out on the international stage. the disease, caused by a novel coronavirus, resulted from spread of the virus from civet cats to humans in the food markets of southern china; once individuals were hospitalized, the virus spread nosocomially to infect other patients and staff. the first reports of this novel disease outbreak came from the local media, and were later substantiated by e-mail messages. these caused international concern, in part because it was feared that a new influenza pandemic was emerging, and heightened as formal confirmation from chinese authorities was not forthcoming. 1 whilst the international community remained largely powerless, there being no legal mandate to ensure that china clarified what was occurring, cases appeared in other countries, further raising the stakes. thus, the sars story highlighted a number of challenges to the communication of risk. first, with the advent of, and wide access to, the internet and e-mail, information through informal and largely unverifiable sources can be transmitted to worldwide audiences within the public domain ahead of information sharing through formal channels. second, because of the speed of movement of people, diseases can emerge in countries far from their source before outbreaks or the pathogens that cause them have been confirmed or identified. sars galvanized the international community to finally conclude drafting of the revised ihr. the ihr bind who member countries to not only notify all events that may constitute a public health emergency, but also to respond to requests for verification of information. who has also produced outbreak communication guidelines to aid in the dissemination of information to the public, recognizing that 'expertise [in communications] has become as essential to outbreak control as epidemiological training and laboratory analysis'. 2 the boundaries between risk communication and management are not, however, sharply delineated, as illustrated by the controversy surrounding h5n1 influenza virus sharing. indonesia is one of the countries hardest hit by outbreaks of h5n1. virus sharing with the international community is the mechanism by which, first, viruses developing pandemic potential can be tracked (risk communication), and second, vaccines can be developed to meet global need (risk management). indonesia refused to virus share, not because it was opposed to the sharing of technical information to better understand the threat posed by h5n1 avian influenza, but because it felt excluded from equitable access to the resulting vaccine, meaning that its management of a subsequent pandemic would be constrained. 3 it could be argued that indonesian authorities currently view virus sharing as an important element in risk management and thus a sovereign issue, although the international community, by contrast, views virus sharing as a critical element of risk communication and, by extension, a global risk management issue. differing interpretations of international treaties are possible and resolution is proving challenging. 4 ultimately, the debate is centred on the boundary between the governance of risk communication and risk management, the former now being mandated through international laws, with the latter remaining, to a large degree, a national sovereignty responsibility. implicit to better risk communication is a belief that better risk management will automatically follow. surveillance is, after all, 'information for action'. communication, co-operation and coordination are necessary at an international level. however, they are also, as the illustration below highlights, necessary at national and subnational levels. in august 2005, hurricane katrina made landfall on the gulf coast of the usa. the worst consequences were felt in new orleans, louisiana, where the levee system was breached and billions of dollars of damage occurred. the storm also caused significant loss of life and many people were displaced from their homes. the magnitude of the hurricane was anticipated, the risk having been communicated at both local and national level. however, this risk warning was not heeded appropriately. for example, although mandatory evacuation was eventually ordered, there was little provision for the large numbers involved or for those citizens who could not evacuate themselves. the aftermath of the storm, with many people left living in squalid conditions, also revealed a risk management process that left much to be desired. 5 one notable example was in the coordination of a bi-partisan emergency federal health policy response, attempts at which were blocked by the white house, citing multiple concerns including relevance and cost. the subsequent delay resulted in profound health, economic and political consequences. 6 several lessons may be drawn for the risk management of disease outbreaks. firstly, although risk communication may occur, it does not automatically result in a co-ordinated risk management response. second, this occurred in the usa, a country which clearly has the public health and disaster management resources to deal with such a problem. however, these resources were not mobilized effectively, efficiently or in a timely manner. at the heart of many of the problems were fractured communication systems. among operational problems, there were failures in communication technologies subsequent to the weather conditions and, whilst some decisions required extensive information, others were made on the basis of unverified rumours reported by the media, leading to incoherent responses. 5 communication failures occurred between the local, state and federal agencies, and there was a lack of clear roles and responsibilities. although new orleans had experienced previous hurricanes and had a disaster management plan, the plan was clearly operationally fragile. it is important to ensure that national strategic plans are operational. recent reviews have reported that this does not yet seem to be the case. [7] [8] [9] the confusion and lack of clarity in the response to hurricane katrina show that traditional ways of working and their dependency on traditional communication systems may falter in the heat of a crisis. new ways of communicating allied to clearly defined roles and responsibilities may be needed. in the changing landscape outlined, there are clearly many challenges for effective risk communication and risk management. in terms of the communication of risk, this article has focused on progress on the international stage. it is recognized that challenges still remain at national level, but the diversity of these is beyond the scope of this brief paper. as illustrated by the examples above, tensions exist at national level between international commitments to communicate risk and risk management responses. however, because of the speed of movement of people and goods, global risk management is now as fragile as the weakest link in the community of nations. the challenge is, as with risk communication, to develop an operational framework that acknowledges national sovereignty but is also cognisant of national and individual interdependencies and connectedness. the global response is building effectively upon the 'dry-run' of sars, and lessons can be drawn from other public health crises such as hurricane katrina. the current global influenza pandemic and the attendant international attention offer an opportunity that should not be squandered. the almost unprecedented energy, political commitment and resources committed to this need to be built upon and harnessed, integrated and extended to support effective responses to public health threats. as the current h1n1 pandemic unfolds, it will be interesting to see how well lessons drawn from earlier public health emergencies have been learned. 10 ethical approval none sought. none declared. sars and emerging infectious diseases: a challenge to place global solidarity above national sovereignty world health organization. who outbreak communication guidelines. geneva: who jakarta: sulaksana watinsa indonesia influenza virus samples, international law, and global health diplomacy communicating throughout katrina: competing and complementary conceptual lenses on crisis communication federal health policy response to hurricane katrina: what it was and what it could have been pandemic influenza preparedness in the asia-pacific region pandemic influenza preparedness in africa is a profound challenge for an already distressed region: analysis of national preparedness plans pandemic influenza preparedness in latin america: analysis of national strategic plans influenza a (h1n1) and pandemic preparedness under the rule of international law none declared. key: cord-298652-96l3h3ih authors: aragona, m.; barbato, a.; cavani, a.; costanzo, g.; mirisola, c. title: negative impacts of covid-19 lockdown on mental health service access and follow-up adherence for immigrants and individuals in socio-economic difficulties date: 2020-08-06 journal: public health doi: 10.1016/j.puhe.2020.06.055 sha: doc_id: 298652 cord_uid: 96l3h3ih objectives: lockdown measures in response to the coronavirus disease 2019 (covid-19) pandemic can have serious mental health effects on the population, especially in vulnerable groups, such as those living in poor socio-economic conditions, those who are homeless, migrant workers and asylum seekers/refugees. in addition, these vulnerable groups frequently have greater difficulty accessing health services and in treatment adherence. the aim of this study is to estimate the impact of the covid-19–related lockdown on service utilisation and follow-up adherence in an italian mental health outpatient service for migrants and individuals in socio-economic difficulties. study design: the design of this study is a retrospective cross-sectional study. methods: all patients who visited the mental health outpatient service in the months of february and march in the years 2017–2020 were included in the study. to compare service utilisation before and after the lockdown, the number of patients who visited the mental health outpatient service for psychiatric interview were recorded. follow-up adherence was calculated as the percentage of patients who visited in february and subsequently attended a follow-up visit in march of the same year. results: the number of patients who visited the outpatient service between february 2017 and february 2020 was continuously increasing. in march 2020, fewer patients visited the service for psychiatric interview, in line with the introduction of lockdown measures. in addition, the number of the patients who visited in february 2020 and returned for their follow-up visits in march 2020 declined from approximately 30% over the same months in 2017–2019 to 17.53% in march 2020. conclusions: the lockdown-related reduction in numbers of patients accessing the mental health service makes it difficult to help vulnerable populations during a period of time in which their mental health needs are expected to increase. moreover, the reduction seen in follow-up compliance increases the risk of treatment discontinuation and possible relapse. proactive alternative strategies need to be developed to reach these vulnerable populations. the coronavirus disease 2019 (covid-19) pandemic, as a result of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) infection, has led to a public health emergency, thousands of deaths, generalised economic depression, unemployment and worldwide quarantines. italy was the first european country to be severely impacted by the disease, with the total number of cases currently being 238,499, with 34,634 deaths. 1 on 8 march 2020 , in response to the growing pandemic of covid-19 in the country, the italian government imposed a national restriction of movements of the population, with the exceptions of buying food and other necessary items (e.g. drugs, disinfectants), essential work and health emergencies. 2 the national lockdown ended in june 2020 and proved to be useful in reducing the spread of sars-cov-2 infection. however, such restrictive measures will likely have serious mental health effects on the population. 3e6 in particular, there are certain subgroups of the population that are particularly at risk in this situation due to their precrisis vulnerability. among them, there are those who live in poor socio-economic conditions, 7, 8 those who are homeless, 9 migrant workers, 10,11 asylum seekers and refugees 12, 13 and patients with existing mental health disorders. 14, 15 in addition, some individuals will fall into several of these subgroups, thus increasing their risk. 16 for example, asylum seekers whose request of international protection has been rejected are often homeless, without documents, without jobs, live in poverty and also have symptoms of post-traumatic stress disorder (ptsd) due to their migratory experience, as well as depressive and adjustment disorders related to their present poor living conditions. this is not an unusual problem in italy, and it has actually worsened over the last year due to a law removing the 'humanitarian' forms of permission of stay in the country and consequently the right for those people to be hosted in reception centres and get a job. 17 previous research has shown that migrants in poor sociocultural conditions have an increased risk of mental health problems, including the worsening of ptsd, 18 higher rates of psychoses 19 and difficultly in access and/or inadequate treatment in some mental health services of the italian national health service. 20, 21 there is evidence that the covid-19 crisis has had a negative impact on the mental health of vulnerable populations through different mechanisms. 22, 23 unfortunately, no data are currently available in specific populations, such as those investigated in this study; however, the authors recently performed a phone-based data collection survey (personal data, article in preparation) showing that there are several pathways leading to mental distress. for example, participants reported intrinsic effects related to anxieties of being infected; consequences of the quarantine, both on living experience (e.g. sense of imprisonment reminding traumatic experiences, intolerance to inactivity, boredom, depression) and interpersonal relationships (e.g. forced and conflictual cohabitation in reception centres); fears for the health of relatives living in their home countries; increased social marginalisation (e.g. homeless remained without food, clothing, furniture, laundry and washing facilities or without acceptance in public dormitories); job loss and additional economic difficulties; reduction of the activities in the mental health outpatient services, with increased difficulty in accessing them; increased fears of being taken by the police in the cases of undocumented migrants (the reduction of people around the city made them more visible in the streets) and inability to obtain necessary medications. the aim of this study is to evaluate the impact of the covid-19erelated lockdown on two specific problems possibly faced by mental health patients with a history of immigration and/or socioeconomic difficulties: that is, difficulties in mental health service utilisation and follow-up adherence. in particular, the study was conducted in an italian public health outpatient service that was specifically dedicated to migrants and individuals with socioeconomic difficulties. the authors believe that this study is necessary because problems at this level have been predicted on the basis of theoretical considerations but, to the authors' knowledge, no evidence measuring this effect is currently available. moreover, centres dedicated to migrants are frequently based on volunteers, and their reports often remain in the grey literature, thus remain difficult to access by the scientific community. this retrospective study was conducted by the mental health unit of the italian national institute for health, migration and poverty (inmp), based in rome. to facilitate access of migrants and homeless people, the inmp uses a low-threshold setting with a transcultural approach model. information routinely and systematically collected in medical records was used, and all patients signed an informed consent form to use their data for study and research purposes. the study included all patients who received at least one psychiatric interview in february (286 patients) and march (269 patients) in the years 2017e2020. patients who visited the service in february were considered as the baseline population. their sociodemographic data and diagnoses were considered in the sample description. psychiatric disorders were categorised into eleven groups, reflecting the frequency of international classification of diseases (icd)-9 disorders diagnosed in the healthcare unit (the icd-9 diagnostic system is currently for official statistical recording used in italy). the number of patients who visited in february was also compared with those who visited in march for each particular year group. for 2020, the number of patients who visited in february and march was divided into three time periods of about ten days for each month (1-10th, 11-20th and 21-end of the month) to highlight the fact that the change started after the lockdown was established. furthermore, to assess follow-up compliance, we used, as proxy, the number of patients who visited the service in february and then attended at least one follow-up visit the following month. the sociodemographic characteristics and psychiatric categories of the study population are reported, and trends in the number of patients attending interviews are shown graphically. continuous variables were computed as means ± standard deviations (sds), and categorical variables were calculated as frequencies. trend differences were reported as absolute numbers or percentage change when appropriate. in addition, the 95% confidence interval (ci) of percentage change was calculated and significance reported. table 1 summarises the characteristics of the 286 patients who visited the mental health outpatient service in february. participants were mainly men (75.17%) and had a mean age (±sd) of 37.37 (±13.43) years. patient age and gender did not differ significantly between the study years. geopolitical areas of provenance and diagnostic groups changed each year depending on unpredictable pathways of access related to the population dynamics, although the main provenance of africa (above all western/central africa) remained, and a prevalence for ptsd and depressive, adjustment and psychotic conditions was maintained. the proportion of italians in poor socio-economic conditions who visited the outpatient service fluctuated between 5% and 10%. as shown in fig. 1 , there was a trend of increasing numbers of patients who visited the service between 2017 and 2020, until february 2020. subsequently, a drop of the number of patients who visited in march was registered (fig. 1) and, more specifically, a reduction in the number of psychiatric interviews after the 10th of march 2020, which corresponds with the period in which the lockdown was established in italy (fig. 2) . in addition, whereas in the period 2017e2019, at least 30% of the patients who visited in february attended a follow-up visit in march of the same year; only 17.53% of patients accessing the mental health outpatient service in february 2020 came back for the scheduled follow-up appointment in march 2020 (fig. 3) , showing a significant decrease of 46.57% (95% ci: 19.80 to 71.03; p < 0.001). as a result of the covid-19 pandemic and consequent lockdown, migrants and, more generally, individuals in poor socioeconomic conditions can experience a greater negative impact than the general population. the first key factor is the psychopathological reaction to the situation (i.e. the covid-19 pandemic). indeed, in these subgroups of the population, difficult living conditions, together with previous experience of severe traumas and mental distress, are expected to increase levels of anxiety and consequently negatively impact mental health. 10, 12, 24 to the authors' knowledge, this feared effect on the mental health of migrants, refugees and homeless people has not yet been quantified, so further research on this issue is needed. the second key factor is the difficulty in access to treatment if mental conditions are deteriorating, as expected. theoretically, lockdown measures should not hamper the ability of receiving medical care, 2 and the italian national mental health service has modified its organisation and procedures to enable treatment of emergent needs. 25 however, factors such as insufficient information, 10 total quarantine in reception centres that report covid-19 cases among their asylum seekers and other barriers to the access to mental health services 26 can limit the possibility of receiving adequate psychiatric help. to the authors' knowledge, this study is the first evaluation of the effect of the covid-19 lockdown measures on the accessibility and follow-up use of public mental health services for immigrants and individuals with poor socio-economic conditions. it should be noted that, in some outpatient services, after the start of lockdown measures, appointments for psychiatric interviews were not available or were restricted only to emergencies. however, even during this period, the psychiatric service in the present study continued regular interviews on a free-access model; accordingly, the effects registered here are not due to changes in the organisation of the outpatient service but due to possible external factors (e.g. information about available facilities, movement restrictions). this study shows a relevant reduction in the total number of patients who visited the mental health outpatient service after the lockdown, with the risk that new mental health needs are neglected in a period when they are expected to increase. moreover, a significant reduction in the number of follow-up visits has also been demonstrated, which has potential negative effects on therapeutic compliance and increases the risk of relapse. this study is limited by that fact that it is a retrospective singlecentre study, so the findings cannot be directly generalised to other services. however, it has been reported that mental health services such as the one in this study, specifically oriented to migrants and individuals in poor socio-economic conditions, usually perform better than general mental health services in terms of both accessibility and patient satisfaction. 20, 21 consequently, it is highly probable that the situation described in this study can be an indication of a more general issue for the entire national health service. owing to the relevance of these problems of accessibility and continuity of treatment for the mental health of the most vulnerable individuals in the population, proactive strategies should be implemented to monitor emergent needs and provide territorial assistance, with online assistance where feasible. 27, 28 author statements this study has been performed in accordance with the helsinki declaration. the research design and ethical considerations were reviewed and approved by the italian national institute for health, migration and poverty review board. coronavirus: la situazione in italia [coronavirus, the situation in italy ulteriori disposizioni attuative del decreto-legge 23 febbraio 2020, n. 6, recante misure urgenti in materia di contenimento e gestione dell'emergenza epidemiologica da covid-19 covid-19 pandemia and public and global mental health from the perspective of global health security mental health during and after the covid-19 emergency in italy psychological symptoms of ordinary chinese citizens based on scl-90 during the level i emergency response to covid-19 the differential psychological distress of populations affected by the covid-19 pandemic socioeconomic gradient in health and the covid-19 outbreak combating covid-19: health equity matters people experiencing homelessness: their potential exposure to covid-19 the neglected health of international migrant workers in the covid-19 epidemic undocumented u.s. immigrants and covid-19 refugee and migrant health in the covid-19 response covid-19 will not leave behind refugees and migrants assurer les soins aux patients souffrant de troubles psychiques en france pendant l' epid emie a sars-cov-2. [ensuring mental health care during the sars-cov-2 epidemic in france: a narrative review percentage of patients who visited in february with at least one follow-up visit in march in the years patients with mental health disorders in the covid-19 epidemic covid-19: immense necessity and challenges in meeting the needs of minorities, especially asylum seekers and undocumented migrants conversione in legge, con modificazioni, del decreto legge 4 ottobre 2018, n. 113, recante disposizioni urgenti in materia di protezione internazionale e immigrazione, sicurezza pubblica, (omissis) post-migration living difficulties as a significant risk factor for ptsd in immigrants: a primary care study treated incidence of psychotic disorders in the multinational eu-gei study the provision of mental health services to immigrants and refugees in italy: the barriers and facilitating factors experienced by mental health workers indagine sui bisogni sanitari e di salute mentale dei rifugiati e richiedenti asilo ospiti dei centri di accoglienza nel territorio di roma. [inquiry about the sanitary and mental health needs of refugees and asylum seekers hosted in the reception centers of the territory of rome a crisis within the crisis: the mental health situation of refugees in the world during the 2019 coronavirus (2019-ncov) outbreak generalized anxiety disorder, depressive symptoms and sleep quality during covid-19 outbreak in china: a web-based cross-sectional survey homeless mentally ill people and covid-19 pandemic: the two-way sword for lmics mental health services in lombardy during covid-19 outbreak what are the barriers to access to mental healthcare and the primary needs of asylum seekers? a survey of mental health caregivers and primary care workers mobilization of telepsychiatry in response to covid-19-moving toward 21st century access to care online mental health services in china during the covid-19 outbreak none declared. none declared. key: cord-339822-cewpqddk authors: plotkin, bruce title: human rights and other provisions in the revised international health regulations (2005) date: 2007-09-27 journal: public health doi: 10.1016/j.puhe.2007.08.001 sha: doc_id: 339822 cord_uid: cewpqddk in may 2005, the world health assembly of the world health organization (who) adopted the revised international health regulations (2005), which have now entered into force for who member states across the globe. these regulations contain a broad range of binding provisions to address the risks of international disease spread in international travel, trade and transportation. important elements include multiple provisions, whether denominated in terms of human rights or other terminology, that are protective of interests of individuals who may be subject to public health measures in this international context. with the vast (and increasing) numbers of persons undertaking international voyages and the global coverage of these revised regulations, they are an important development in this area. this article describes a number of these key provisions and some of the related issues they present. for several decades, the world health organization's (who) international health regulations ('ihr' or 'regulations'), 1 formerly the who international sanitary regulations, were the primary global legal agreement against the international spread of infectious disease. while important, these prior regulations were quite limited in scope, dealing primarily with three to six infectious diseases, but none of the new, emerging or reemerging diseases (including those that had become drug resistant), or other critical longstanding diseases. by the 1990s, the version of the regulations adopted in 1969 had also become outdated in terms of policy and technical approach. 