Public perceptions of pandemic influenza resource allocation: a deliberative forum using Grid/Group analysis

The shared ethical framework to allocate scarce medical resources: a lesson from COVID-19

The COVID-19 pandemic has helped to clarify the fair and equitable allocation of scarce medical resources, both within and among countries. The ethical allocation of such resources entails a three-step process: (1) elucidating the fundamental ethical values for allocation, (2) using these values to delineate priority tiers for scarce resources, and (3) implementing the prioritisation to faithfully realise the fundamental values. Myriad reports and assessments have elucidated five core substantive values for ethical allocation: maximising benefits and minimising harms, mitigating unfair disadvantage, equal moral concern, reciprocity, and instrumental value. These values are universal. None of the values are sufficient alone, and their relative weight and application will vary by context. In addition, there are procedural principles such as transparency, engagement, and evidence-responsiveness. Prioritising instrumental value and minimising harms during the COVID-19 pandemic led to widespread agreement on priority tiers to include health-care workers, first responders, people living in congregate housing, and people with an increased risk of death, such as older adults and individuals with medical conditions. However, the pandemic also revealed problems with the implementation of these values and priority tiers, such as allocation on the basis of population rather than COVID-19 burden, and passive allocation that exacerbated disparities by requiring recipients to spend time booking and travelling to appointments. This ethical framework should be the starting point for the allocation of scarce medical resources in future pandemics and other public health conditions. For instance, allocation of the new malaria vaccine among sub-Saharan African countries should be based not on reciprocity to countries that participated in research, but on maximally reducing serious illness and deaths, especially among infants and children.

Community engagement for outbreak preparedness and response in high-income settings: A systematic review

BACKGROUND

This review aims to (i) identify and critique existing methods of community engagement for outbreak preparedness and response in high-income settings, and (ii) understand community members' experiences of community engagement, and their views and concerns towards pandemic planning/response.

METHODS

Following the PRISMA guidelines, a systematic review was conducted by searching Medline, Embase, PubMed, Global Health, CINAHL Plus and Scopus for publications from 2004 to June 2019. Potential literature was screened using explicit inclusion and exclusion criteria. Included studies were appraised using the Critical Appraisal Skills Programme Qualitative Research checklist. Those using deliberative approaches were appraised using additional criteria for judging deliberation quality. Thematic synthesis was then conducted.

RESULTS

Primary studies employed participatory research approaches, deliberative forums, interviews/focus groups to engage community members on pandemic planning/response with varying degrees of involvement and methodological rigour. This review indicates such endeavours must take into account instrumental and relational considerations: socioeconomic pressures; agency and capacity; diversity and divergent views; educate, communicate and engage; trust and transparency.

CONCLUSION

Community engagement for pandemic planning/response requires clear methods, processes and who 'community' constitutes. Instrumental and relational considerations must be addressed concurrently in pandemic planning/response to enhance preparedness for public health emergencies.

Cultural Theory's Contributions to Risk Analysis: A Thematic Review with Directions and Resources for Further Research

Cultural theory (CT) developed from grid/group analysis, which posits that different patterns of social relations-hierarchist, individualist, egalitarian, and fatalist-produce compatible cultural biases influencing assessment of which hazards pose high or low risk and how to manage them. Introduced to risk analysis (RA) in 1982 by Douglas and Wildavsky's Risk and Culture, this institutional approach to social construction of risk surprised a field hitherto focused on psychological influences on risk perceptions and behavior. We explain what CT is and how it developed; describe and evaluate its contributions to the study of risk perception and management, and its prescriptions for risk assessment and management; and identify opportunities and resources to develop its contributions to RA. We suggest how the diverse, fruitful, but scattered efforts to develop CT both inside and outside the formal discipline of RA (as exemplified by the Society for Risk Analysis) might be leveraged for greater theoretical, methodological, and applied progress in the field.