2 in the intervening decades, international travel and other traffic flows have increased sharply, and with them the opportunities for globalized disease spread. 3 to address these concerns, the world health assembly in 1995 4 commenced the process of revising the regulations to update them in policy and technical aspects, and to broaden their scope to address the full range of internationally transmissible disease risks, whether currently known or as yet unknown. these newly revised ihr (2005) were adopted by the world health assembly on 23 may 2005 5 and are now in force and legally binding for 191 of who's 193 member states; the last two member states are expected to become parties in august 2007 and in early 2008. one of the important areas of innovation in the ihr (2005) involves their inclusion of explicit protections of the interests of individuals within the scope of this agreement, primarily with reference to international 'travellers' (defined in the regulations as a 'person undertaking an international voyage') in a range of circumstances. this subject was one of the key parts of the negotiations of the who member states resulting in the revised regulations negotiations. the importance of these protections for national delegations in the negotiations is underlined by the placement of human rights as the first 'principle' articulated in paragraph 1 of article 3 of the regulations, requiring that the 'implementation of these regulations shall be with full respect for the dignity, human rights and fundamental freedoms of persons'. the global agreement to the revised regulations reflects a broad consensus in a binding legal instrument, including agreement on the provisions that are the subject of this article. the broad scope of the ihr (2005) in terms of their global geographic coverage, the important subjects they cover, their coverage of an expansive array of diseases and public health events, and the escalating numbers of international travellers worldwide contributes to the potential overall impact of these new legal provisions. at the same time, the ihr (2005) are only now entering into force, and the practices under, and interpretations of, the new regulations by states parties, who and other international actors are in the process of being established. as with many complex, freshly negotiated international legal instruments, the precise meaning or import of some provisions, and how they may relate to other articles in the regulations or other relevant international instruments in particular circumstances, may not always be readily apparent. this article presents a summary description of some of the key provisions and some of the issues that they raise. diseases, public health risks and events the ihr (2005) completely revise the prior 1969 regulations, with extensive new mandates and obligations for the states parties and for who. article 2 provides that their overall 'purpose and scope are to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade'. more specifically, the fundamental term 'disease' is defined as 'an illness or medical condition, irrespective of origin or source that presents or could present significant harm to humans'. as indicated in table 1 , the definitions of other key terms, such as 'event' and 'public health risk', are similarly broad. in terms of notifying diseases and events to who, for example, states parties are obligated to notify any public health 'event that may constitute a public health emergency of international concern' based on specified criteria, as well as other international public health risks. with regard to travellers, the ihr (2005) also regulate key public health measures that states parties may implement against disease risks in international travel (persons), as well as in international transport (ships, aircraft, other conveyances) and trade (goods, cargo). under the 1969 regulations, protections for travellers were often stated in the context of limitations on health measures that countries could implement against the three 'quarantinable' diseases (cholera, plague and yellow fever) covered under the regulations since 1981. for example, the prior regulations disease: 'an illness or medical condition, irrespective of origin or source, that presents or could present significant harm to humans'; event: 'a manifestation of disease or an occurrence that creates a potential for disease'; and public health risk: 'a likelihood of an event that may affect adversely the health of human populations, with an emphasis on one which may spread internationally or may present a serious and direct danger'. prohibited vaccination against plague as a condition of entry to a state, as well as rectal swabbing in the context of cholera. under the revised ihr (2005), with the expanded coverage of disease, the scope of regulation of health measures applicable to international travellers is also broadened in light of the many covered diseases that may be spread by persons on an international voyage. some of the other, more prominent current diseases of concern include: polio; tuberculosis (particularly drugresistant tuberculosis); influenza; ebola and marburg viral haemorrhagic fevers; meningococcal disease; west nile fever; and severe acute respiratory syndrome. the breadth of coverage of the ihr (2005) and the vast numbers of travellers undertaking voyages that cross international borders every year guarantee that its provisions will be applicable to large numbers of individuals. in 2005, according to the world tourism organization, there were more than 800 million international tourist arrivals. overall, the numbers of travellers (international tourist arrivals) to each region were substantial: africa, 36.7 million; americas, 133.5 million; asia and pacific, 155.4 million; europe, 441.5 million; and the middle east, 39.1 million. the areas of greatest growth in international tourist arrivals were africa (+9%), asia and pacific (+8%), and the middle east (+8%). 6 health measures applicable to travellers as noted, the ihr (2005) provide for a range of health measures potentially applicable to international travellers depending upon the particular circumstances and requirements. specific examples include: physical/medical examinations; health document requirements (including proof of vaccination or prophylaxis); certain types of itinerary and contact information; vaccination/prophylaxis; inspection of baggage; placing persons under public health observation; and the possibility of quarantine or isolation. additional provisions address when international travellers may be denied entry to a country on public health grounds. in the context of an event that has been determined by the director-general of who to be a public health emergency of international concern, article 15 provides that the director-general will also issue specific temporary recommendations under the ihr (2005) of appropriate health measures to prevent or reduce spread of the disease and interference with international traffic. in article 18, the regulations contain a non-exclusive list of 13 potentially relevant recommendations applicable to persons as appropriate to the circumstances (as well as others for baggage, cargo, containers and conveyances), from advice that no specific measures are appropriate, to advice that states require vaccination or prophylaxis, to recommending implementation of contact tracing or potential exit screening or other restrictions on persons from affected areas. for the purposes of this article, a number of these provisions can be divided into several categories (see table 2 ). as noted above, the central principle on this issue mandates that the ihr (2005) are to be implemented 'with full respect for the dignity, human rights and fundamental freedoms of persons'. in contrast to most other related provisions, which refer to (international) 'travellers', this principle expressly refers to 'persons', a potentially broader category. although not as explicit on this issue, another principle mandates that implementation of the regulations is also to 'be guided by the charter of the united nations and the constitution of the world health organization', which can also provide guidance on evaluating application of ihr (2005) provisions to travellers, whether denominated as 'human rights' or otherwise. although generalized, these principles provide guidance on interpreting and applying the other, more specific articles to travellers. a number of provisions expressly provide for the prior informed consent of travellers (with certain exceptions) before being subject to medical examination, vaccination, prophylaxis or other health measures under the regulations. while the basic focus of each of these provisions is clear, the requirements are additionally to be 'in accordance with the law and international obligations of the state party'. as elsewhere in the ihr (2005) generally, this 'law' (presumably including applicable national law) and these 'international obligations' are not further specified. although not involving prior informed consent, the same article requires that medical examinations and procedures, as well as vaccination or other prophylaxis, be carried out in accordance with established national or international safety guidelines or standards. potentially, some of the most important of these protections are in article 32. in language similar to the principle on human rights and fundamental freedoms noted above, the article requires in general that states parties 'treat travellers with respect for their dignity, human rights and fundamental freedoms and minimize any discomfort or distress' associated with implementation of health measures under the regulations, including by taking into consideration their gender, sociocultural, ethnic and religious concerns. in more concrete terms, the article specifically requires that states parties minimize this discomfort or distress by 'providing or arranging for adequate food and water, appropriate accommodation and clothing, protection for baggagey, appropriate medical treatment, means of necessary communicationy and other appropriate assistance for travellers who are quarantined, isolated or subject to medical examinations or other procedures for public health purposes'. this provision may be particularly relevant in the context of a major outbreak or epidemic that involves quarantining or isolating substantial numbers of international travellers. from a financial perspective, additional important issues for international travellers concern whether they will be financially responsible for any health measures applied to them that are implemented for public health purposes. this was another intensely debated set of issues during the negotiations. in general, the ihr (2005) requirements distinguish between charges for vaccinations or prophylaxis provided on arrival (which are not generally prohibited from being charged to the traveller under the regulations unless the charges were not published at least 10 days earlier) and certain other measures that may generally not be charged to the traveller, such as medical examinations under the regulations or supplemental examinations required to ascertain the traveller's health status, appropriate isolation or quarantine requirements, any certificates issued to a traveller documenting the measures applied, health measures applied to baggage, and vaccination or other prophylaxis requirements that were not published in advance as required. in addition, where such charges are permitted, each state party must have a single tariff for them, they may not exceed the actual cost of the service rendered, and the charge must not discriminate based upon nationality, domicile or residence of the traveller concerned. however, these restrictions on charges do not apply to travellers seeking temporary or permanent residence or to charges for health measures that are not implemented primarily for a public health purpose. in addition to these provisions, many others are also relevant in this context. a further set of issues concerns identification of those who are subject to these provisions in the regulations. as noted, under the ihr (2005), 'travellers' are, by definition, international (i.e. 'undertaking an international voyage'). most of the above provisions, but not all of them (the general 'principle' in article 3.1 refers to 'persons'), refer to treatment of 'travellers'. although it may not turn out to be an issue in 'real life', there may be questions about the status of particular individuals (see definition of 'international voyage' applicable to travellers). theoretically at least, a related set of issues may arise in events involving both (international) travellers, to whom the ihr (2005) would generally apply, as well as local nationals, perhaps those in or near a port or airport. separately, it should be noted that some of these provisions exclude travellers who are seeking temporary or permanent residence from the otherwise broader category of travellers covered under the regulations, as in article 31.1 (concerning health-related entry requirements for travellers) and article 35 (concerning requirements for health documents in international travel). basic issues for resolution will also involve the underlying relationship within or between various relevant provisions in the regulations themselves. some have both types of exceptions; article 30 (restrictions on health-based requirements for entry), for example, includes both specifically stated exceptions and a cross-reference to measures permitted under other articles. also, the breadth of some of these exceptions is not always clear. for scholars and other interested persons, it is also worth noting that the last three drafts of the proposed text of the revised regulations, prior to the final adopted text, are available on the who international health regulations website, with information on the evolution of these provisions in the course of the revision process and negotiations. [9] [10] [11] designing an international policy and legal framework for the control of emerging infectious diseases: first steps world health organization. world health report 1996: fighting disease, fostering development world health assembly. revision and updating of the international health regulations world health assembly. revision of the international health regulations tourism highlights 2006 edition: overview international tourism united nations economic and social council, un sub-commission on prevention and protection of minorities. siricusa principles on the limitation & derogation of provisions in the international covenant on civil and political rights world health organization. international health regulations: working paper for regional consultations review and approval of proposed amendments to the international health regulations: draft revision. geneva: who review and approval of proposed amendments to the international health regulations: proposal by the chair. geneva: who this paper was presented at the president session of the american public health association conference, boston, november 2006.disclaimerthe author is a staff member of the world health organization. the author alone is responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the world health organization. key: cord-252218-jrgl0x06 authors: heerfordt, c.; heerfordt, i. m. title: has there been an increased interest in smoking cessation during the first months of the covid-19 pandemic? a google trends study date: 2020-04-20 journal: public health doi: 10.1016/j.puhe.2020.04.012 sha: doc_id: 252218 cord_uid: jrgl0x06 [figure: see text] the city of wuhan in china became the centre of a pneumonia outbreak of unknown cause in december 2019. on 7 january 2020, a novel coronavirus, severe acute respiratory syndrome coronavirus 2, was isolated from the patients with pneumonia in wuhan. 1 the official name of the disease is coronavirus disease (covid-19) and common symptoms include fever, coughing and shortness of breath. most cases resolve spontaneously; however, some develop severe complications, including pulmonary oedema, severe pneumonia and acute respiratory distress syndrome. 2,3 on 10 april 2020, the total number of covid-19 cases reported worldwide was 1,563,857, including 95,044 deaths. the majority of deaths have been reported in italy (18,281), the us (16,690), spain (15,238), france (12,210) and the uk (7978). 11 unfortunately, the covid-19 pandemic is continuing to spread and there is an urgent need for measures to limit the harmfull effects of the virus. smokers are known to be more vulnerable to infectious diseases, including influenza and middle east respiratory syndrome-related coronavirus. 4, 5 smoking has also been found to be associated with negative progression and adverse outcomes for covid-19. 6 the current evidence comes from five chinese studies, which find smokers who are hospitalised with covid-19 have 2-9 times greater risk of serious covid-19 complications compared with non-smokers. 6 in the short term, smoking cessation leads to reduced respiratory symptoms and brochial hyperresponsiveness, and prevents unnecessary decline in lung function. 7 the covid-19 pandemic is having a major impact on the whole world and has gained huge public awareness. globally, millions of people search for health-related information online, which makes web search queries on google trends a valuable source of information on collective health trends. 8 the number of google searches on 'covid' and 'hand sanitizer' rose sharply in late february and march (see fig. 1 ). 9 this study aims to investigate the interest in quitting smoking during the first months of the covid-19 pandemic. as the interest in 'covid' and 'hand sanitizer' increaded rapidly in late february, we have examined the interest in smoking cessation from january to april 2020. data were collected from google trends (trends.google.com), which provides information on how many 'hits' different words had on a given day on google. this can be used as a measurement of public interest over time. the highest interest on a search query is quantified as 100 relative search volume (rsv), decreasing to 0 rsv indicating no interest. 8 we retrieved worldwide public query data for the following terms: 'quit smoking', 'smoking cessation', 'help quit smoking' and 'nicotine gum' between 9 january 2020 and 6 april 2020. we investigated whether there was an increased interest in quitting smoking in late febrary and march compared with the preceeding weeks. the google trends data for web search queries for the terms 'smoking cessation' and 'nicotine gum' from 9 january 2020 to 6 april 2020 are shown in fig. 1 . all search terms show stable interest over the selected time period; there was no tendency for increased interest in any of the key terms. outputs for the terms 'help quit smoking' and 'how do i quit smoking' are not shown in fig 1, but are available on trends.google.com and show the same stable trend. previous google trends studies have found increased numbers of seaches relating to smoking cessation in association with the launch of national smoking cessation programmes and changes in tobacco control policies. 10 we found no increase in the number of searches for smoking cessation on google in the first months of the covid-19 pandemic. this could indicate that there has been no actual increase in smoking cessation during the pandemic; however, this may change over the coming weeks and months, as the covid-19 pandemic is likely far from over. we hope that public health messages will focus on smoking cessation to improve lung health during this continued pandemic. smoking cessation campaigns are important as smokers are more vulnable to viral infections and lung diseases, and appear to have worse outcomes when hospitalised with covid-19 than non-smokers. 4-6 the novel coronavirus originating in wuhan, china: challenges for global health governance epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study clinical characteristics of 138 hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china mers transmission and risk factors: a systematic review cigarette smoking and infection covid-19 and smoking: a systematic review of the evidence the impact of smoking cessation on respiratory symptoms, lung function, airway hyperresponsiveness and inflammation google trends: a web-based tool for real-time surveillance of disease outbreaks more effective strategies are required to strengthen public awareness of covid-19: evidence from google trends. ssrn electron j [internet associations of the stoptober smoking cessation program with information seeking for smoking cessation: a google trends study. drug alcohol depend european centre for disease control and prevention. situation update worldwide, as of 10 key: cord-286290-85l99l13 authors: goddard, n.l.; delpech, v.c.; watson, j.m.; regan, m.; nicoll, a. title: lessons learned from sars: the experience of the health protection agency, england date: 2005-11-16 journal: public health doi: 10.1016/j.puhe.2005.10.003 sha: doc_id: 286290 cord_uid: 85l99l13 the united kingdom was assessed as a low risk country throughout the 2003 global sars outbreaks. despite this, 368 reports of potential sars cases were made to the health protection agency (hpa) between march and july 2003. the public health actions undertaken in response to these reports, the establishment of reporting mechanisms and the development of guidance documents were substantial. lessons learned from mounting a uk response to sars included: the importance of international collaboration; formation of a uk-wide, multidisciplinary task force; flexible case reporting mechanisms; integration of surveillance and laboratory data; generation of prompt and web-accessible guidance and advice; availability of surge capacity; and contingency planning. lessons learned are being incorporated into the hpa's preparedness to prevent and control future newly emerging infectious disease threats. on 12 march 2003, the world health organisation (who) issued an unprecedented global alert regarding outbreaks of a severe pneumonia, subsequently characterised as severe acute respiratory syndrome (sars), caused by the sars-coronavirus. sars was the first new severe disease transmissible from person-to-person to emerge in the 21st century. during the global outbreak, a total of 8096 probable cases of sars and 774 deaths were reported from 29 countries and areas. 1 china (mainland), taiwan and hong kong special administrative region (sar) experienced substantial outbreaks, although considerable numbers of cases were also reported from canada, singapore and viet nam. 1 the united kingdom (uk) was assessed to be at low risk from sars throughout the outbreak. 2 between march and july 2003, 368 reports of suspected sars cases were made to the health protection agency (hpa). 2 of these, only nine were initially classified as probable sars cases, and only one patient, a 23-year-old male, was positive for sars coronavirus (co-v) on pcr testing and later showed evidence of seroconversion. nonetheless, the volume of work within the uk in response to sars was far greater than suggested by the number of potential sars cases reported to the hpa. in this paper, we summarise key elements to the uk public health response and lessons learnt from sars. key components of the uk response to sars collaboration at an international level was fundamental to the prompt recognition of sars cases throughout the global outbreak. in response to requests for assistance from who and its partner, the global outbreak alert and response network (goarn), field teams were sent to locations in china, hong kong sar, taiwan, singapore and vietnam to assist with the investigation and management of outbreaks. given the unprecedented speed of electronic communication, continuous international liaison through secured web-sites, email and teleconferencing was essential to ensure that international and national public health agencies disseminated accurate and consistent information throughout the outbreaks. the global response to sars provided new opportunities for the uk to collaborate with who (geneva and western pacific region), a number of public health organisations in south east asia, as well as national public health centres such as the centers for disease control and prevention in the usa and health canada. the hpa has subsequently worked with colleagues in hong kong to establish a centre for health protection (chp) in light of recommendations of the hong kong sars expert committee report. 3 there was also collaboration with the european commission (ec), however, this was constrained by the lack of central capacity and experience in the commission. it is intended that the new european centre for communicable diseases will address this. 4 despite good levels of international collaboration, some aspects, such as global case reporting to who were problematic. some countries did not contribute to the global dataset that was established to inform and refine evidence-based control measures, and there has been no systematic review of super-spreading events that occurred during the outbreak. the revision of the international health regulations (ihr) proposed by who in january 2004 provides a mechanism for strengthening early and coordinated responses to outbreaks of international public health concern. 5 staff throughout the hpa and the uk devolved administrations undertook secondments abroad with who geneva and who western pacific region, which provided useful contact points for information and discussion. the hpa enteric, respiratory and neurological virus laboratory (ernvl), contributed staff to the multi-national team that identified the causative agent of sars as a coronavirus, sars-cov, within 1 month of the who global alert being issued. the ernvl has had subsequent involvement in the development of diagnostic tests for sars-cov. the hpa also contributed to the international surveillance response through the development of guidelines, research priorities and modelling activities. participation in teleconferences with who geneva and the ec provided prompt access to information as it became available, and was beneficial to the hpa in informing and developing its response. more detailed epidemiology, laboratory and other working groups were also convened by who focusing on knowledge and lessons learnt from countries experiencing substantial outbreaks. the hpa played a major role in the international cohort study of the outbreak that occurred in a large hong kong hotel believed to have been pivotal to the initial international spread of sars. 6 one hundred and thirty-six uk residents who stayed at this hotel during the early stage of the outbreak were followed up. the convalescent sera of two patients tested positive for sars-cov antibodies. the crucial trigger for the uk response were the global alerts issued by who to all its goarn partners, as well as more broadly. for the uk, the first substantive incident came at 04:00 on saturday 15 march 2003 concerning the need to intercept a flight coming to europe with a sars patient on board. this event led to the formation of the uk sars taskforce, the taskforce, chaired by the hpa, had representatives from the health departments, national health service (nhs), and national surveillance centres in england and the devolved administrations. it regularly convened by teleconference throughout the outbreak period. the invited participants included virologists, epidemiologists and specialist advisors on clinical infectious disease and infection control, as well as hpa communications staff. the objectives of the task force included: † oversee and coordinate the surveillance of potential sars cases † provide guidance on the management of cases and contacts † consider and recommend broader public health control measures † provide timely information to professionals and the public other specialist groups, such as the independent sars expert advisory group (eag) were set-up to advise the taskforce, the uk health departments and others on research and strategic issues arising. the uk task force was an effective mechanism for rapid exchange of information and expertise, and attaining consensus on operational issues and strategic response to sars. a similar model has been employed during 2004 to address issues related to the outbreak of avian influenza in south east asia. discussions are underway to adopt the process more formally as a mechanism for the five nations (england, scotland, wales, northern ireland and ireland) to respond in a co-ordinated manner to future public health threats. the centre for infections (cfi) co-ordinated surveillance of potential cases of sars including the development and review of case definitions, establishing reporting mechanisms, and dissemination of data and information. 7 the surveillance relied on passive reporting of potential cases by hospital and general practice physicians directly to the cfi by email, fax and telephone. patients were classified according to hpa case definitions by cfi staff and the reporting clinician. surveillance arrangements were revised during the outbreak to encourage initial alerting to hpa regional offices and ensure that local public health authorities were aware of the potential cases. whilst central reporting allowed for prompt reporting and consistent classification of potential sars cases, this mechanism of reporting would have been unsustainable in the event of a substantial uk outbreak when more responsibility would be devolved to regional staff, and cfi would concentrate on producing aggregate summaries. uk case definitions were based on the who definitions, but were adapted to reflect the low level of risk in the uk. in order to prioritise the public health measures and laboratory investigation, the suspect case definition was aimed at differentiating cases epidemiologically linked to a known probable sars case from an affected area ('suspect-high'), from those who had travelled to an affected area but had no contact with a probable case ('suspect-low'). 2 priority investigation was given to cases assessed as probable, or suspecthigh. follow-up of clinical status was requested on all suspect and probable cases at 48 h, 10 days and weekly until recovery. samples were collected for acute and convalescent (o21 days) sera for sars-cov antibodies. follow-up generated substantial workload at national, regional and local levels. given the common and non-specific nature of initial clinical symptoms of sars and the lack of diagnostic tests, the recording of a detailed epidemiological history of relevant travel or contact history was key to identifying potential sars cases. early detection and reporting of potential cases was subsequently found to be fundamental in limiting secondary spread in countries that experienced substantial outbreaks during the first sars outbreak period. 8, 9 database development data collection and management of epidemiological and virological information undertaken by cfi required modification during the course of the outbreak. these systems, while appropriate for the low case load experienced, would have been limited in the event of an outbreak within the uk. most importantly, the data were entered centrally and the system did not have the capacity for local staff to record and manage case reports or their contacts. experience from toronto suggests that for each case of sars, health authorities should expect to quarantine up to 100 contacts, and to investigate eight possible cases. 10 data systems must have the capacity to report and track both cases and contacts. furthermore, an integrated virological and epidemiological database would have reduced the considerable time cfi and regional offices spent liaising with the laboratories to ensure that appropriate specimens had been submitted and that the laboratory could efficiently prioritise testing of specimens from cases by case definition the challenge remains for the development of a real-time national database for an emerging disease which will facilitate all stages of reporting, link epidemiological, clinical, laboratory and contact tracing information and have the flexibility to evolve as information on the clinical presentation, potential risk factors, and implications for the follow-up of close contacts becomes available. provision of guidance and advice for healthcare professionals and the public formed an important component of the uk response to sars during the outbreak period. the hpa website was the predominant mechanism for making guidance documents available in a timely manner. 11 whilst the information and advice was generally well received, there are inherent difficulties in using a web site for disseminating information that is updated during an evolving situation. users are required to undertake a proactive approach and check the website regularly for updates, which might prove particularly difficult in healthcare settings, where there is not regular access to the internet within the workplace, or where there are regular changes of staff due to shift working. furthermore, the constantly evolving situation highlighted the requirement to keep archives of web pages to create an audit trail of issued travel advisories and guidance documents. there are also difficulties in maintaining an upto-date web resource when regular updates are being published on other external sites. for example, in england, travel guidance for the public was published by a number of different organisations; the hpa, the national travel health network and centre (nathnac), the department of health and the foreign and commonwealth office (fco), as well by international organisations such as the who. close collaboration was essential to ensure consistent messages were being conveyed. in addition to information on the website, telephone queries from health care professionals and the media resulted in considerable demands on hpa staff time. during the peak period, approximately sixty telephone calls per day were received by the cfi which required public health advice; many more calls were made to the press office, and to regional and local centres. management of the response process was challenging in ensuring that staffing was adequate and that all team members were kept up to date with current information. regular team meetings at the beginning and end of each day were used to brief key staff and allocate tasks. day-to-day operational response to the evolving outbreak involved epidemiologists who undertook strategic planning and response tasks in addition to their normal responsibilities; administrative support was largely provided on an ad hoc basis, which resulted in some lack of continuity. particular areas of shortfall during the outbreak period included continuity of staff, especially experienced medical and non-medical epidemiologists, and lack of a centralised operations centre to facilitate sharing of epidemiological and virological information during the investigation of potential cases. these issues were addressed in the short term by utilising experienced staff undergoing higher medical training (e.g. specialist registrars), and by seconding a medical epidemiologist to the cfi's respiratory department. cfi has responded to national and international infectious disease incidents for many years, primarily through the redeployment of staff working within other areas of the organisation, as outlined in its major outbreak and incident plan. the hpa strategic emergency response plan also makes provision to redeploy staff and operate shift working to provide round the clock cover. 12 staff redeployment is likely to become easier to achieve politically as the level of escalation increases and the pressures become more widely acknowledged both within and outwith the organisation. there is currently limited surge capacity to respond to an incident such as sars that requires a large team over a prolonged period of time to prevent fatigue and potential burn-out of key staff involved in the response. future re-emergence of sars, or any other newly emergent infection would lead to the prompt escalation of surveillance activities, with corresponding demands on staffing and resources. the emergence of sars illustrated the need to strike a balance between mounting a multi-agency outbreak response and ensuring nhs and partner organisations maintain continuity of key services. similarities noted with the planning requirements for an influenza pandemic and those of a phased escalation of response to sars were recognised, developed and exercised. 13 this set out specified actions at local, regional and national levels for the hpa at each level of escalation dependant upon the extent of disease transmission abroad and in the uk. the hpa sars contingency plan also complemented activities specified by the department of health for the nhs. 14 implementation of the phased contingency plan response raised a number of issues regarding nhs acute and primary care trust (pct) preparedness. the most notable of these concerned the purchase and supply of personal protective equipment (ppe) consumable items such as masks, gowns and respirators, as clear lines of responsibility were difficult to identify. implementation of infection control guidelines, including appropriate staff training were also highlighted as areas of concern. conclusions sars demonstrated the speed with which a readily transmissible disease could spread around the world during the 21st century, resulting in considerable social, economic and political impact in some countries. international collaboration was fundamental to the rapid identification of the causative agent, and also to the containment of sars. despite the uk being assessed as low risk from sars throughout the first global outbreak the public health response was substantial and provided many challenges. it has provided the opportunity to test many mechanisms already in place so that they will be further strengthened for the future. it has also prompted the drafting of detailed plans to respond to the re-emergence of sars, or any other newly emergent infectious disease threat based on the lessons learned. both national and international collaboration proved vital in sharing timely information to inform the uk public health response. the use of electronic communication and teleconferencing was particularly effective in eliciting prompt responses from organisations and facilitating communication between expert groups (e.g. infection control and infectious disease experts) without the need to meet face-to face frequently. the model has been utilised subsequently for assessing the threat to the uk of avian influenza and is due to be adopted more formally as a component of the uk response to future threats. data from countries with substantial outbreaks demonstrated that basic public health and infection control measures such as contact tracing, infection control procedures, quarantine and voluntary home isolation were effective in controlling the outbreaks in the absence of a rapid diagnostic test, a vaccine or effective treatment. the outbreak highlighted that all levels of the healthcare system in the uk need to be prepared to respond; especially as the level of threat remains ever present in light of the continuing widespread avian influenza outbreaks in south east asia, and the potential emergence of a strain of the influenza virus with pandemic potential. 1. the prompt sharing of epidemiological and virological data through international collaboration was fundamental to understanding this newly emergent infection and informing the uk public health response, and underpinned an early recognition of the importance of 'real time' clinical epidemiology and the need for rapid liaison between clinicians, virologists and public health colleagues. 2. the formation of a national (uk) sars task force contributed to consistent approaches to professional and public information and advice across the uk, particularly on the use of case definitions and management algorithms. 3. flexible case reporting mechanisms need to be implemented at central, regional and local level during an evolving outbreak to inform appropriate public health measures. 4. sars demonstrated the need for an integrated system of surveillance information, laboratory data and local public health response data, including contract tracing, to enable coordination and strengthening of the response across the uk. 5. dissemination of timely guidance and advice during an evolving outbreak is crucial and requires close collaboration of key organisations to ensure regular and consistent situation updates. 6. a prolonged level of response to an incident such as sars requires adequate surge capacity. this is being addressed through the development of an hpa strategic emergency response, and contingency plans. 7. the rapidly evolving understanding of the diagnosis, clinical management and transmission of sars underlined the importance of having explicit planning assumptions upon which critical control points of escalation of response within contingency plans were based. the ability to respond to any large outbreak in the uk requires substantial surge capacity to develop guidelines, establish robust reporting mechanisms, follow-up large numbers of contacts, respond to enquiries from health care professionals and the public, and to undertake risk assessment. the development of comprehensive contingency plans, clearly outlining the roles and responsibilities of key players has been undertaken at all levels within the uk, from the health departments through to nhs acute and primary care trusts in the light of sars. national surveillance, such as that undertaken by the hpa, is essential for monitoring the spread of an infection, however, the vigilance of primary health care professions is crucial in the early warning response. the uk was spared by not experiencing a substantial outbreak of sars. nonetheless, valuable lessons have been learnt which will ensure that it is better prepared in the event of future public health threats. summary of probable sars cases with onset of illness from 1 surveillance of severe acute respiratory syndrome (sars) in a low-risk setting during the first global outbreaks. uk: poster cfi, health protection agency roles and functions of a european union public health centre for communicable diseases and other threats to health world health organisation. ihr revision proposals update: outbreak of severe acute respiratory syndrome-worldwide sars: uk public health responsepast, present and future sars in health care facilities, toronto and taiwan sars transmission and hospital containment public health measures to control the spread of the severe acute respiratory syndrome during the outbreak in toronto health protection agency. the hpa strategic emergency response plan. london: hpa interim contingency plan for severe acute respiratory syndrome (sars) this paper was drafted with the support of the uk sars taskforce, whose comments were greatly appreciated. the uk sars taskforce membership includes representatives of: key: cord-270278-d61n3v90 authors: choi, s.m.y.; lam, p. y. title: enhancing legal preparedness for the prevention and control of infectious diseases: experience from severe acute respiratory syndrome in hong kong date: 2009-03-31 journal: public health doi: 10.1016/j.puhe.2009.01.004 sha: doc_id: 270278 cord_uid: d61n3v90 summary the use of legislation as a health protection tool forms an important and distinct aspect in the arena of public health. a review of hong kong's infectious disease legislation was conducted with a view to updating the legal framework for the prevention of infectious diseases, in order to strengthen the capacity of law to support strategy in the control of infectious diseases. this article shares hong kong's experience in reforming its public health legislation to: (1) update terminology and re-organize provisions in accordance with modern public health disease control principles and control mechanisms for disease; (2) enhance responsiveness for better preparedness and flexibility in handling emergent infections; (3) ensure appropriate checks and balances to coercive powers; and (4) introduce emergency powers for the handling of public health emergencies. public health law consists of the legal powers and duties of the state to assure the conditions for people to be healthy, and the limits on that power to constrain the individual autonomy, privacy, liberty and proprietary interests for the protection or promotion of community health. 1 infectious disease law is a branch of public health law. the use of legislation as a health protection tool forms an important and distinct aspect in the arena of public health. in the wake of the series of anthrax attacks occurring in the usa after 11 september 2001 and the outbreak of severe acute respiratory syndrome (sars) in 2003, the global community started a process to strengthen public health infrastructures. as part of their legal preparedness in response to bioterrorism or naturally occurring disease outbreaks, many western countries have conducted exercises to review and update their infectious disease laws. in the east, both china and macao special administrative region reformed their infectious disease legislation in 2004. singapore updated its infectious disease legislation in early 2008. the situation in hong kong is no exception to that in the rest of the world. after the sars outbreak in 2003, a sars expert committee was commissioned by the chief executive of hong kong special administrative region to conduct a review of the capacity of the hong kong healthcare system to better prepare for any future outbreak. during the outbreak of sars in 2003, the quarantine and prevention of disease ordinance 2 (qpdo) of the laws of hong kong was the legal tool that provided the legal framework for the prevention and control of infectious diseases of public health importance in hong kong. as part of the review, the legislative framework for the prevention and control of infectious diseases was examined. the committee concluded that the legislation had not kept pace with modern developments, such as the increase in international travel, and recommended that the adequacy of the legislation should be reviewed. 3 on the advice of the sars expert committee, a comprehensive review of hong kong's infectious disease legislation was conducted with a view to updating the legal framework for the prevention of infectious diseases. this article shares hong kong's experience in reforming its public health legislation, leading to the passing of the prevention and control of disease ordinance 4 in order to strengthen the capacity of law to support strategy in the control of infectious diseases. the qpdo was first enacted in 1936 as part of a major re-organization of the infrastructure of medical and sanitary services and the related legislative framework. before the enactment of the qpdo, provisions relevant to prevention and control of infectious diseases were spread across two ordinances, namely the public health ordinance 1887 (later amended and renamed the public health and buildings ordinance 1903) and the merchant shipping ordinance 1899. the public health ordinance 1887 regulated the manufacturing and sale of food and drugs, and provided for the abatement of nuisances, the proper construction and sanitary maintenance of buildings, and measures for control of infectious diseases. in relation to measures for control of infectious diseases, this 1887 legislation provided for compulsory reporting of cases of smallpox, and compulsory vacation, cleansing and disinfection of infected premises. the law also provided a mechanism for the government to proclaim a state of epidemic and to make bye-laws for the mitigation of such epidemic. the merchant shipping ordinance 1899 provided for quarantine regulations concerning vessels and seaports of hong kong. infectious diseases covered by the merchant shipping ordinance 1899 only included the quarantinable diseases defined in the previous world health organization's (who) international health regulations (ihr), namely cholera, smallpox, plague, typhus fever and yellow fever. the purpose of the enactment of the first qpdo in 1936 was to consolidate those provisions empowering measures for the prevention of spread of infectious diseases contained in the public health and buildings ordinance 1903 with the border control measures against quarantinable diseases contained in the merchant shipping ordinance 1899. 5 the enactment also recognized the requirements of the international sanitary convention 1926. 6 in 1951, the international sanitary regulations, renamed the ihr, were adopted by member states of the who to prevent the international spread of quarantinable infectious diseases and to impose requirements for the notification of cases of these diseases. the qpdo was subsequently amended to reflect the requirements of later revisions of the ihr. despite these legislative revisions, the amendments did not seek to make major changes, nor has there been any subsequent restructuring of the qpdo. as such, the qpdo, to a large extent, closely resembled the original version, consisting of provisions taken from two century-old ordinances. the antiquity of law does not in itself give rise to the inadequacy of its provisions. however, the qpdo consisted of the consolidation of old laws and subsequent piecemeal amendments. without a review with reference to developing international practices and the evidence base, the qpdo had become outmoded and was not in conformity with contemporary legal standards. the outbreak of sars in 2003 was a major public health threat. the epidemic highlighted the fact that the marked increase in intensity and speed of international traffic has resulted in rapid international spread of disease. although many of the powers necessary for the control of sars were already provided by the qpdo, the epidemic uncovered some deficiencies in the legislation. the key deficiencies are grouped under the following four areas for the purpose of discussion. in 2003, an outbreak of sars occurred in hong kong affecting 1755 individuals, with a high case-fatality rate of 17.0%. globally, 8096 probable cases from 28 countries or areas have been recorded since 2003. 7 this emerging infection had the ability to transmit directly from person to person through contact with infected respiratory secretion. it is worth noting that, among the last few cases reported towards the end of 2003 and early 2004, all were confirmed to be laboratory-acquired cases or secondary cases of an index case who acquired the infection from a laboratory environment. as sars is a disease that transmits from person to person, contact tracing proved to be one of the most effective public health measures for prompt control of spread of the disease. during the sars outbreak, contacts were placed under medical surveillance or quarantine. perhaps for historical reasons, medical surveillance was defined in the qpdo as a substitute for isolation. medical surveillance took place on the conditional release of a person from isolation, subject to the signing of a bond by that person to submit to surveillance. however, the qpdo did not provide separate specific powers of isolation or quarantine of persons. rather, it provided for the removal and detention of cases, contacts or carriers of infectious diseases to a place appointed by public health doctors, without reference to separation of the ill or the exposed from the healthy, which is the key element of both isolation and quarantine. as mentioned, the qpdo constitutes a merger of provisions from two old laws together with updating in accordance with the requirements of the international sanitary convention and later versions of the ihr. due to the piecemeal approach to development of the qpdo, it is not surprising that its structure was inconsistent with recognized processes for control of spread of infectious disease, which encompass the four logical steps of prevention, surveillance, investigation and control. the legal powers to support these steps were scattered randomly through the legislation, making the law difficult to understand for both the public and public health doctors. the definitions and use of terms provided in the legislation were not in line with recognized public health convention. in the eyes of the public, the law poorly articulated the purpose and content of public health measures. in the eyes of public health doctors, the law was confusing regarding which public health measure was covered by which provision of law, and when a power could be exercised. this confusion jeopardized the function of law to communicate health policy, and was not conducive to the use of legal powers to control disease by public health doctors. the efficiency of law as a public health tool for disease control was thus affected. the occurrence of laboratory-related cases of sars indicated that the handling of dangerous pathogens in laboratories was an emerging public health issue. ensuring laboratory safety was the main concern for these cases, and the who published a postoutbreak biosafety guideline for handling sars co-v and culture. however, no measure was prescribed under the qpdo for detection of incidents of leakage of dangerous pathogens or its management. this gap further signified that the qpdo was unable to keep pace with new threats of infectious disease. in order to prevent the spread of sars from hong kong, border control measures were implemented, despite the fact that clear evidence on the effectiveness of such measures was not yet available. on the question of border control measures, the qpdo followed the requirements of earlier versions of the ihr, and hence most of the provisions of the qpdo were only applicable to the quarantinable diseases. a considerable portion of the legislation was devoted to disease-specific powers for each of the quarantinable diseases. medical examinations and surveillance of travellers were only provided for cholera and plague for passengers of incoming vessels and aircraft. health declarations were applicable to travellers entering hong kong by air or sea, but without application to the busy land border. as legal powers were disease specific, the government was unable to use legal powers to support border control measures for new diseases such as sars. in addition, as the provisions relevant to border control measures, including in relation to health declarations, were contained in the principal ordinance rather than in regulations, any amendment was required to undergo a process of positive vetting by the legislature; a process which would normally take months to complete. these features of the qpdo hampered the response to the prevention and control of sars, and led to the necessity for urgent amendments to the subsidiary legislation in the midst of the sars outbreak. amendments were needed to authorize medical examination of travellers for the purpose of prevention of cross-border spread of the disease; as a result, health declarations at the land border needed to be conducted administratively. the hong kong legislative council scrutinizes proposals for legislative amendments in hong kong. as part of the administration's response to the recommendations of the sars expert committee, the issue of review of the qdpo was discussed in the legislative council in 2004. legislative council members expressed serious concern that the qpdo was antiquated and therefore inadequate to deal with new and serious infections such as sars. members also supported the proposal that international best practice, as stipulated in the ihr, should be followed, and urged the administration to reform the qpdo expeditiously. 