The Fair Allocation of Scarce Medical Resources: A Comparative Study From Jordan

The allocation strategies during challenging situations among the different social groups is based on 9 principles which can be considered either individually: sickest first, waiting list, prognosis, youngest first, instrumental values, lottery, monetary contribution, reciprocity, and individual behavior, or in combination; youngest first and prognosis, for example. In this study, we aim to look into the most important prioritization principles amongst different groups in the Jordanian population, in order to facilitate the decision-making process for any potential medical crisis. We conducted an online survey that tackled how individuals would deal with three different scenarios of medical scarcity: (1) organ donation, (2) limited hospital beds during an influenza epidemic, and (3) allocation of novel therapeutics for lung cancer. In addition, a free-comment option was included at the end of the survey if respondents wished to contribute further. Seven hundred and fifty-four survey responses were gathered, including 372 males (49.3%), and 382 females (50.7%). Five groups of individuals were represented including religion scholars, physicians, medical students, allied health practitioners, and lay people. Of the five surveyed groups, four found “sickest-first” to be the most important prioritization principle in all three scenarios, and only the physicians group documented a disagreement. In the first scenario, physicians regarded “sickest-first” and “combined-criteria” to be of equal importance. In general, no differences were documented between the examined groups in comparison with lay people in the preference of options in all three scenarios; however, physicians were more likely to choose “combination” in both the second and third scenarios (OR 3.70, 95% CI 1.62–8.44, and 2.62, 95% CI 1.48–4.59; p < 0.01), and were less likely to choose “sickest-first” as the single most important prioritization principle (OR 0.57, CI 0.37–0.88, and 0.57; 95% CI 0.36–0.88; p < 0.01). Out of 100 free comments, 27 (27.0%) thought that the “social-value” of patients should also be considered, adding the 10th potential allocation principle. Our findings are concordant with literature in terms of allocating scarce medical resources. However, “social-value” appeared as an important principle that should be addressed when prioritizing scarce medical resources in Jordan.

Priority allocation of pandemic influenza vaccines in Australia - Recommendations of 3 community juries

BACKGROUND

Pandemic planning has historically been oriented to respond to an influenza virus, with vaccination strategy being a key focus. As the current COVID-19 pandemic plays out, the Australian government is closely monitoring progress towards development of SARS-CoV2 vaccines as a definitive intervention. However, as in any pandemic, initial supply will likely be exceeded by demand due to limited manufacturing output.

METHODS

We convened community juries in three Australian locations in 2019 to assess public acceptability and perceived legitimacy of influenza pandemic vaccination distribution strategies. Preparatory work included literature reviews on pandemic vaccine allocation strategies and on vaccine allocation ethics, and simulation modelling studies. We assumed vaccine would be provided to predefined priority groups. Jurors were then asked to recommend one of two strategies for distributing remaining early doses of vaccine: directly vaccinate people at higher risk of adverse outcomes from influenza; or indirectly protect the general population by vaccinating primary school students, who are most likely to spread infection.

RESULTS

Thirty-four participants of diverse backgrounds and ages were recruited through random digit dialling and topic-blinded social media advertising. Juries heard evidence and arguments supporting different vaccine distribution strategies, and questioned expert presenters. All three community juries supported prioritising school children for influenza vaccination (aiming for indirect protection), one by 10-2 majority and two by consensus. Justifications included that indirect protection benefits more people and is likely to be more publicly acceptable.

CONCLUSIONS

In the context of an influenza pandemic, informed citizens were not opposed to prioritising groups at higher risks of adverse outcomes, but if resources and epidemiological conditions allow, achieving population benefits should be a strategic priority. These insights may inform future SARS-CoV-2 vaccination strategies.

Influence of Community and Culture in the Ethical Allocation of Scarce Medical Resources in a Pandemic Situation: Deliberative Democracy Study

BACKGROUND

Stark gaps exist between projected health needs in a pandemic situation and the current capacity of health care and medical countermeasure systems. Existing pandemic ethics discussions have advocated to engage the public in scarcity dilemmas and attend the local contexts and cultural perspectives that shape responses to a global health threat. This public engagement study thus considers the role of community and culture in the ethical apportionment of scarce health resources, specifically ventilators, during an influenza pandemic. It builds upon a previous exploration of the values and preferences of Maryland residents regarding how a finite supply of mechanical ventilators ought to be allocated during a severe global outbreak of influenza. An important finding of this earlier research was that local history and place within the state engendered different ways of thinking about scarcity.

OBJECTIVE

Given the intrastate variation in the themes expressed by Maryland participants, the project team sought to examine interstate differences by implementing the same protocol elsewhere to answer the following questions. Does variation in ethical frames of reference exist within different regions of the United States? What practical implications does evidence of sameness and difference possess for pandemic planners and policymakers at local and national levels?

METHODS

Research using the same deliberative democracy process from the Maryland study was conducted in Central Texas in March 2018 among 30 diverse participants, half of whom identified as Hispanic or Latino. Deliberative democracy provides a moderated process through which community members can learn facts about a public policy matter from experts and explore their own and others' views.

RESULTS

Participants proposed that by evenly distributing supplies of ventilators and applying clear eligibility criteria consistently, health authorities could enable fair allocation of scarce lifesaving equipment. The strong identification, attachment, and obligation of persons toward their nuclear and extended families emerged as a distinctive regional and ethnic core value that has practical implications for the substance, administration, and communication of allocation frameworks.

CONCLUSIONS

Maryland and Central Texas residents expressed a common, overriding concern about the fairness of allocation decisions. Central Texas deliberants, however, more readily expounded upon family as a central consideration. In Central Texas, family is a principal, culturally inflected lens through which life and death matters are often viewed. Conveners of other pandemic-related public engagement exercises in the United States have advocated the benefits of transparency and inclusivity in developing an ethical allocation framework; this study demonstrates cultural competence as a further advantage.

Development of Seasonal Influenza Vaccination Recommendations: Relevance and Influence of the Evidence on the Decision-Making Process in France and the Netherlands

BACKGROUND

Target groups for seasonal influenza vaccination are defined at the country level and are based on several factors. However, little is known about the national decision-making procedures.

OBJECTIVE

The purpose of this study was to compare the evidence used for the development of recommendations and its impact on the choice of target groups in France and the Netherlands.

METHODS

A preliminary documentary analysis identified institutions to include in the assessment: governmental authorities, research institutions, associations, and manufacturers. At least one expert from each group was invited to our study. Thirty-three semi-structured interviews were conducted in 2013 (16 France, 17 the Netherlands). We used NVivo10® to perform a thematic content analysis.

RESULTS

Clinical/epidemiological studies were the evidence most used in both countries. Economic models were increasingly being used; these had greater influence on the decision making in the Netherlands than in France, probably because of the presence of a modeler. Generally, the quality of the evidence used was poor, although no systematic use of standard protocol for its assessment was observed. A general protocol was sometimes used in France; however, the personal judgment of the experts was crucial for the assessment in both countries.

CONCLUSIONS

There were differences in the target groups, for example, pregnant women, recommended only in France. France and the Netherlands use similar evidence for developing vaccination recommendations, although different decisions are sometimes made regarding target groups. This could be associated with the lack of systematic standard appraisals, increasing the influence of the experts' judgment on decision making. The development of standards for the appraisal of evidence is recommended.

Adoption of Preventive Measures and Attitudes Toward the H1N1 Influenza Pandemic in Schools

BACKGROUND

This study describes the perceived impact of H1N1 influenza and the adoption of the recommended measures to address the pandemic in schools.

METHODS

A cross-sectional self-reported survey was conducted in 433 schools in Barcelona addressed to the school principal or the H1N1 influenza designated person. A descriptive analysis was performed, stratifying by educational level and type of school. A logistic regression analysis also was conducted.

RESULTS

Around 70% of the respondents reported that there had been H1N1 influenza cases among students, being this percentage significantly higher among those schools offering primary education (74.4%) (p < .05). The main measures (single-use paper towels, availability of sanitizer solutions and 15 minutes ventilation per day of enclosed spaces) were implemented in most of the centers. However, the correct adoption of the main measures took place in around 30% of the schools, being the percentage lower in those offering only secondary education (Odds ratio [OR]: 0.518; 95% confidence interval [CI]:0.272-0.986) and those located in medium (OR: 0.438, 95% CI: 0.234-0.811) or low socioeconomic status (SES) districts (OR: 0.321, 95% CI: 0.159-0.649).

CONCLUSIONS

Despite the climate of social alarm, the perceived impact of H1N1 influenza in most schools was moderate. In future potential threats, the educational level and the SES of the school should be considered, especially when measures requiring purchasing any product are recommended but not provided.

Ethical considerations: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement

BACKGROUND

Mass critical care entails time-sensitive decisions and changes in the standard of care that it is possible to deliver. These circumstances increase provider uncertainty as well as patients' vulnerability and may, therefore, jeopardize disciplined, ethical decision-making. Planning for pandemics and disasters should incorporate ethics guidance to support providers who may otherwise make ad hoc patient care decisions that overstep ethical boundaries. This article provides consensus-developed suggestions about ethical challenges in caring for the critically ill or injured during pandemics or disasters. The suggestions in this article are important for all of those involved in any pandemic or disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials.

METHODS

We adapted the American College of Chest Physicians (CHEST) Guidelines Oversight Committee's methodology to develop suggestions. Twenty-four key questions were developed, and literature searches were conducted to identify evidence for suggestions. The detailed literature reviews produced 144 articles. Based on their expertise within this domain, panel members also supplemented the literature search with governmental publications, interdisciplinary workgroup consensus documents, and other information not retrieved through PubMed. The literature in this field is not suitable to support evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process.

RESULTS

We report the suggestions that focus on five essential domains: triage and allocation, ethical concerns of patients and families, ethical responsibilities to providers, conduct of research, and international concerns.

CONCLUSIONS

Ethics issues permeate virtually all aspects of pandemic and disaster response. We have addressed some of the most pressing issues, focusing on five essential domains: triage and allocation, ethical concerns of patients and families, ethical responsibilities to providers, conduct of research, and international concerns. Our suggestions reflect the consensus of the Task Force. We recognize, however, that some suggestions, including those related to end-of-life care, may be controversial. We highlight the need for additional research and dialogue in articulating values to guide health-care decisions during disasters.