8, 9 nevertheless, it was also the responsibility of the legislative council to scrutinize law to ensure that coercive power vested in the government was not unfettered. in the process of amendment of the qdpo during the outbreak of sars in 2003, legislative council members were critical of two key issues of the bill. firstly, the proposed powers, which were potentially applicable to all infectious diseases, were too generic. it was decided that the new provisions should only be applicable to sars. secondly, it was determined that there should be a limit (sunset clause) on the effective period of the provisions. 10 this limit recognized the important legal principle that any coercive power should be the least restrictive necessary in terms of scope and duration. in the definition of public health law proposed by gostin, referred to at the beginning of this article, there are two arms to public health law: law confers power to the state or government, and at the same time, law limits such power to constrain individual liberty. it follows that in the creation of a new power, appropriate checks and balances should be provided, particularly in relation to legal powers that intrude into people's liberty, privacy and proprietary interests. the qpdo contained no emergency powers. the emergency preparedness plan for influenza pandemic in hong kong and the sars contingency plan are the most recent and most important contingency plans developed by the centre for health protection of the hong kong government. measures to manage a public health emergency as provided in these plans were matched against provisions under the qdpo to assess the adequacy of the qpdo to deal with a public health emergency. it was found that while the qpdo might allow for some limited public health emergency measures, it lacked provisions to enable the following measures as recommended in the emergency plans: surveillance (the power to access information collected by healthcare facilities); investigative power (the power to release contact information); disease control (the power to order closure of public places); and maintenance of essential healthcare service (the power to acquire healthcare facilities, drugs, vaccines, personal protective equipment etc.). analysis of the qpdo with reference to contingency measures in the sars and influenza pandemic plans assisted in identifying gaps that called for consideration for inclusion in the legislation. to address the deficiencies of the qpdo, it was considered necessary to update the terminology and re-organize provisions in accordance with modern public health disease control principles and control mechanisms for disease, to enhance responsiveness for better preparedness and flexibility in handling emergent infections, to ensure appropriate checks and balances to coercive powers, and to introduce emergency powers for the handling of public health emergencies. the amendment exercise also took into account the requirement to comply with the revised ihr (2005). in the amendment exercise, interpretations of terms were amended where appropriate to reflect current usage. the term 'medical surveillance' was redefined to mean regular medical monitoring and observation with a view to ascertaining the health status of a person. in the new legislation, public health doctors are empowered to subject a person suspected to be a contact or infected with an infectious disease to medical surveillance. should medical examinations or tests be required for the purposes of surveillance, the law requires that those examinations and tests should not be more intrusive or invasive than required to ascertain the state of the person's health. power to order quarantine and isolation of persons are clarified in accordance with accepted public health principles. it is made clear in the amended legislation that the power of quarantine is applicable to persons who are contacts (i.e. persons who have been or who are likely to have been exposed to the risk of contracting an infection), while isolation is applicable to persons who are infected with the disease. the qpdo provisions were re-arranged to follow, as far as possible, the four logical steps for control of spread of infectious diseases: prevention, surveillance, investigation and control. in order to enable compliance with the requirements of the ihr (2005), control measures governing inbound and outbound travellers across the boundaries of hong kong were also strengthened. provisions relevant to travellers and border control measures were grouped under separate parts of the new law. through the above amendments, the law has markedly improved the ability of the public health authority to communicate with the public and healthcare professions on issues of responsibility under the law, and to communicate with public health doctors on their duties and powers with respect to prevention and control of infectious diseases. to enhance legal responsiveness, a major structural reform of the qpdo was undertaken. unlike the old qpdo, the new principal ordinance only contains fundamental and enabling provisions, such as those providing powers of arrest, seizure and forfeiture, as well as the power to make subsidiary legislation. the principal ordinance serves the key function of defining the scope of the subsidiary legislation, providing a framework within which the legislature is willing to empower decision making by the government. provisions that are operational in nature are included in new subsidiary legislation. under this new structure, the new subsidiary legislation will provide a holistic plan of measures for the prevention, surveillance and control of cross-boundary spread of disease, as well as for spread of disease within the boundaries of hong kong. moreover, a new section of the legislation addressing control of laboratory handling of dangerous infectious agents was introduced. in line with the ihr 2005, the concepts of quarantinable diseases and quarantinable-disease-specific legal powers were removed. the applicability of the subsidiary legislation is defined by schedules of infectious diseases and dangerous infectious agents. this major restructuring of the law will allow more flexible and speedy amendment procedures where they become necessary. subsidiary legislation is subjected to a process of negative rather than positive vetting by the legislature. this will assist in expediting any amendment process, thereby improving legal responsiveness to emerging infections. the schedules of infectious diseases and infectious agents are to be amended by order of the director of health; a process that will take only hours to complete. when a new infection of public health importance emerges, the government will be able to acquire a full range of disease control powers simply by adding the emergent infection to the list in the schedules. inevitably, any enhancement in responsiveness will result in giving the government and government public health agencies greater discretion in exercise of their legal powers. therefore, it is pivotal to include appropriate checks and balances so that the exercise of discretionary powers is not unfettered. in accordance with revisions to infectious disease legislation conducted in other countries, it was recommended that while a full range of legal powers for disease control should be provided, the exercise of any such power should follow the principle of 'least restrictive alternative'. the legislation should clearly articulate when the use of each power is appropriate. [11] [12] [13] similar principles had been expressed by the legislative council during the debate on the amendments to the qpdo during the sars outbreak. in updating the qpdo, appropriate checks and balances have been introduced to bring the law into line with this public health law standard. medical surveillance, examinations and tests must not be more intrusive and invasive than is necessary to ascertain a person's health condition. when and how the power of quarantine or isolation can be exercised is now clearly spelled out in the law. a new power has been introduced to require authorization from a magistrate for a warrant to enter residential premises for investigation of a case or suspected case of infectious disease. a further protection against abuse of powers is that any exercise of power under public health legislation or any exercise of discretionary power will be subject to judicial review. in considering whether emergency powers for disease control should be introduced, the experience of overseas countries was taken into account. opinions of hong kong public health doctors responsible for an emergency response were sought, particularly in the light of their experience of the sars outbreak. experience elsewhere suggested that legal powers to acquire information for heightened surveillance, powers of closure of public places to achieve better social distancing in outbreak control, and powers to acquire property and a healthcare work force to maintain essential healthcare services were common features of legislation for public health emergencies. on the other hand, compulsory release of contact history was not a consistent feature of legislation in other states. it appears that, in general, public health emergency powers focus mainly on control and management of property and information, rather than on individuals. compulsory release of contact history raised concerns about intrusion into bodily integrity and privacy. in addition, the possible 'side effect' of driving people underground in response to exercise of coercive powers was considered. consultation with public health physicians in hong kong revealed similar views. legal powers in relation to control and management of property intrude into property rights rather than into people's bodily integrity and privacy. the experience of the sars outbreak in hong kong highlighted circumstances in which shortages of hospital beds, facilities and services for large-scale quarantine, as well as shortages of personal protective equipment, might occur. as indicated by overseas practices and by the experience of sars, consideration was given to include this group of emergency powers in the new public health legislation. analysis of overseas legal practice revealed that the typical application of an emergency statutory power was more restricted than application of other provisions. in particular, emergency powers were generally time limited (to times of emergency) and could only be invoked upon a declaration made by a leader of the country or region. in relation to emergency powers where people's property rights were forfeited (such as in acquisition of facilities, personnel and drugs), a compensation mechanism was expressively included. in view of the foregoing analysis, to enhance the legal preparedness for any major disease outbreak in hong kong, the decision was made to introduce an emergency power into public health legislation to enable response to a public health emergency within the shortest time frame. however, as such a power is not expected to be required in ordinary circumstances, and will only be exercised in very exceptional circumstances, the new legislation has provided for the chief executive of hong kong to make public emergency regulations only when an occasion of public health emergency (as evident by the occurrence or imminent threat of disease or epidemic) exists. the scope of the emergency regulations would include a legal power for the purpose of combating and controlling the particular public health emergency situation. in particular, it may empower the government to access and to disclose information to the public relating to the state of the public health emergency for the purpose of protecting public health, provide for the requisition of private property (e.g. vaccines, medicine, personal protective gear, vehicles, vessels, etc.) and healthcare workers, provide for closure of places for public gathering, and provide other necessary powers with regard to the nature and circumstance of the public health emergency. the provision of emergency powers is contained in the revised public health legislation and is to be exercised within the framework of that legislation. hong kong has chosen not to amend its emergency regulations ordinance, 14 as some states have done. 15 this illustrated the government's intention for a holistic approach to deal with anticipated public health emergencies caused by the spread of infectious diseases in the same legislation. in the face of the challenge of emerging infections, the international community has actively strengthened its legal preparedness for public health emergencies. the recent occurrence of sars in hong kong indicated that infectious disease legislation is necessary to facilitate response to public health threats in a timely manner. with regard to the deficiencies of the qpdo, a major reform of the qpdo and its subsidiary legislation has been conducted, leading to the passing of the new prevention and control of disease ordinance 4 and regulations. the legislation commenced operation in july 2008. the effectiveness of application of this legislation as a public health tool has yet to be assessed. nevertheless, the prevention and control of disease ordinance has brought the hong kong legal framework for prevention and control of infectious diseases up to date. the author is confident that this legislation will enhance hong kong's capacity to respond to emerging diseases, both in ordinary times and during public health emergencies. none sought. none declared. public health law: power, duty, restraint cap 141. the laws of hong kong report of the sars expert committee cap 599 subcommittee to monitor the implementation of the recommendations of the sars expert committee and the hospital authority review panel on the sars outbreak, hong kong. minutes of meeting on 15 subcommittee to monitor the implementation of the recommendations of the sars expert committee and the hospital authority review panel on the sars outbreak, hong kong. minutes of meeting on 6 minutes of 22nd meeting held in the legislative council chamber on 25 improving state law to prevent and treat infectious disease the state of communicable disease law. london: the nuffield trust public health legislation -promoting public health, preventing ill health and managing communicable diseases cap the role of law in pandemic influenza preparedness in europe. public health none declared. key: cord-281645-vvucoiqd authors: li, l. title: the challenges of healthcare reforms in china date: 2010-12-17 journal: public health doi: 10.1016/j.puhe.2010.10.010 sha: doc_id: 281645 cord_uid: vvucoiqd china is in the process of a new round of healthcare reforms. the chinese government has launched ambitious healthcare reforms aiming to achieve equitable access to basic health services; and to build a safe, effective, convenient and inexpensive healthcare system for both urban and rural residents. this paper will provide a brief overview of china’s healthcare reforms, and describe the challenges and opportunities facing these reforms. health s u m m a r y china is in the process of a new round of healthcare reforms. the chinese government has launched ambitious healthcare reforms aiming to achieve equitable access to basic health services; and to build a safe, effective, convenient and inexpensive healthcare system for both urban and rural residents. this paper will provide a brief overview of china's healthcare reforms, and describe the challenges and opportunities facing these reforms. ª 2010 the royal society for public health. published by elsevier ltd. all rights reserved. china is in the process of a new round of healthcare reforms. to understand its approach, it is helpful to describe the chinese healthcare system in the period between the founding of the people's republic of china (prc) in 1949 and the market-oriented economic reforms since the early 1980s, and then the period in which the consequences of the market reforms contributed to the current situation e i.e. soaring medical fees, lack of access to affordable medical services, profit-driven (or even profit-making) public hospitals and poor patientedoctor relationships e which compelled the chinese government to launch the new round of reforms. in 2009, we celebrated the 60th anniversary of the prc. from 1949 to 1978, the first 30 years of the prc, china had many achievements to be proud of in the health field. it had a universal coverage healthcare system, and created a low-cost, wide-coverage primary healthcare model, despite china's low income per capita at the time. in urban areas, public hospitals provided free or very cheap healthcare services for everyone, in addition to preventative strategies. in rural areas, barefoot doctors provided healthcare to farmers at minimal cost. barefoot doctors were considered to be one of the great successes of the mao era in china. china's health status had improved significantly, with some indicators reaching the level of developed countries at that time. the life expectancy of the population increased from around 35 years in 1949 to 68 years in 1978; higher than that of some countries which were richer than china. the infant mortality rate declined from 250 per 1000 live births per year to less than 50 per 1000 live births per year during the same period. when china began its economic reforms in the early 1980s, the old system ended as the country attempted to switch to a market-oriented healthcare system. after 30 years of economic reforms, china has achieved an economic miracle. the annual growth in gross domestic product (gdp) is 9.8%, 1 but china's healthcare system has not improved as much as the economy. instead, it has deteriorated in many aspects in both rural and urban areas. in terms of quality, efficiency and equity of healthcare, china's healthcare system is far behind the current level of economic development and people's demands. the improvement in life expectancy slowed down, especially compared with other countries such as australia, hong kong, japan, malaysia and sri lanka. medical costs (but not health outcomes) escalated rapidly, and relationships between doctors and patients deteriorated. the healthcare sector has been one of the areas in china's social system receiving the most complaints. the reasons for the above problems in china's healthcare system are mainly due to government failure and market failure. the failure of the government to insure people's basic healthcare needs led to breakdown of the public health service system; the lack of government regulations exacerbated market failure; and some hospitals and doctors induced too many unnecessary healthcare services, which not only increased the costs for the patients but may also have damaged their health. the government reduced the budget in line with market principles, and people were paying for more and more medical costs out of their own pocket. total health expenditure has increased nearly 90 times over the last three decades, much faster than the growth in gdp. it now accounts for 5% of the gdp, and most is out-of-pocket payments. by 2000, around 60% of health costs were paid for out-of-pocket. 3 in addition, even the more affluent people who were able to pay for care were unable to access satisfactory healthcare services due to the number of patients. the tertiary hospitals have a daily outpatient load of over 10,000 people. the other important factor is health inequality. health inequality slows down health development. in china, there is huge income disparity. the poorer rural population accounts for over 70% of the total population, but only uses 20% of the total resources. a national health survey in 2003 revealed that around 73% of people in rural areas who were advised by physician to be hospitalized chose not to do so because of concerns about the high costs. 4 the severe acute respiratory syndrome (sars) outbreak in 2003 was the turning point for china's healthcare system reforms. it not only focused the government's attention on the deficiencies of the public health system, but also on the need for balanced economic and social development. the government realized that if attention is only paid to economic growth, an epidemic such as sars could completely slow down or even stop that growth, and the government should take responsibility to protect people's basic health needs. the china central political bureau committee workshop on 23 october 2006 marked a milestone for china's healthcare reforms when chinese president hu jintao acknowledged that the government would shoulder more responsibility for strengthening the health system: the government will reform the healthcare system and build a safe, effective, convenient and inexpensive healthcare network covering both urban and rural residents. the goal is for everyone to enjoy a basic healthcare service. since then, the government has set healthcare reforms as one of its top priorities, and work has commenced on the healthcare reform plan. the chinese government put forth a global open bidding for different healthcare reform plans to be submitted, and groups from around the world were asked to participate such as the world bank, the world health organization, etc. healthcare reforms are hotly debated and highlighted by the media on a daily basis. on 6 april 2009, the state council issued china's healthcare reform guideline and promised to spend 850 billion yuan (123 billion us dollars) by 2011 in addition to the current regular expenditure to provide universal primary medical services to the country's population of 1.3 billion people. the general framework and the long-term goal for the reforms is to build up a universal health security system, not just a healthcare system, which recognizes the impact of the environment, lifestyle and socio-economic circumstances on health. within this framework, the current healthcare reform guideline is a very comprehensive reform plan aiming to co-ordinate all the related systems including the health financing system, the public health system, the healthcare delivery system, the management and regulation system, the drugs and equipment supply system, healthcare personnel training system and other supporting strategies to ensure that people can access the best care. the long-term reform plan aims to establish a universal healthcare system by 2020. in the short term (up to 2011), five key tasks have been identified to make primary health services available, affordable and accessible for everyone (box 1). the first is to expand the coverage of health insurance by 2010. at least 90% of the population will be covered. an essential drug system will be created, including a catalogue of the main drugs needed by the public. this will mainly be through development of the primary healthcare network. the chinese government has used the economic stimulus plan to build another 5000 clinics at the township level, 2000 hospitals at the county level and 2400 urban community clinics over a 3-year period. they have also promised to provide equal public health services for both urban and rural residents. the last task in the first 3-year period is to push forward the pilot reform of public hospitals, the main supply of health services. currently around one-half of hospitals are private and the other half are public (non-profit) in china, but the vast majority of hospital beds are in public hospitals. this is the largest challenge we are facing and no consensus on reform measures has been reached to date. the 16 cities pilot project for hospital reforms has been set up to try new models of medical care delivery. currently, the delivery system has no incentive to control the costs and they need to make money to pay staff salaries and to buy equipment. at the same time, health insurance coverage is expanding rapidly and could potentially make the problems worse. the government has spent a lot of money buying insurance for rural and urban populations, but medical fees are also rising quickly. more services are now provided and more drugs are prescribed with more medical tests, leading to box 1 five key tasks of healthcare reforms in china up to 2011. rural and urban areas. 2. establishing a basic/essential drugs system. 3. improving capacities of primary healthcare network. 4. promoting equitable access to public health services. 5. pushing forward with the reform trial in public hospitals. oversupply. if we use an analogy and consider that the fullygovernment-funded public hospitals in the premarketization era were like a nice cat, during the market-oriented economic reforms when the government cut funding to hospitals as part of its market approaches, the cat was put outside and told to feed itself. the cat had to find ways to survive in the market and managed to do this successfully. now, the cat has grown up and become a tiger. when the government calls it back and says, 'i have the money. i can support you', the tiger says 'no, i don't want to come back because the food you give me is not good enough'. this is a huge challenge, especially to improve the management of public hospitals. however, it is also an opportunity, as new technology has created new ways to solve problems that could not be solved previously. one example is the national public health information system; a direct reporting system for infectious diseases and public health emergencies in china. after sars, the chinese government developed this population-based public health information system. now at the township level, it is possible to report directly to the central government and the government can respond quickly. the second example of achievements through the use of information technology is in dongcheng district in beijing, where an integrated community health network has been established. there is integration between the 126 healthcare centres, 82 general practitioner workstations, community healthcare centres and the hospitals. the network provides lifetime monitoring of people's health statuses with a comprehensive health record which links to management as well as performance evaluation of the doctors, who are paid according to their workload and the quality of their performance. online consultation is also available. the individual health records can also link to family health records. if a family has a problem with hypertension, a general practitioner or nurse will visit the household and give some dietary advice (e.g. salt intake). shanghai min hang district also has an integrated information system for health management, which has successfully combined individual health status information with diagnostic and treatment information in the local hospital. a regional integrated health network has been set up with software packages which help to manage non-communicable diseases and enhance early detection. this system can also support remote consultation, and patients can assess doctors' performance which is one of the key performance indicators of doctor's pay. this system has been proved to decrease the total costs of the healthcare system. as these examples show, the developments in information technology can help to restructure the entire healthcare system, and to integrate health delivery across public health and primary care to the secondary and tertiary services. in conclusion, a lifetime seamless health maintenance system needs to be created. china has 1.3 billion people and is facing an ageing society. china's disease pattern is increasingly similar to that of developed countries. cancer is the main cause of death. however, the per capita gdp in china is only around us$3000 which is not sufficient to set up a disease care system; a healthcare system is needed. china will spend the limited resources on maintaining people's health, reducing the risk of getting ill and providing maintenance from birth to death. currently, the healthcare reforms are pushing forward smoothly, and ordinary people are already benefiting from the changes. with government determination, public support and the help of information technology, china's healthcare reforms will provide universal healthcare coverage to the whole population in the near future, and create a low-cost, efficient healthcare system. review of the thirty years of reform and opening up (i): big reform, wide open and great development zhongguo gonggong weisheng de weiji yu zhuanji. [the crises and turning points in china's public health china health statistical yearbook. beijing: beijing union medical university press centre for health statistics and information, chinese ministery of health. an analysis report of national health services survey in 2003 none sought. this paper is funded by chinese moe fund for the humanities and social sciences research base (07jjd840182). none declared. r e f e r e n c e s key: cord-307520-8zmwh9ch authors: smith, l.e.; amlȏt, r.; lambert, h.; oliver, i.; robin, c.; yardley, l.; rubin, g.j. title: factors associated with adherence to self-isolation and lockdown measures in the uk: a cross-sectional survey date: 2020-09-06 journal: public health doi: 10.1016/j.puhe.2020.07.024 sha: doc_id: 307520 cord_uid: 8zmwh9ch objectives: to investigate factors associated with adherence to self-isolation and lockdown measures due to covid-19 in the uk. study design: online cross-sectional survey. methods: data were collected between 6th and 7th may 2020. a total of 2240 participants living in the uk aged 18 years or older were recruited from yougov's online research panel. results: a total of 217 people (9.7%) reported that they or someone in their household had symptoms of covid-19 (cough or high temperature/fever) in the last 7 days. of these people, 75.1% had left the home in the last 24 h (defined as non-adherent). men were more likely to be non-adherent, as were people who were less worried about covid-19, and who perceived a smaller risk of catching covid-19. adherence was associated with having received help from someone outside your household. results should be taken with caution as there was no evidence for associations when controlling for multiple analyses. of people reporting no symptoms in the household, 24.5% had gone out shopping for non-essentials in the last week (defined as non-adherent). factors associated with non-adherence and with a higher total number of outings in the last week included decreased perceived effectiveness of government ‘lockdown’ measures, decreased perceived severity of covid-19 and decreased estimates of how many other people were following lockdown rules. having received help was associated with better adherence. conclusions: adherence to self-isolation is poor. as we move into a new phase of contact tracing and self-isolation, it is essential that adherence is improved. communications should aim to increase knowledge about actions to take when symptomatic or if you have been in contact with a possible covid-19 case. they should also emphasise the risk of catching and spreading covid-19 when out and about and the effectiveness of preventative measures. using volunteer networks effectively to support people in isolation may promote adherence. during the coronavirus pandemic, governments have imposed restrictions of movement to prevent the spread of the virus. commonly used measures are self-isolation, in which people who are ill separate themselves from others, and quarantine, in which people who may have been exposed to the illness separate themselves from others. 1 on 23rd march 2020, the uk government introduced 'lockdown' measures to slow the spread of covid-19. 2, 3 these required people to: stay at home except for several, limited reasons; not leave the home at all for 7 days, if suffering from a new continuous cough or fever; and not leave the home at all for 14 days, if someone else in the household developed cough or fever. adherence to these measures may be influenced by multiple factors. according to protection motivation theory, 4 uptake of a protective behaviour is influenced by your appraisal of a threat, including its severity and your susceptibility to it, and your appraisal of the behaviour, including perceptions about its efficacy, your ability to perform it and the costs associated with it. a review of quarantine measures in previous public health crises found that knowledge and perceived social norms were also associated with adherence to quarantine. 5 conversely, fear of missing out, perceived social pressure, perceived legal consequences, running out of supplies (e.g. food or medicine) and financial pressures were associated with decreased adherence. there is some evidence that people who think they have had covid-19 are less likely to adhere to lockdown measures. 6 in this study, we investigated factors associated with adherence to lockdown measures in a demographically representative sample of the uk adult population. we commissioned the market research company yougov to carry out this cross-sectional survey, between 6th and 7th may 2020. participants (n ¼ 2240) were recruited from yougov's online research panel (n ¼ 800,000þ uk adults) and were eligible if they aged 18 years or older and living in the uk. quota sampling was used, based on age, gender, social grade, level of education and government office region, to ensure that the sample was broadly representative of the uk general population. in total, 74 participants were excluded because of a lack of data for sociodemographic variables, suspiciously fast completion of the survey or providing identical answers to multiple consecutive questions. participants were reimbursed in points equivalent to approximately 50p. full survey materials are available in the supplementary materials. we asked participants how many times they had left their home 'in the past 24 h' and 'in the past seven days': to go to the shops for groceries, toiletries or medicine; to go to the shops for other items; for exercise; for a medical purpose excluding going to the shops/ pharmacy for medicine; to go to work; to help someone else; and to meet friends or family who they did not live with. we asked participants if they or a household member had experienced any of 13 symptoms, including cough and high temperature/fever, in the past 7 and 14 days, respectively. we asked participants whether they thought they had 'had, or currently have, coronavirus' and if they were currently selfisolating. we asked participants a series of true/false statements about the current uk government guidance. we asked participants how worried they were about covid-19 on a five-point likert-type scale from 'not at all worried' to 'extremely worried'. to measure perceived social norms, we asked participants to estimate the percentage of people the same age as them who were fully following the uk government's recommendations to stay at home. we asked participants whether they thought the current lockdown had made their physical health better or worse. possible answers were 'a lot better', 'a little better', 'no difference', 'a little worse' and 'a lot worse'. we asked participants to rate their general health on a fivepoint likert-type scale from 'poor' to 'excellent' using one item from the sf-36. 7 table 1 participants' personal and clinical characteristics, by report of symptoms in the household. we asked participants if they had helped someone, or received help from someone, outside their household in the past 7 days (yes/ no). we asked participants to rate 14 perception statements on a five-point likert scale from 'strongly disagree' to 'strongly agree'. statements included the perceived severity of covid-19, perceived effectiveness of government measures, perceived likelihood of catching and spreading covid-19, perceived costs of following government measures, fear of losing touch with friends and relatives, social pressure from friends and family to follow government measures, perceived legal consequences of not following government measures and positive consequences of the lockdown. we asked participants to report their age, gender, employment status, highest educational or professional qualification and marital status. we also asked whether there was a child in their household, whether they or someone else in their household received a letter from the national health service telling them they were extremely clinically vulnerable to covid-19, and whether they lived alone. participants were asked for their postcode to determine indices of multiple deprivation (imd) and whether they lived in an urban or rural area. we also collected social grade. we asked participants if their primary home had access to any outdoor space, and whether they were pet owners. ethical approval for this study was granted by the king's college london research ethics committee (reference: lrs-19/20-18687). we calculated achieved power for the analyses (in households with and without symptoms) using post-hoc power calculations. achieved power is presented underneath relevant analyses. for all variables, unless stated otherwise, we coded answers of 'don't know' as missing data. we investigated whether out-of-home activity (total number of outings, percentage of people reporting shopping for nonessentials, going to meet friends or family, and having visitors to their home) differed by presence of symptoms in the household. we split the sample by presence of symptoms in the household. among those who reported symptoms in their household in the last 7 days, we defined those who reported having gone out in the last 24 h as not adhering to self-isolation measures. we ran a series of logistic regressions investigating univariable associations between personal and clinical factors, psychological and situational factors, and having left the home in the past 24 h. we ran a second set of logistic regressions controlling for personal and clinical characteristics. among those who reported no symptoms in the household, we used uk government guidelines that were in force at the time of data collection 2 to define non-adherence (shopping for nonessentials, meeting friends or family and having visitors to your home). we ran a series of linear regressions investigating univariable associations between personal and clinical factors, psychological and situational factors, and total number of outings reported in the past 7 days. we ran a second set of linear regressions controlling for personal and clinical characteristics (personal and clinical characteristics entered as the first block, other independent variables as the second block). we ran a series of logistic regressions investigating univariable associations between personal and clinical factors, psychological and situational factors, and going out shopping for items other than groceries, toiletries or medicines (non-essentials) in the past 7 days. we ran a second set of logistic regressions controlling for personal and clinical characteristics. weighting data by age, gender, social grade, highest level of education and region altered prevalence of outcome behaviours only slightly. we therefore used unweighted data in our analyses. owing to the large number of analyses (n ¼ 39) run on each outcome, we applied a bonferroni correction to our results (p 0.001). those meeting this criterion are marked by a double asterisk (**) in the tables. results of adjusted analyses are reported narratively; unadjusted results are reported in tables. a minority of participants (9.7%, n ¼ 217) reported that either they or a household member had a cough or a high temperature/ fever in the last 7 or 14 days, respectively. participants' characteristics are shown in table 1 . male participants were more likely to report symptoms in their household. there were no other differences between groups. of participants who reported symptoms in their household (n ¼ 217), 75.1% (n ¼ 163, 95% confidence interval [ci; 69.3e80.9]) reported leaving the home at least once in the past 24 h. this finding has been reported elsewhere. 8 a few participants (n ¼ 54, 2.4%) reported going out many times; we grouped responses of over 20 times in the past 7 days. there was no difference in out-of-home activity by presence of symptoms in the household (total number of outings made in the last week, t(2160) ¼ 0.20, p ¼ .84; percentage of people reporting shopping for non-essentials, c 2 (1, 2162) ¼ 0.38, p ¼ .54; having had a visitor to one's home, c 2 (1, 2076) ¼ 0.40, p ¼ .53; or going to meet friends or family, c 2 (1, 2162) ¼ 1.34, p ¼ .25). of those who reported symptoms in the household, 34.1% (n ¼ 74) reported that they were self-isolating. of those 'selfisolating', 60.8% (n ¼ 45) nonetheless reported having gone out in the last 24 h. men were more likely to leave the home in the last 24 h (see table 2 ). non-adherence to self-isolation (reporting having left home in the last 24 h) was associated with: thinking that the lockdown had made your mental health worse; feeling a greater sense of community with your neighbourhood due to covid-19 (see table 3 ). 13.89 0.007 <0.001** à0.08 <0.001** à0.09 <0.001** age, years 18e24, n ¼ 76 for analyses where symptoms were present in the household, we achieved 94% power to detect small effect sizes in logistic regression analyses (odds ratio [or] ¼ 1.68, 9 a ¼ .05, sample size n ¼ 217, probability of having left the home ¼ 0.75, one-tailed logistic regression; 89% power when using a two-tailed logistic regression). 10 of those who reported no symptoms in their household, 24 personal and clinical factors (gender, age, having a child in the household, being extremely clinically vulnerable oneself, employment status, highest level of education or professional qualification, imd, social grade, living in a rural or urban area, living alone, marital status and region [results for region not reported]) explained 8.0% of the variance in number of outings in the past week (see table 4 ). more outings were made by men, those who reported working and who lived in rural areas. fewer outings were made by those who were clinically extremely vulnerable and who lived in more deprived areas. having a pet was also associated with going out more often. more outings in the past week were associated with: helping someone outside your household; decreased perceived effectiveness of government measures; thinking that you would lose touch with friends and relatives if you followed government advice; not enjoying spending more time at home during the lockdown; better self-reported general health; decreased perceived severity of covid-19; decreased perceived likelihood of spreading covid-19; decreased perceived legal consequences of not following government advice; decreased perceived social pressure from friends and family to follow government measures; full, correct knowledge of government measures if no-one in the household was symptomatic; believing that you have had or currently have covid-19; increased perceived financial cost of following government measures; and decreased perceived social norms (see table 5 ). fewer outings were associated with: receiving help from someone outside your household; decreased perceived impact of lockdown on physical health; reporting that you were self-isolating; increased worry about covid-19; and increased perceived likelihood of catching covid-19. going out shopping for non-essentials in the past week was associated with male participants, working and lower social grade (see table 6 ). shopping for non-essentials in the past week was associated with: thinking you have had covid-19; helping someone outside your household; thinking that you will lose touch with friends or relatives if you follow government guidance; and thinking that following government guidance will negatively impact you financially (see table 7 ). not going out shopping for non-essentials was associated with: having received help from someone outside your household in the last 7 days; reporting that you were self-isolating; increased perceived likelihood of catching and spreading covid-19; increased worry about covid-19; increased perceived effectiveness of government advice; increased perceived severity of covid-19; increased perceived disapproval from friends or family if you do not follow government advice; increased perceived legal consequences of not following government advice; not knowing or being unsure about government measures; and decreased perceived social norms. for analyses where no symptoms were present in the household, we achieved 100% power to detect small effect sizes in logistic regression analyses (or ¼ 1.68, 9 a ¼ .05, sample size n ¼ 1945, probability of having gone out shopping for items other than groceries, toiletries or medicines ¼ 0.25, one-tailed and two-tailed logistic regression). we achieved 94% power to detect small effect sizes in linear regression analyses (f 2 ¼ 0.02, 10 a ¼ .05, sample size n ¼ 1945, number of tested predictors ¼ 39, total number of predictors ¼ 39). to the best of our knowledge, this is the first comprehensive study to investigate factors associated with self-isolation and behaviour during lockdown in the uk. almost 10% of participants reported that either they or a household member had symptoms of covid-19 (a cough or high temperature/fever) in the last week. prevalence estimates by the uk office for national statistics indicate that at the time of data collection, 0.27% of the community population had covid-19. 11 government regulations required all those with symptoms, or with symptoms in their household, to self-isolate. our results suggest that adherence to this is poor. three-quarters of those with symptoms in their household reported leaving their home in the past 24 h. we found no difference in out-of-home behaviour by presence of symptoms in the household. the uk will shortly enter a new phase of the pandemic, in which extensive testing, contact tracing and isolation will be required to keep the spread of covid-19 in check. 12 for this to succeed, adherence must be improved. there is some evidence that institution-based isolation is more effective compared to homebased isolation, in part because this is less reliant on personal adherence to guidelines. 13 some countries have used large-scale, temporary shelter hospitals, which are primarily for patients with mild and moderate symptoms of covid-19. shelter hospitals allow patients to isolate effectively from their family and community; be triaged, reducing pressure on other health care services; provide basic medical care; frequent monitoring and rapid referral if a patients' symptoms worsen; and provide living and social support. 14 our findings highlight several risk factors for poor adherence. notably men were more likely to report having been out in the last 24 h if they or someone in their household was symptomatic, having gone out more times in the last week and shopping for nonessentials. lower adherence among men was also noted in the uk during the 2009/10 h1n1 influenza pandemic. 15 communication campaigns that specifically target men may therefore have merit. adherence with self-isolation was associated with increased worry about covid-19 and increased perceived likelihood of catching covid-19. as incidence declines, it is possible that worry will also decline, reducing adherence further. although it may be tempting to use fear-based messaging to combat this, this may influence other behaviours that the government may wish to encourage, such as return to work. 16 adherence was also associated with having received help from someone outside your household. this makes intuitive table 5 associations between psychological and situational factors and total number of outings in the past week in participants who reported no symptoms in the household. because of the current lockdown, there is more conflict between people that i live with 5-point scale, 1 ¼ strongly disagree to 5 ¼ strongly agree, n ¼ 1859 if i follow the government's advice, i will not be able to carry out important religious activities 5-point scale, 1 ¼ strongly disagree to 5 ¼ strongly agree, n ¼ 1719 associations between personal and clinical characteristics of participants who reported no symptoms in their household in the last week and having gone shopping for items other than groceries, toiletries or medicines (non-essentials). had not gone out shopping for nonessentials; n ¼ 1469, n (%) had gone out shopping for nonessentials; n ¼ 476, n (%) sensedhaving someone else to run errands should reduce the need for you to leave home. much has been made recently of the remarkable altruism of 750,000 people who signed-up to volunteer for the national health service, and the lack of jobs for them to do. 17 allowing those in self-isolation to submit requests for help may be a pragmatic way to improve adherence. adherence to lockdown measures among those not reporting symptoms in their household was better, but still not perfect, with 75% reporting not going out to shop for non-essential items. percentages reporting not meeting up with friends or family from outside one's household and not having visitors to the home were higher (94% and 95%, respectively). adherence was lower in men and those who reported working. it is plausible that workers may be more likely to be out and about for work and while out, go shopping for non-essentials. those working may also be more financially able to shop for non-essential items. although perceiving greater negative financial consequences of government measures was associated with non-adherence to lockdown measures, there was no longer evidence for an association after correcting for multiple adjustments. this is different from research finding decreased intention to adhere to quarantine measures in israel. 18 adherence to lockdown measures was also associated with higher threat appraisals and positive appraisals of the coping response. these findings mirror research in other countries. 19e21 non-adherence was associated with decreased perceived social norms, 19, 22 lower perceived social pressure to adhere to measures and decreased knowledge of measures. 5 these findings suggest that improvement in adherence to lockdown measures is likely to be achieved by emphasising these are actions that most people are taking, that are having a positive impact, and that others around you want you to do. this study has several limitations. first, despite using quota sampling, we cannot be sure that survey respondents are representative of the general population. 23, 24 second, all data were selfreported and may have been susceptible to social desirability bias. 25 however, preliminary data indicate that self-reported physical distancing is associated with real-world behaviour. 26 third, we did not ask participants if they came into close contact with anyone from another household while they were out and about. clearly, non-adherence does not always increase the risk of disease transmission. fourth, we used a cumulative measure of 'outings' for our outcome measure. it is possible that participants may have shopped for essentials and non-essentials in the same trip, which might be double-counted in our questionnaire. fifth, the cross-sectional nature of data collection means we are unable to draw causal inferences. sixth, although the total sample size was large, a small percentage of the population reported that they or someone in their household had experienced symptoms of covid-19 in the last week. thus, analyses investigating adherence to selfisolation were based on smaller sample sizes, resulting in decreased power and wider confidence intervals. overall, our data suggest that self-reported adherence to selfisolation measures was poor. this has important implications for policies that attempt to prevent the spread of covid-19 through self-isolation, such as contact tracing. psychological factors including perceived effectiveness of lockdown measures, should be emphasised in communications. effective use of volunteer programmes and help within the neighbourhood or community may also improve adherence. anonymised data will be made available on reasonable request. the study was conceptualised by ra, hl, io, cr, ly and gjr. ls completed all analyses, using data from yougov plc. all authors contributed to, and approved, the final manuscript. for any enquiries about the data in this report please contact king's college london. isolation, quarantine, social distancing and community containment: pivotal role for old-style public health measures in the novel coronavirus (2019-ncov) outbreak new rules on staying at home and away from others pm address to the nation on coronavirus protection motivation theory how to improve adherence with quarantine: rapid review of the evidence the impact of believing you have had covid-19 on behaviour: cross-sectional survey the mos 36-item short-form health survey (sf-36) conceptual framework and item selection improving adherence to 'test, trace and isolate how big is a big odds ratio? interpreting the magnitudes of odds ratios in epidemiological studies statistical power analysis for the behavioral sciences coronavirus (covid-19) infection survey pilot: england feasibility of controlling covid-19 outbreaks by isolation of cases and contacts institutional, not home-based, isolation could contain the covid-19 outbreak fangcang shelter hospitals: a novel concept for responding to public health emergencies public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: cross sectional telephone survey the impact of communications about swine flu (influenza a h1n1v) on public responses to the outbreak: results from 36 national telephone surveys in the uk nhs coronavirus crisis volunteers frustrated at lack of tasks. the guardian self-isolation compliance in the covid-19 era influenced by compensation: findings from a recent survey in israel social, cognitive, and emotional predictors of adherence to physical distancing during the covid-19 pandemic predictors of non-adherence to public health instructions during the covid-19 pandemic covid-19 is rapidly changing: examining public perceptions and behaviors in response to this evolving pandemic social norms motivate covid-19 preventive behaviours researching internet-based populations advantages and disadvantages of online survey research, online questionnaire authoring software packages, and web survey services how to survey citizens' compliance with covid-19 public health measures? evidence from three survey experiments connecting self-reported social distancing to real-world behavior at the individual and u.s. state level supplementary data to this article can be found online at https://doi.org/10.1016/j.puhe.2020.07.024. key: cord-308821-j4vylbhy authors: martin, r. title: the role of law in pandemic influenza preparedness in europe date: 2009-03-04 journal: public health doi: 10.1016/j.puhe.2009.01.002 sha: doc_id: 308821 cord_uid: j4vylbhy the european union (eu) is composed of 27 states with widely varying histories, economies, cultures, legal systems, medical systems and approaches to the balance between public good and private right. the individual nation states within europe are signatories to the international health regulations 2005, but the capacity of states to undertake measures to control communicable disease is constrained by their obligations to comply with eu law. some but not all states are signatories to the schengen agreement that provides further constraints on disease control measures. the porous nature of borders between eu states, and of their borders with other non-eu states, limits the extent to which states are able to protect their populations in a disease pandemic. this paper considers the role that public health laws can play in the control of pandemic disease in europe. the 27 states of the european union (eu) form a political and economic community with supranational and intergovernmental responsibilities, and constitute a single market that seeks to guarantee the freedom of movement of people, goods, services and capital between member states. the emergence or re-emergence of diseases such as severe acute respiratory syndrome (sars) and tuberculosis highlighted the need for eu-level health policy, and led to the community action programme 2003-2008 in the field of public health. this programme is now the cornerstone of community public health strategy, focusing on health information and on the community's capacity to react to health threats. in the context of disease control, the executive arm of the eu, the european commission (ec), has responsibility for the co-ordination of epidemiological surveillance of disease between member states and for regulating matters such as case definitions, disease notification and development of disease networks across europe. the ec is assisted by the european centre for disease control (ecdc), which issues protocols on matters of disease reporting and communication of disease information between states and to the ec. the ec and ecdc can only recommend appropriate disease control measures to states. neither is responsible for the management of disease protection and control in individual states. public health powers in relation to disease lie with national governments. it is member states, not the eu, which are signatories to the revised international health regulations (ihr) 2005, although the ihr recognize the role of 'regional economic integration organizations' such as the eu. a thus, if the world health organization (who) were to recommend under the ihr measures falling within eu legislation, such as restrictions on the movement of goods or the processing of personal data, b the eu would need to act collectively, at the initiative of the ec, as member states would be unable to take unilateral action. otherwise, ihr responsibilities lie with individual states. in 2007, a report on pandemic influenza preparedness in the eu 1 noted that substantial progress had been made in preparing for a possible pandemic influenza, but it remained the case that disease control operated at national level. despite encouragement from the eu towards harmonization of approaches, european national plans vary widely in the strategies they have adopted and the public health powers they propose for implementation of those strategies. harmonization of legislative responses to infectious diseases, based upon sound evidence, will be necessary if collaborative efforts in support of infectious disease control are to be effective. to assist in drawing together national responses to pandemic disease, the phlawflu project c was funded to develop public health law expertise across europe, 2 and to examine the legal underpinning of pandemic disease preparedness across the eu and five further european states. d this paper examines obstacles to european commonality of legal responses to communicable disease. there is no doubt that law is an important tool in containment of communicable and non-communicable disease. in the context of pandemic influenza, it is considered that social measures authorized by law will be at least as important as medical interventions. 3 evidence from the 1918 influenza pandemic suggests that compulsory home isolation and quarantine were not particularly effective disease control measures because of the difficulty in diagnosing mild cases. nor were such measures likely to be feasible beyond the initial cases. 4 however, compulsory interventions such as school closures, closure of public places and restriction of mass gatherings, along with disease surveillance and hygiene improvement, have proved effective both in influenza outbreaks and in the sars epidemic. 5 international and eu instruments require states to undertake such measures, many of which will require a legal underpinning. the requirement of compliance with the revised ihr and the globalization of disease information and exchange have prompted many states to revise their public health laws. other states, which had no public health legislation, have now enshrined public health laws in legislative form. these initiatives were long overdue. across europe, as elsewhere, national public health laws tended to be old, based on flawed science, and to predate contemporary understandings and protection of human rights. 6, 7 the allocation of responsibility for public health practice and the role of the state in regulating private behaviours have very different histories across europe. 8 not surprisingly, states have adopted very different positions on the issue of the extent to which constraints can be placed upon individuals for the public benefit. earlier research on european national public health laws in relation to tuberculosis 9 enabled the identification of four different 'families' of public health legislative models in europe. these were: authoritarian (the enforcement of a high number of compulsory control measures); moderate (the enforcement of predominantly compulsory control measures without recourse to prevention powers such as compulsory vaccination or population screening); preventive (where compulsory provisions were oriented towards preventive measures, including screening, medical examination and/or vaccination, rather than compulsory treatment or detention); and the laissez faire model, where few or no compulsory measures existed. a further complication to a comparison of national legal approaches to disease control is the range of different legal systems in europe. while the majority of european states have a civil law legal system based on the french or german systems, some states operate common law systems, e the former soviet states have vestiges of soviet law, and the legal systems of the scandinavian states recognize civil law overlain with some common law. whereas the definitive public health law of some states can be found in statutory form, other states also include the binding decisions of courts. some national legal systems recognize customary law, local edicts or administrative orders as having legal authority. it cannot be assumed that because a particular power does not lie within public health legislation, that power does not exist. determination of the full range of public health legal powers across european states is a technical and difficult task. following the eu working paper on community influenza pandemic preparedness and response planning in 2004, 10 european states have published national preparedness plans. as with the range of approaches to law, there is a wide range of approaches to pandemic preparedness planning across europe. coker and mounier-jack examined 21 european national plans against a who checklist and found considerable gaps and inconsistencies among preparedness plans, with implications for health in both individual states and for europe as a whole. the authors noted that 'the eu has a critical function in protecting its citizens from public health threats. the role of the eu will be essential to ensure improved sharing of knowledge on pandemic response among eu members, to support the effective provision of services, and to coordinate the response at a community level'. 11 few plans address the extent to which proposed interventions are authorized by their national laws. indeed, few state plans acknowledge the need for legal authorization for their proposed measures, and there is often a lack of clarity about the legality of measures. f while there is some commonality across european states in the measures considered appropriate in an epidemic, the formulation of those measures differs from state to state, reflecting the culture and social priorities of individual states. across europe, states have proposed disease reporting networks, social distancing powers, restriction on travel and trade, closure of premises and facilities, and measures regulating the provision of goods and services. however, the extent and scope of these powers vary widely. while most states contemplate powers of isolation and quarantine, some states also propose quarantining flight crews, and authorize compulsory vaccination, compulsory administration of prophylaxis, and compulsory medical treatment. most states authorize the closure of schools and leisure facilities in a pandemic, but some states would also close diplomatic and consular representation, restrict trade union activity or prohibit visitors to inpatients in hospitals. there is variation in the extent to which states will be prepared to requisition persons and property. many states have passed, or are in the process of passing, new legislation to support their preparedness planning. in england and wales, for example, the health and social care act 2008 has introduced into the public health act 1984 new powers of isolation outside a hospital, powers of quarantine, powers to require the wearing of protective equipment, powers to require people to attend counselling or disease risk training, and the power to require individuals to provide health information. it also provides for the application of compulsory power orders to groups of persons as well as to individuals, provides new border control measures and imposes new obligations to monitor health risk. states that had taken a liberal approach to intrusion on individual liberties for the benefit of the public health have, in the face of the threat of a pandemic, passed laws providing considerable public health powers. french public health law had previously c the phlawflu project has received funding from the eu in the framework of the public health programme. d croatia, turkey, iceland, liechtenstein and norway. e including the countries of the uk, ireland, malta and cyprus. f the spanish preparedness plan, for example, expresses concern regarding the legality of proposals for isolation, restriction of movement and the proposal to make compulsory the administration of antivirals to staff in contact with patients, noting that 'the legal services of the ministry of health will need to study the legal aspects relative to compulsory vaccination and isolation and the restriction of movement according to the constitutional act 3/1996 of 14 april of special public health measures in public health, articles 2 and 3'. focused on preventive measures and provided few compulsory powers for disease control. 9 the new french public health code now authorizes isolation and quarantine, obliges individuals to submit to temperature checks, and provides powers to close facilities such as schools, restrict use of public transport, requisition health personnel including students and retired persons, and regulate distribution of medicines. school buildings will be used as centres for vaccination and for accommodation of vulnerable persons. the new code withdraws employment rights such as the right not to work in a situation of danger. employees and public servants in france currently have the right to withdraw from their workplace if they reasonably believe that their work situation presents a grave and imminent danger to life and health, provided that they have alerted their employer to the danger and provided that their leaving does not create a new risk for others. under the new code, which only applies in the particular case of pandemic influenza, this right of withdrawal will not apply in circumstances where the employer has taken all foreseeable measures to reduce the risk of exposure to disease. the formulation of public health measures across europe reflects cultural values and priorities. french law, for example, proposes the possible closure of schools in an epidemic, but the new french public health code, recognizing the importance of education in france, provides very specific measures to protect the right to education of its children. the code acknowledges the need for school closures because children are more susceptible to the influenza virus than adults. however, the code requires that during a school closure, every effort must be made to continue educational provision via the internet, radio and television, and sets out detailed provisions on ways in which education might be continued throughout the pandemic. the difficulty of predicting what legal powers will be needed to exercise effective disease control has led some states to include in their public health legislation a power to make emergency regulations to provide powers that were not foreseen or which would not be appropriate outside an emergency. the health and social care act 2008 for england and wales, for example, proposes that where there is sufficient urgency, a legal instrument may be made without following normal parliamentary procedures. 12 the regulation will then cease to have effect after 28 days, unless it has been ratified by a resolution of each of the houses of parliament. the new french code allows that in the case of a grave threat calling for urgent measures, particularly in the case of an epidemic, the minister responsible for health can, by means of an arête, dictate in the interest of public health measures that are proportionate to the risk and appropriate to the time and place, in order to prevent or to limit the consequences of possible threats to the health of the population. in addition to emergency powers specifically addressed to pandemic disease, many european g and other h states have also introduced or updated separate emergency powers legislation to address unexpected threats, to authorize measures that would not normally be acceptable, or to provide powers as a last resort in the face of emergencies where existing legislation is insufficient. other states have constitutional provisions authorizing emergency powers. i it has until now been the case that for the purpose of legislation, emergencies have been conceptualized as aberrations, normally involving an aspect of violence such as war, rebellion or a violent natural disaster. european emergency powers have generally been limited to a 'state of siege' (france), armed rebellion (hungary), or industrial and natural disasters such as earthquakes or the forest fires in greece. they have not been considered a tool for disease control. in the uk, the civil contingencies act 2004 has replaced the 1920 emergency powers act j in relation to temporary special legislation to respond to serious emergencies. the emergency powers act had provided power to make emergency regulations, following a royal proclamation of a state of emergency, in case of an interference with the supply or distribution of food, water, fuel, light or the means of locomotion that deprived the community, or part of it, of the 'essentials of life'. the civil contingencies act expands the domain of emergency powers so that an emergency is widely defined to include 'an event or situation which threatens serious damage to human welfare', which could potentially include a public health threat such as a serious disease outbreak. while no regulations have been passed to date, there is clearly scope for a heavy-handed response in the event of a public health threat. the civil contingencies bill in its original form underwent prelegislative scrutiny by a joint committee which noted that the bill: ' in the wrong hands, [the bill] could be used to undermine or even remove legislation underpinning the british constitution and infringe human rights. our democracy and civil liberties could be in danger if the government does not take account of our recommended improvements'. 13 the bill was revised and the government agreed to remove a clause that would have prevented emergency regulations from being subject to judicial review with the consequence that the regulations could not be suspended or struck down by a court if they were challenged on human rights grounds. the committee recommended that certain acts of parliament of major constitutional significance should be exempted from a power to modify or disapply legislation, but this remains in the final legislation. the committee also proposed that those powers set out in part 2 of the bill should be subject to a 'sunset clause' and expire every 5 years from royal assent unless renewed by parliament. this was rejected by the government as inappropriate, because the bill contained enabling powers that were intended to deal with a problem that was 'not short-term'. this suggests that a new approach is being taken to the meaning of 'emergency'. under earlier emergency powers legislation, an emergency was determined by a royal proclamation, but under the civil contingencies act, a state of emergency is to be announced, without initial reference to parliament, by the secretary of state or a senior minister. public health emergency planning in the uk appears to acknowledge that the civil contingencies act will have a more general role in the control of disease, although how these plans relate to new powers under the public health act 1984 remains to be seen. a senior spokesperson from the english department of health told the author that the department does not intend to use emergency powers contained in the civil contingencies act for pandemic influenza. powers, contained in the health and social care act 2008 should provide all the necessary legal powers to contain and control disease. however, it is clear from government documents on pandemic planning that there is every expectation that civil contingencies act powers will be used should the need arise. 14, 15 the finnish national preparedness plan for pandemic influenza 16 recommended amending finland's 1991 emergency powers act so that a major epidemic can be classified as a state of emergency as defined in the act. previously, an emergency was defined to include an armed attack against finland, a serious violation of the territorial integrity of finland, a threat of war, a serious threat to the livelihood of the population or the economy by interrupted import of indispensable fuels and other energy, or a catastrophe. finland's communicable disease act of 2005 already contains quite intrusive powers including the power to administer compulsory mass vaccination by the defence forces, compulsory medical treatment, isolation from the workplace, and disease reporting that discloses personal information. the concern with use of emergency powers for disease control is that disease control ceases to be a matter of health protection, and becomes an issue of foreign and national security, with the risk of being hijacked by the agendas of security policy and politics. 17 ,l this has become even more pronounced with the merging of responses to naturally occurring infectious disease and bioterrorism within emergency powers legislation. the who and european commission have both established committees with responsibility for public health as a security issue. m it is questionable whether the suspension of separation of powers and potentially of civil rights and liberties is justified in the name of public health, and arguable that recognition of human rights is essential for dealing effectively with an epidemic. draconian quarantine measures can be counterproductive, and may even encourage people to avoid seeking medical treatment. emergency powers exercised for public health reasons treat citizens as the enemy, and reinforce the philosophy of original public health legislation which classified diseased persons as a public health nuisance to be removed and excluded from society for the benefit of the well. 18 hong kong, which has had recent experience of epidemic disease, considered but rejected expanding its emergency regulations ordinance to cover pandemic influenza, concluding that public health powers were sufficient and appropriate to disease control even during a pandemic. n hong kong has instead amended its quarantine and prevention of disease ordinance in the light of its sars experience. 19 emergency powers and human rights all council of europe member states are party to the european convention for the protection of human rights and fundamental freedoms, and any person whose convention rights have been violated by a state party can take a case to the european court of human rights. in the uk, the human rights act 1998 brings provisions of the convention into uk domestic law and enables human rights actions to be brought in a domestic court. rights with particular relevance to public health powers include article 2 (right to life), article 3 (an absolute right to freedom from torture and inhumane and degrading treatment), article 5 (a qualified right to liberty) and article 8 (a qualified right to private and family life). in enhorn v sweden, 20 a human immunodeficiency virus (hiv)-positive man detained by swedish public health authorities on public health grounds successfully challenged his detention on the grounds that it breached articles 5 and 8 of the convention. the european court of human rights held that any detention must comply with the principle of proportionality, there must be an absence of arbitrariness, detention must be a last resort measure, and any detention must have as its objective not only protection of the healthy but also care of the ill. 21 there has been little judicial challenge in british courts of the exercise of emergency powers. in relation to the english emergency powers act and the emergency powers (defence) act, the courts have played a minimal role, striking down only a handful of emergency measures as ultra vires, usually well after the emergency. more recently, in a case where the british parliament had sanctioned the indefinite detention of any person not a british citizen and certified as a 'suspected terrorist', and where the government had derogated from both the european convention and the international covenant on civil and political rights (iccpr) on the grounds that there was a 'public emergency', the house of lords rejected the government's assertion that the derogation was consistent with the european convention. although the majority of judges declined to question whether there was a public emergency on the grounds that the existence of such an emergency was largely a matter for the government to determine, they concluded that imprisonment of non-citizens alone was neither proportional, given the equal threat from citizens, nor necessary, and questioned the irrationality of singling out a minority (non-citizens) for special burdens, when members of the majority could present an equal risk. 22 lord hoffmann was prepared to consider the notion of an emergency and he found it to be a threat to the 'organised life of the community', which would include not merely a threat to the physical safety of the nation, but also to its fundamental values: 'the real threat to the life of the nation, in the sense of a people living in accordance with its traditional laws and political values, comes not from terrorism but from laws such as these.' 23 the decision suggests a judicial role in overseeing government powers in emergencies. the concept of a 'public emergency' is considered under article 15 of the european convention for the protection of human rights and fundamental freedoms as 'a situation of exceptional and imminent danger or crisis affecting the general public, as distinct from particular groups, and constituting a threat to the organised life of the community which composes the state in question.' o article 15 allows that states might derogate from some of their obligations under the convention 'in time of war or other public emergency threatening the life of the nation', but not from article 2 (right to life) or article 3 (prohibition of torture and inhuman or degrading treatment). the former european commission of human rights, which in 1961 defined a public emergency to consist of a 'threat to the organised life of the community', 24 was called upon to determine the criteria of a public emergency threatening the life of the nation in a case in which the greek government sought to justify derogation of rights on grounds of a public emergency. 25 the commission held that the emergency must be actual or imminent; it must affect the whole nation; the continuance of the organised life of the community must be threatened; and the crisis or danger must be exceptional, in that the normal exceptions permitted by the convention for the maintenance of public safety, health and order are inadequate. derogations may only last for as long as, and only be exercised to the extent required by, the demands of the circumstances. they must not limit the subject's rights of access to court protected in article 6 of the convention, nor the right of a remedy protected in article 13. in circumstances where a state wishes to exercise emergency powers which might contravene human rights, the state is required to make a formal derogation under article 15 of the european convention indicating the rights and the territory to which the derogation applies, 26 and to keep the secretary general of the council of europe informed of the measures taken, the justifications, and the cessation of operation of emergency powers. 27 similar requirements can be found in the iccpr. 28 if european states are to abide by their commitments under the convention, it seems that use of emergency powers will be subject to human rights examination. states will not then be able to exercise their powers in an arbitrary way, and will not be able to respond in a manner that is not proportional to the risk. despite these safeguards, the use of emergency powers legislation for serious ongoing disease outbreaks is questionable. an influenza epidemic could, on a worst case scenario, last for years, which would potentially allow the operation of emergency powers that derogate from human rights protections for a considerable period of time. there is a danger that laws made in the form of emergency regulations might, if in force for long enough, become embedded in the legal system and so constitute a permanent assault on liberties which had previously been achieved, as might be suggested of terrorism legislation in the uk. 29 emergency powers in the context of disease, based as they are on responses to war and catastrophes, tend to operate in such a way that persons affected with disease are characterized as the enemy. they propose that in public health emergencies, there must be a trade-off between the protection of civil rights and effective public health interventions. however, the ideals of democracy, individual rights, legitimacy, accountability and the rule of law suggest that even in times of acute danger, government should be limited in the activities that it can pursue and the powers that it can exercise. as gostin points out in the context of the us model state emergency health powers act, 30 this is not to say that individual rights should always trump public health, but that individual rights should never be infringed 'unnecessarily, arbitrarily or brutally'. 31 nevertheless, there has been significant criticism of the us legislation, and concern that measures proposed in the act are sufficiently dangerous as to 'undermine.constitutional values'. 32 while emergency powers might provide short-term solutions to serious threats, they could also do long-term harm to public trust in public health services, and encourage health behaviours which are counterproductive to the public health. in many countries, including the usa, 33 there are signs that public health and national security are increasingly conflated. the ihr are framed around the assumption that disease is a security issue. 34 however, the danger of subsuming disease control within foreign and national security is that the focus is on security rather than on health. wider national and international interests may not always coincide with public health. global public health may not always coincide with the security concerns of individual states, particularly more powerful states. mcinnes and lee note that policy responses to the sars epidemic elicited a 'garrison mentality' whereby strict border controls and control of movement of persons became central to disease containment, with consequences for the movement of persons, goods and services. 35 it has been widely argued that the promotion and protection of human rights is inextricably linked to the promotion and protection of public health, and that lack of respect for the rights and dignity of persons or groups of persons can increase their vulnerability to disease contagion. 36, 37 the importance of human rights to health has been acknowledged in the revised ihr article 3, which requires that the ihr be implemented with full respect for the dignity, human rights and fundamental freedoms of persons. as mann argues, '.the human rights framework is indispensable both for analyzing the central societal issues which must be confronted and for guiding the direction of societal transformation needed to promote and protect health.' 38 states have a significant number of non-medical tools at their disposal in a disease pandemic, and public health law reform has been undertaken with pandemic influenza in mind. public health legislation around the world now authorizes a wide range of social distancing powers and compulsory screening, examination and treatment measures. in addition, much public health legislation provides for the possibility of some limited emergency measures. nevertheless, some european states have proposed the use of emergency powers legislation to provide exceptional powers in the case of a pandemic; powers which will inevitably constrain the rights of individuals. the evidence base for the need for such exceptional powers has yet to be established, and in the absence of such evidence, there is concern that too heavy a hand will result in long-term harm to public trust in the exercise of population-based disease prevention strategies. early responses to public health threats as reflected in 19th century public health legislation were premised on building fortresses to protect the healthy (and generally wealthy) from those suffering from disease, rather than on care and protection of the population. public health legal powers tend to focus on containment and exclusion, representing 'the community response to social and economic pressures and the wide spread fear of death and disease' 39 rather than on positive public health outcomes. immigrant populations have long been targeted as carriers of disease, and in relation to diseases such as drug-resistant tuberculosis, increasing incidence in the western world is often attributed to persons entering from states with high tuberculosis rates. 40 much contemporary public health policy has rejected the 'fortress' approach to disease control in favour of seeing the public health mandate as imposing duties upon all members of a society or population, 18 or indeed duties of global health protection. the evidence base for border control as a public health, as distinct from a security, measure is limited, especially in a pandemic. 5 in relation to other diseases such as hiv and tuberculosis, border screening has proved to be unreliable and has shown little benefit for the health of the population. 41 compulsory border screening and refusal of entry to affected persons are contemplated by many states in their pandemic influenza preparedness plans, p and the revised ihr 2005 contemplate that who might recommend refusal of entry of suspect and affected persons and refusal of entry of unaffected persons to affected areas, 42 subject to the ethical consideration of respect, to the extent possible, for the individual right to freedom of movement. 43 article 19 of the ihr requires all signatory states to establish points of entry with surveillance and border control capacities. a consequence of having no internal eu borders is that the eu needs a strong common external border. under the 2004 eu free p for example, bulgaria, denmark, greece and latvia. movement directive, 44 member states may deny entry of eu citizens and their family members if they are considered to be a threat to public health, but only if this is proportionate and meets strict material and procedural safeguards. most eu member states q have signed the schengen convention, eliminating border controls between participating countries and creating an external frontier. the convention called for a common visa policy, harmonization of policies to deter illegal migration, and an automated schengen information system to coordinate actions in relation to individuals who had been denied entry. the 1997 amsterdam treaty incorporated the schengen convention into eu treaties, and set out a plan to integrate policies on visas, asylum, immigration and external border controls into community procedures and into the community legal framework. this has resulted in what is for all intents and purposes an eu external border, with much social and economic activity operating at regional rather than national level. however opt-out r and opt-in s possibilities make it difficult to define an administrative space that falls within the frontier, and there is no overarching political control. 45 rather, decisions are made by means of a complexity of intergovernmental and supranational institutions, and there remains considerable sovereign power in relation to many issues of border and public health relevance. the schengen agreement includes consent to share information about people, via the schengen information system. this means that a person cannot 'disappear' simply by moving from one participant country to another. a country is permitted by article 2.2 of the schengen agreement to reinstate border controls for a short period if it is deemed to be in the interest of national security. any schengen country can impose temporary or permanent border controls if it believes itself to be unprotected by other members. under this provision, portugal restricted border entry during the 2004 european football championship, as did france for the ceremonies marking the 60th anniversary of d-day, and again shortly after the london terrorism bombings of july 2005. with foot-and-mouth disease having been confirmed in france, the netherlands and britain, norway, in particular, put its border officers on high alert to prevent spread of the disease into the country. other nordic countries have also increased spot checks on entries into the region, irrespective of their new borderless status, in an attempt to contain foot-and-mouth disease. under the schengen borders code, third-country nationals may be refused entry if considered a threat to public health. one issue that arises from the lack of border controls within europe is the disparity in levels of disease preparedness across europe. in 2004, 10 new member states joined the eu, eight of which are former communist countries in central and eastern europe (slovenia, hungary, czech republic, poland, lithuania, latvia and estonia). these states are characterized by a history of underfunding of health and surveillance systems, unreliability of access to drugs, continuing increase in diseases such as drug-resistant tuberculosis and hiv/acquired immunodeficiency syndrome, and inadequate public health responses to disease. 46 since these states have entered into the eu, citizens can cross borders into other, better-resourced states. in the context of a pandemic, this could mean an influx of persons who are possible disease carriers from poor states with a frail public health system and with insufficient medicines, to other eu states, putting citizens at risk and draining health resources in those states. this creates difficult choices for host countries in terms of the assistance they offer. should they fail to offer healthcare services to mobile populations, these populations will put state population health at risk. should they offer healthcare services to mobile populations, this will strain resources and drain services from home populations. in their comparative study of european national preparedness plans, 11 mounier-jack and coker found that 15 eu states intended to take at least one measure to restrict travel to and from the state during a pandemic, and 13 of these states recommended border restrictions on entry and departure. one state proposed drafting new laws to give stronger border control powers. other states, however, conceded that by phase 6 of a pandemic, 47 while there might be political grounds for restrictions on travel, there would be little public health benefit. the possibility of border closure was an issue examined in exercise common ground, a pandemic influenza exercise for the european union, conducted by the uk's health protection agency over a 2-day period in november 2005. 48 this was the second of two eu exercises commissioned by the ec to evaluate the ability and capabilities of member states to respond to a health-related crisis, in this case an influenza pandemic. concern was expressed when switzerland indicated that it might consider the closure of its borders, given the location of drug manufacturers in switzerland. france's border closure proposals contained exceptions for pharmaceutical and vaccine materials and workers. the feasibility of instituting border controls within europe in a pandemic was then examined at an eu pandemic influenza workshop in august 2007. 49 it was concluded that while border closure might be a useful early containment strategy, at a pandemic stage, it would be impractical to enforce border controls within europe because of the porous nature of european borders and because of the need for cross-border traffic of goods. any prolonged border control would disrupt critical supply chains, and there was a risk that the consequent disruption of border controls within europe would result in greater harm than benefit. 50 screening at borders for diseases such as tuberculosis and hiv is common practice in many states, but has been much criticized on grounds of evidence and ethics. 41 a systematic review looking at the effectiveness of physical interventions such as screening in relation to respiratory viruses concluded that '(g)lobal and highly resource intensive measures such as screening at entry ports.lacked proper evaluation'. 51 there is also limited evidence regarding the efficacy of screening international passengers on departure or arrival in a flu pandemic, except possibly in the early phase. while control and screening measures may have worked in the days of slow travel, it is now the case that travel times are likely to be shorter than incubation periods, such that port screening will be ineffective in disease identification. nevertheless, the mounier-jack and coker study found that eight eu states proposed entry screening in their pandemic preparedness plans. 11 some european states indicated in exercise common ground that they intend to undertake border screening regardless of the evidence base, on the grounds that such measures provide reassurance to the public, and because the surveillance information might prove useful. the ihr 2005 authorize states to require information from travellers about their travels, and to undertake a non-invasive medical examination which is the least intrusive to achieve the public health objective. 52 entry may be refused where the traveller refuses to co-operate. 53 article 31 of the ihr provides that invasive medical examination, t vaccination or other prophylaxis shall not be required as a condition of entry except in limited circumstances, such as to determine whether a public health risk exists, or in relation to persons seeking temporary or permanent residence. in these circumstances, if a traveller refuses to comply, entry may be refused or be made subject to the least invasive procedure to achieve the public health objective. article 23 stipulates that such measures be undertaken within the confines of express informed consent and national and international safety guidelines, and article 32 requires that in implementing measures, travellers are to be treated with dignity and respect, and with recognition of gender, sociocultural, ethnic or religious concerns. within the eu, border measures are a matter of community competence that require state co-ordination. where eu member states intend to adopt border measures for the control of communicable diseases, they must inform and, where possible, consult other member states and the commission in advance. the exercise common ground report and the eu pandemic influenza workshop concluded that there was variability in the extent to which member states, european economic area states (including all eu countries plus iceland, norway and liechtenstein) and switzerland have included an international dimension in their pandemic influenza plans. rather, they have focused on national, domestic issues. it is necessary to consider an international dimension because: 'in a community like the eu, free of internal borders and with many common activities and free movement of people and goods, any countermeasures taken in one member state will be bound to affect at least some if not all, other member states'. 54 the reports noted that states also needed to address issues surrounding expatriates, travel restrictions, restriction of emigration, issues of contact persons and the potential for social disorder. there was a lack of clarity around community law on implementation of travel restrictions, and some confusion regarding the extent to which issues of freedom of mobility needed to be handled differently according to an individual's nationality. to be practical and costeffective, border measures would require policy coordination between countries of arrival and departure, and consensus between neighbouring states to avoid disruption. however, as mounier-jack and coker note, 11 few countries address the issue of collaboration with neighbouring states on matters of travel restrictions in their plans: ' there is clearly a need for countries within a european region to be informed and to inform others of their respective strategies in order to ensure that policies are consistent where necessary, or pose as few challenges as possible to public health protection where differences or inconsistencies exist. there may also be a need to ensure that european response mechanisms work together in harmony if public health interventions are to be similar in different countries'. national generic plans in europe have addressed issues of border control rather inadequately. questions have been raised about mobile populations and their implications for healthcare resources, but the issues remain unresolved. there appears to be political reluctance in the context of a united europe to invoke exemptions from internal market rules of free movement of goods and persons on grounds that neighbouring states are failing to address public health threats, and while there is concern about the consequent risk to populations, most states have taken the pragmatic view that any border control should take place at europe's external borders and not within europe. the variation in public health resources and in public health legal powers across eu states, in a context of free borders, is a concern for europe-wide pandemic disease strategies. it is not impossible that states with the strongest national public health powers, which permit, for example, compulsory vaccination or detention, will find some citizens moving states to avoid imposition of these powers. ideally, states within the eu will work together to achieve some commonality of pandemic disease policy and some commonality in their public health legal frameworks. much has been done to develop common policy approaches to preparation for an influenza pandemic across europe. however, article 152 of the european treaty, which states the eu objective of a high level of health protection and requires the european community to work with nation states to deal with health threats, does not allow for a policy of harmonization of state laws. the most that can be hoped for is some convergence of legal powers resulting from discussion and negotiation between states. the differing histories, politics, culture and legal systems of this group of highly divergent states does not bode well for agreement across europe on the appropriate legal response to disease threats. in an attempt to identify the extent to which there is variation in public health legal powers and the consequences of such variation for public health in europe, the phlawflu project is examining the role of national laws in the control of and protection against pandemic human influenza across europe. 2 the objective of the project is to provide an evolving critical study of national laws supporting and constraining defined issues of communicable disease control across europe, and to provide a resource to support public health law reform and public health policy making in europe. the project methodology includes workshops bringing together public health policy makers from 32 european states to examine legal responses to disease scenarios. it is to be hoped that some common legal responses emerge from these exercises, and given the absence of attention paid to public health laws in europe in recent years, that much can be learned by all states on ways in which to use law as a tool in pandemic disease control. meanwhile, europe is in a complex place in relation to its public health approach to pandemic disease. in times of economic strength and freedom from threats of war and disease, the commonality of eu states comes to the fore, and states are ready and willing to engage in joint enterprise. where states are at threat, however, they tend to turn inward on themselves, and political and cultural differences emerge. in times of threat, states which have traditionally been strong on public intervention in private rights are unwilling to accede to the approaches of more liberal states. traditionally, liberal states are reluctant to impose draconian measures, but at the same time may be unwilling to carry the public health burden of citizens from poorer states. the revised ihr have done much to focus public health law reform measures and to ensure some minimum commonality of content, but it is clear that some states, in accordance with their legal culture, are prepared to undertake more intrusive interventions than others. for all these concerns, it is clear that public health laws will be a mainstay of pandemic disease strategies, both in relation to the eu and in relation to nation states within europe. public health laws will be essential in providing powers to enable actions to be taken to control disease spread, but also to constrain states from taking actions that might reassure short-term security concerns but that have potentially harmful long-term public health consequences. of course, such issues are not unique to europe, but the nature of europe as a continent and as a legal entity creates particular complications for the ways in which law might best be used to create a coordinated european pandemic disease strategy. one unexpected benefit of the pandemic threat has been the renewed interest in exploring the role of law as a communicable disease tool, and in the examination of the range of public health legal approaches across europe. globally, a greater understanding of the role of public health law as a tool for managing and minimizing the spread of communicable disease will be a lasting and invaluable legacy of governance efforts in relation to pandemic influenza. none sought. none declared. european centre for disease prevention and control. technical report: pandemic influenza preparedness in the eu. status report as of autumn european public health law network website. available at: www.ephln.org social measures may control pandemic flu better than drugs and vaccine report on the influenza epidemic in nsw in 1919 world health organization writing group. nonpharmaceutical interventions for pandemic influenza, national and community measures the exercise of public health powers in an era of human rights: the particular problem of tuberculosis introduction. the importance of law for public health policy and practice public health powers in relation to tuberculosis in england and france: a comparison of approaches public health law and tuberculosis control in europe how prepared is europe for pandemic influenza? an analysis of national plans cabinet office and department of health. pandemic flu, a national framework for responding to an influenza pandemic. london: department of health pandemic flu, influenza pandemic contingency planning: operational guidance for health service planners. london: department of health ministry of social affairs and health. finnish national preparedness plan for pandemic influenza; proposal of the working group on national pandemic preparedness. helsinki: ministry of social affairs and health uk international priorities: a strategy for the fco. cmnd 6052. london: hmso the limits of law in the protection of public health and the role of public health ethics quarantine and prevention of disease ordinance the exercise of public health powers in cases of infectious disease: human rights implications a v secretary of state for the home department a v secretary of state for the home department greek case, 12 yb 1, opinion of the commission russian federation. ecthr judgment of 24 european commission for democracy through law (venice commission) the interface between public emergency powers and international law the law of exception: a typology of emergency powers drafted by the centre for law and the public's health at georgetown and johns hopkins universities the model state emergency health powers act bioterrorism, public health and civil liberties public-private health law: multiple directions in public health global public health security health, security and foreign policy public health strategies for pandemic influenza: ethics and the law health and human rights: a reader human rights and the new public health human mobility and population health increasing drug resistant tuberculosis in the uk compulsory screening of immigrants for tuberculosis and hiv world health organization. ethical considerations in developing a public health response to pandemic influenza directive 2004/58/ec of the european parliament and of the council of 29 mapping schengenland: denaturalizing the border health-care system frailties and public health control of communicable disease on the european union's new eastern border world health organization pandemic phases exercise common ground: a pandemic influenza exercise of the european union department of health and cabinet office. pandemic influenza -sharing of evidence and response policies across the eu. london: department of health workshops 11 and 12 facilitated by dr miguel betancourt cravioto and dr daniel reynders physical interventions to interrupt or reduce the spread of respiratory diseases: a systematic review specifications attached to the invitation to tender document, sanco/c3/ 2004/05, quoted in health protection agency, exercise common ground, a pandemic influenza exercise for the european union, final report. london: health protection agency none declared. key: cord-286361-wh6aaqlu authors: calman, k. title: beyond the ‘nanny state’: stewardship and public health date: 2009-01-09 journal: public health doi: 10.1016/j.puhe.2008.10.025 sha: doc_id: 286361 cord_uid: wh6aaqlu background: some public health measures restrict personal freedom more than others, and deciding what type of measure will be appropriate and effective has long been a problem for policy makers. existing bioethical frameworks are often not well suited to address the problems of public health. methods: the nuffield council on bioethics set up an expert working party to examine the ethical issues surrounding public health in january 2006. following evidence gathering and a public consultation exercise, the council published its conclusions and recommendations in the report ‘public health: ethical issues’ in november 2007. results: a spectrum of views exists on the relationship between the state's authority and the individual. the council set out a proposal to capture the best of the libertarian and paternalistic approaches, in what it calls the ‘stewardship model’. this model suggests guiding principles for making decisions about public health policies, and highlights some key principles including mill's harm principle, caring for the vulnerable, autonomy and consent. an ‘intervention ladder’ is also proposed, which provides a way of thinking about the acceptability of different public health measures. the report then applies these principles to a number of case studies: infectious diseases, obesity, alcohol and tobacco, and fluoridation of water supplies. conclusions: the idea of a ‘nanny state’ is often rejected, but the state has a duty to look after the health of everyone, and sometimes that means guiding or restricting people's choices. on the other hand, the state must consider a number of principles when designing public health programmes, and justification is required if any of these principles are to be infringed. the nuffield council on bioethics is an independent body that identifies, examines and reports on ethical questions raised by advances in biological and medical research. the council seeks to contribute to policy-making and stimulate debate in bioethics. it has published major reports on a range of topics, including genetic screening, healthcare research in developing countries, research involving animals, and the forensic use of dna. in january 2006, the council set up a working party to examine the ethical issues surrounding public health. this was chaired by lord krebs, and included members with expertise in health economics, law, philosophy, public health policy, health promotion and social science. this article summarizes some of the conclusions and recommendations that were published in the report 'public health: ethical issues' 1 in november 2007, and presented to the uk public health association annual public health forum in april 2008. public health has been defined as 'the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society'. 2 but whose job specifically is it to ensure that we lead a healthy life? is it entirely up to us as individuals to choose how to lead our lives, or does the state also have a role to play? also, if the state does decide it should intervene, what type of intervention would be most appropriate and effective? the nuffield report presents an ethical framework that aims to help answer the question of when and how the state should act. a question that was fundamental to the council's inquiry was the relationship between the state's authority and the individual. a spectrum of views exists on this matter, from those who give priority to the individual, to those who believe that the collective interests of the population as a whole are the most important. the libertarian perspective finds that the authority of the state is limited to ensuring that members of the population are able to enjoy the 'natural' rights of man, such as life, liberty and property rights, e-mail address: chancellor@gla.ac.uk public health j o u r n a l h o m e p a g e : w w w . e l s e v i e rh e a l t h. c om / j ou r na l s / pu b h without interference from others. the libertarian state does not see the promotion of the welfare of its population as its proper role. at the other end of the spectrum is what can be called the 'collectivist' point of view. there are several forms, such as utilitarian and social contract approaches. the primary aim of the utilitarian approach is to maximize utility by focusing on achieving the greatest possible collective benefit. this means that actions or rules are generally measured by the degree to which they reduce pain and suffering, and promote overall happiness and wellbeing. in principle, they may allow the welfare or interests of some people to be 'sacrificed' if this were to lead to an increase in overall welfare. the social contract approach finds that the state's authority is based on the collective will of a community (e.g. as expressed in a democratic vote) to live together as an enduring nation state. this position will typically favour measures to promote the welfare of its citizens, including public goods and services of all kinds. there are, of course, a range of intermediate positions in between these two ends of the spectrum. essentially, they would recognize that the state should uphold certain fundamental individual rights, but also that it has a responsibility to care for the welfare of all citizens. these welfare considerations may include ensuring that all have a fair opportunity to make a decent life for themselves, and that efforts are made to level out unfair inequalities. positions of this type are generally thought of as liberal. most modern western states are, according to this analysis, liberal. an important question is how far it is proper for the state to introduce programmes that interfere, to different degrees, in the lives of its population in order to reduce the risks to the health of all or some of them. one way to start thinking about resolving this tension is provided by the 'harm principle', established by the philosopher john stuart mill. this suggests that state intervention is primarily warranted where an individual's actions affect others, i.e. coercion is legitimate where it acts to avoid harm to third parties. mill's harm principle was not limited to preventing harm to others. he also said: 'those who are still in a state to require being taken care of by others, must be protected against their own actions as well as against external injury.' so, mill recognized that the state can rightfully intervene to protect children, and other similar vulnerable people who require protection from, for example, damaging their own health. mill also saw the importance of educating and informing people so that they can make up their own minds about how to lead their life. hence, although mill's discussion of the harm principle shows that he would strongly oppose public health programmes which simply aim to coerce people to lead healthy lives, he is likely to support programmes which seek to 'advise, instruct and persuade' them so that they can make informed decisions about, for example, what to eat, how to exercise and so on. building on the harm principle, the council identified several further issues that are important to public health: individual consent, health inequalities, changing behaviour and community. the concept of consent is rightly at the centre of the practice of clinical medicine. consent for public health measures, however, is more complex. the practicalities of requiring each individual to consent to population-based interventions is extremely difficult, and may be impossible when rapid action is required. other mechanisms need to be identified. particular groups of people may differ in their health status, have varying health needs and respond differently to particular programmes. the uneven burden of ill health among different groups raises not only practical issues, but also the question of whether public health programmes should seek to reduce health inequalities. the council viewed the reduction of health inequalities as central to any public health programme. public education and information have a key role in the liberal framework, since they are non-coercive ways of bringing about improvements in health. however, long-term behaviour change is a major challenge. for example, information campaigns were not very effective in getting people to wear seatbelts; legislation was much more effective. the council used the term 'community' to describe the value of belonging to a society in which each person's welfare, and that of the whole community, matters to everyone. a shared commitment to collective ends is a key ingredient in public support for programmes aimed at securing goods that are essentially collective. the initial liberal framework therefore needs to be revised to make it less individualistic, and to better accommodate the value of the community. does this mean that we need to advocate paternalism, usually understood as the 'interference of a state or an individual with another person, against their will, and justified by a claim that the person interfered with will be better off or protected from harm'? the council suggests that it does not. in its report, the council set out a proposal that it considers appropriate to capture the best of the libertarian and paternalistic approaches, in what it calls the 'stewardship model'. the concept of stewardship means that liberal states have responsibilities to look after important needs of people, both individually and collectively. therefore, they are stewards to individual people, taking account of different needs arising from factors such as age, gender, ethnic background or socio-economic status, and to the population as a whole. 3, 4 in the author's view, the notion of stewardship gives expression to the obligation on states to seek to provide conditions that allow people to be healthy, especially in relation to reducing health inequalities. the lists below summarize the core characteristics that should be included in public health programmes carried out by a stewardship-guided state. concerning goals, public health programmes should: aim to reduce the risks of ill health that people might impose on each other; aim to reduce causes of ill health by regulations that ensure environmental conditions that sustain good health, such as the provision of clean air and water, safe food and decent housing; pay particular attention to the health of children and other vulnerable people; promote health not only by providing information and advice, but also with programmes to help people to overcome addictions and other unhealthy behaviours; aim to ensure that it is easy for people to lead a healthy life, for example by providing convenient and safe opportunities for exercise; ensure that people have appropriate access to medical services; and aim to reduce unfair health inequalities. in terms of constraints, such programmes should: not attempt to coerce adults to lead healthy lives; minimize interventions that are introduced without the individual consent of those affected, or without procedural justice arrangements (such as democratic decision-making procedures) which provide adequate mandate; and seek to minimize interventions that are perceived as unduly intrusive and in conflict with important personal values. these positive goals and negative constraints are not listed in any hierarchical order. the implementation of these principles may, of course, lead to conflicting policies. however, in each particular case, it should be possible to resolve these conflicts by applying those policies or strategies that achieve the desired social goals while minimizing significant limitations on individual freedom. various third parties also have a role in the delivery of public health. these may be medical institutions, charities, businesses, local authorities, schools and so on. corporate agents whose activities affect public health include businesses such as food, drink, tobacco, water and pharmaceutical companies, owners of pubs and restaurants, and others whose products and services can either contribute to public health problems or help to alleviate them. in the same way that one would not judge the ethical acceptability of actions of individuals by merely assessing whether or not they have broken the law, it is reasonable to argue that commercial companies have responsibilities beyond merely complying with legal and regulatory requirements. genuine corporate social responsibility clearly has a role to play in public health. however, if there is a lack of corporate responsibility, or a 'market failure', it is acceptable for the state to intervene where the health of the population is at significant risk. there are two main types of evidence relevant to public health: evidence about causes of ill health, and evidence about the efficacy and effectiveness of interventions. achieving an ethical public health policy may seem straightforward: data on a particular public health problem need to be assessed, and an evidence-based strategy that can be justified in ethical terms needs to be adopted. however, even where every reasonable step has been taken to ensure that evidence is robust, in practice it is often incomplete or ambiguous, and will usually be contested. thus, scientific evidence does not necessarily lead to a clear policy that is likely to be the most effective. there are several other factors that are important for successfully planning and implementing public health policies, such as the perception of risk, the notion of a precautionary approach, individual choice, preservation of autonomy, and targeting of at-risk groups. the challenge for public health measures at the population level is to achieve the right balance when several of these goals have to be met simultaneously. personal behaviours can have a significant effect on health, and a range of different interventions can be used to attempt to change the behaviour of individuals or communities, such as regulation, taxes, subsidies and incentives, and provision of services and information. to assist in thinking about the acceptability and justification of different policy interventions to improve public health, the council devised what it calls the 'intervention ladder'. in general, the higher the rung on the ladder at which the policy maker intervenes, the stronger the justification has to be. eliminate choice; for example, through compulsory isolation of patients with infectious diseases. restrict choice; for example, removing unhealthy ingredients from foods, or unhealthy foods from shops or restaurants. guide choice through disincentives; for example, through taxes on cigarettes, or by discouraging the use of cars in inner cities through charging schemes or limitations of parking spaces. guide choices through incentives; for example, offering tax breaks for the purchase of bicycles that are used as a means of travelling to work. guide choices through changing the default policy; for example, in a restaurant, instead of providing chips as a standard side dish (with healthier options available), menus could be changed to provide a more healthy option as standard (with chips as an option available). enable choice; for example, by offering participation in a national health service (nhs) stop smoking programme, building cycle lanes or providing free fruit in schools. provide information; for example, campaigns to encourage people to walk more or eat five portions of fruit and vegetables per day. do nothing or simply monitor the current situation. there are a number of factors influencing the effectiveness of a public health intervention. these might include, for example, an unwillingness among individuals to change; whether there has been democratic engagement; the existence of commercial interests; the influence of the media; the views of ethnic, religious, voluntary and single issue groups; social movements; and economic issues, both personal and national. to illustrate how the factors discussed so far are born out in practice, the council considered a number of case studies and presented recommendations for policy makers within each. in europe and other western countries, death rates from infectious diseases have decreased over the past century. however, such diseases still account for over 10% of deaths and around one in three general practitioner visits in the uk. 5 information about rates of infection and the emergence of new diseases is crucial for planning public health interventions. collecting anonymized data is not seen as very intrusive, but nonanonymized data interferes more with a person's privacy. when a serious outbreak emerges, it may be necessary for governments to introduce quite stringent, liberty-infringing policies to control its spread, for example by isolating those who are infected. the council concluded that to assess and predict trends in infectious diseases, it is acceptable for anonymized data to be collected and used without consent, as long as any invasion of privacy is reduced as far as possible. it may be ethically justified to collect non-anonymized data about individuals without consent if this means that significant harm to others will be avoided. highly intrusive measures to control infectious diseases, such as quarantine and isolation, would only be justified where there is a real risk of harm to others that could be reduced significantly. outbreaks of infectious diseases can have global implications. all cases of certain serious diseases such as severe acute respiratory syndrome and new strains of influenza must be reported to the world health organization. however, different countries have different capacities for monitoring and reporting infectious diseases. the council concluded that countries such as the uk should provide assistance to developing countries to enable effective surveillance of infectious diseases. vaccination programmes protect individuals against infection and, in many cases, also bring about 'population immunity'. more directive policies, such as penalties for those who do not comply, may achieve higher levels of vaccine uptake. the council concluded that vaccination policies that go further than simply providing information and encouragement to take up the vaccine may be justified if they help reduce harm to others, and/or protect children and other vulnerable people. this would need to take account of the risks associated with the vaccination and the disease itself, the seriousness of the threat of disease to others, and whether a directive measure would be more effective than a voluntary measure. after weighing up the evidence and ethical considerations, the council concluded that there is not sufficient justification in the uk for moving beyond the current voluntary system for routine childhood vaccinations. being overweight or obese is a risk factor for several health conditions, including diabetes, stroke, some cancers, and lung and liver problems. the number of people who are obese has increased substantially over the past few decades in the uk and in many other countries. the uk currently has the highest rate of obesity in europe, and a recent report estimated that 60% of adult men, 50% of adult women and approximately 25% of all children under 16 years of age could be obese by 2050. 6 the causes of obesity are complex and there are no simple solutions. to help people to lead an active life, the council concluded that town planners and architects should be trained to encourage people to be physically active through the design of buildings, towns and public spaces. several different ways of providing front-of-pack information on food packaging have been introduced, and in 2007, a major study on whether food labelling contributes to healthier choices was commissioned by the food standards agency. the results of the study are expected in the spring of 2009. the council concluded that the scheme that is found to be most effective should be taken up. where industry fails to do this, there is an ethical justification for introducing legislation. increasing levels of childhood obesity are a particular concern. children require special protection from harm, and are particularly vulnerable due to their limited ability to make genuine choices, and their susceptibility to influences such as food marketing. the council concluded that there is an ethical justification for the state to intervene in schools to achieve a more positive attitude towards healthy eating, cooking and physical activity. stronger regulation of advertising food to children should be considered. it has been argued that if a person's behaviour has contributed to their need for nhs treatment, they should not have the same access to treatment as other people. obesity, however, is often related to factors outside the individual's control, such as living in an environment that makes it difficult to exercise or eat healthily. the council concluded that it would generally be inappropriate to deny nhs treatment to people simply on the basis of their obesity. however, persuading them to change their behaviour could be justified, provided that this would make the medical intervention more effective and that they were offered assistance. excessive drinking is associated with major health problems and also affects third parties, for example through drink driving and violence. the number of deaths from medical conditions caused by alcohol consumption doubled between 1991 and 2005 in the uk. 7 for tobacco, regular smoking of even a small number of cigarettes is harmful to the health of the smoker and people around them. in the uk, smoking was associated with one in six of all deaths between 1998 and 2002. 8 therefore, the banning of smoking in enclosed public places in the uk was a welcome development. increasing tax on alcohol and restricting the hours of sale have been shown to be effective in reducing alcohol consumption. however, the uk government's policies on alcohol have focused on public information campaigns and voluntary labelling schemes; measures that have been shown to be ineffective. the council concluded that measures that have been found to be effective in reducing alcohol consumption should be implemented by the uk government. these include increasing taxes on alcoholic beverages and restricting hours of sale. 9 the arguments in favour of banning smoking in public spaces can also be used to support banning it in homes where children are exposed to smoke. however, this would be extremely difficult to enforce without compromising privacy. the council concluded that there may be exceptional cases where children would be at such a high risk of harm from passive smoking, such as if they had a serious respiratory condition, that intervention in the home may be ethically acceptable, although any such case would usually need to be decided in court. corporate social responsibility is especially problematic in the case of the tobacco industry; the best strategy would simply be not to market the product. nevertheless, the council believes that the industry does have a role to play in harm reduction, particularly in an international context. it concluded that policies on selling and advertising tobacco and alcohol that provide the greatest protection to consumers should be adopted worldwide. the members of the uk tobacco manufacturers' association and other companies involved with tobacco products should implement a voluntary code of practice to achieve this. fluoridation involves adding fluoride to the water supply with the aim of improving dental health. at present, approximately 10% of the uk population receives a water supply that has been fluoridated to a certain level or has a similar amount of fluoride present naturally. 10 there has long been debate over whether fluoridation schemes should be rolled out in other areas of the uk. fluoridation programmes have been controversial because, although fluoridation has been implemented in some areas for several decades, there is little high-quality evidence available on the benefits and harms, making it difficult to quantify them. in addition, fluoridated water is either supplied or not supplied to a whole area; it is not possible to provide each individual with a choice or obtain their consent. the principle of avoiding coercive interventions could be used to argue against adding anything to the water supply. however, the council does not accept that this should always be ruled out, especially if the substance being added may bring health benefits. the acceptability of any public health policy involving the water supply should be considered in relation to: (i) the balance of risks and benefits; (ii) the potential for alternatives that rank lower on the intervention ladder to achieve the same outcome; and (iii) the role of consent where there are potential harms. the council concluded that the most appropriate way of deciding whether to fluoridate the water supply is to rely on democratic decision-making procedures. these should be implemented at the local and regional, rather than national, level because the need for, and perception of, water fluoridation varies between areas. the idea of a 'nanny state' is often rejected, but the state has a duty to look after the health of everyone, and sometimes that means guiding or restricting people's choices. on the other hand, the state must consider a number of key principles when designing public health programmes, including mill's harm principle, caring for the vulnerable, autonomy and consent (although the latter two may be of lesser importance in public health than in clinical medicine). justification is required if any of these principles are to be infringed. evidence of the causes of ill health and the effectiveness of interventions should also be an integral part of policy-making in public health. existing bioethical frameworks are often not well suited to address the problems of public health. the nuffield council on bioethics tried to address this and its report provides a framework for thinking about, planning and implementing public health measures. none declared what is public health nanny or steward? the role of government in public health. london: king's fund health protection in the 21st century -understanding the burden of disease; preparing for the future. part 4 infectious diseases. london: health protection agency tackling obesities: future choices. london: department of innovation universities and skills. available from: www.foresight.gov.uk/obesity/17.pdf the definition of alcohol-related deaths used by national statistics includes those causes regarded as most directly due to alcohol consumption national statistics. alcohol-related death rates almost double since 1991 the smoking epidemic in england. london: health development agency since the report was published, the uk government has imposed a 6% increase in all alcohol duty rates, and these will increase by 2% above the rate of inflation in future years london: british fluoridation society, uk public health association, british dental association and faculty of public health the nuffield council on bioethics has given permission for the findings of the report, 'public health: ethical issues' to be published in this article. 