Research ethics review during the COVID-19 pandemic: An international study

Research ethics review committees (ERCs) worldwide faced daunting challenges during the COVID-19 pandemic. There was a need to balance rapid turnaround with rigorous evaluation of high-risk research protocols in the context of considerable uncertainty. This study explored the experiences and performance of ERCs during the pandemic. We conducted an anonymous, cross-sectional, global online survey of chairs (or their delegates) of ERCs who were involved in the review of COVID-19-related research protocols after March 2020. The survey ran from October 2022 to February 2023 and consisted of 50 items, with opportunities for descriptive responses to open-ended questions. Two hundred and three participants [130 from high-income countries (HICs) and 73 from low- and middle-income countries (LMICs)] completed our survey. Respondents came from diverse entities and organizations from 48 countries (19 HICs and 29 LMICs) in all World Health Organization regions. Responses show little of the increased global funding for COVID-19 research was allotted to the operation of ERCs. Few ERCs had pre-existing internal policies to address operation during public health emergencies, but almost half used existing guidelines. Most ERCs modified existing procedures or designed and implemented new ones but had not evaluated the success of these changes. Participants overwhelmingly endorsed permanently implementing several of them. Few ERCs added new members but non-member experts were consulted; quorum was generally achieved. Collaboration among ERCs was infrequent, but reviews conducted by external ERCs were recognized and validated. Review volume increased during the pandemic, with COVID-19-related studies being prioritized. Most protocol reviews were reported as taking less than three weeks. One-third of respondents reported external pressure on their ERCs from different stakeholders to approve or reject specific COVID-19-related protocols. ERC members faced significant challenges to keep their committees functioning during the pandemic. Our findings can inform ERC approaches towards future public health emergencies. To our knowledge, this is the first international, COVID-19-related study of its kind.

Demonstrating the reliability of in vivo metabolomics based chemical grouping: towards best practice

While grouping/read-across is widely used to fill data gaps, chemical registration dossiers are often rejected due to weak category justifications based on structural similarity only. Metabolomics provides a route to robust chemical categories via evidence of shared molecular effects across source and target substances. To gain international acceptance, this approach must demonstrate high reliability, and best-practice guidance is required. The MetAbolomics ring Trial for CHemical groupING (MATCHING), comprising six industrial, government and academic ring-trial partners, evaluated inter-laboratory reproducibility and worked towards best-practice. An independent team selected eight substances (WY-14643, 4-chloro-3-nitroaniline, 17α-methyl-testosterone, trenbolone, aniline, dichlorprop-p, 2-chloroaniline, fenofibrate); ring-trial partners were blinded to their identities and modes-of-action. Plasma samples were derived from 28-day rat tests (two doses per substance), aliquoted, and distributed to partners. Each partner applied their preferred liquid chromatography-mass spectrometry (LC-MS) metabolomics workflows to acquire, process, quality assess, statistically analyze and report their grouping results to the European Chemicals Agency, to ensure the blinding conditions of the ring trial. Five of six partners, whose metabolomics datasets passed quality control, correctly identified the grouping of eight test substances into three categories, for both male and female rats. Strikingly, this was achieved even though a range of metabolomics approaches were used. Through assessing intrastudy quality-control samples, the sixth partner observed high technical variation and was unable to group the substances. By comparing workflows, we conclude that some heterogeneity in metabolomics methods is not detrimental to consistent grouping, and that assessing data quality prior to grouping is essential. We recommend development of international guidance for quality-control acceptance criteria. This study demonstrates the reliability of metabolomics for chemical grouping and works towards best-practice.

The ethics of firing unvaccinated employees

Some organisations make vaccination a condition of employment. This means prospective employees must demonstrate they have been vaccinated (eg, against measles) to be hired. But it also means organisations must decide whether existing employees should be expected to meet newly introduced vaccination conditions (eg, against COVID-19). Unlike prospective employees who will not be hired if they do not meet vaccination conditions, existing employees who fail to meet new vaccination conditions risk being fired The latter seems worse than the former. Hence, objections to vaccination mandates commonly centre on the harms that will be visited on existing employees who are unwilling to be vaccinated. However, because this objection does not necessarily entail the claim that vaccination is unnecessary for the effective and safe performance of certain jobs, those making this objection should have less of an objection, or no objection at all (at least on these grounds), to introducing vaccination requirements in some cases for prospective employees. Yet, in this paper, I shall argue that if one has reason to believe vaccination requirements can be justified for prospective employees, one should also believe they are justified for existing employees despite any asymmetry in consequences experienced by the two groups. As a consequence, common objections made against vaccination mandates grounded solely in the harms that may be experienced by existing employees who are unwilling to be vaccinated should be considered unpersuasive.

"She was finally mine": the moral experience of families in the context of trisomy 13 and 18- a scoping review with thematic analysis

INTRODUCTION

The value of a short life characterized by disability has been hotly debated in the literature on fetal and neonatal outcomes.

METHODS

We conducted a scoping review to summarize the available empirical literature on the experiences of families in the context of trisomy 13 and 18 (T13/18) with subsequent thematic analysis of the 17 included articles.

FINDINGS

Themes constructed include (1) Pride as Resistance, (2) Negotiating Normalcy and (3) The Significance of Time.

INTERPRETATION

Our thematic analysis was guided by the moral experience framework conceived by Hunt and Carnevale (2011) in association with the VOICE (Views On Interdisciplinary Childhood Ethics) collaborative research group.

RELEVANCE

This article will be of interest and value to healthcare professionals and bioethicists who support families navigating the medically and ethically complex landscape of T13/18.

What medical-legal partnerships can do for trauma patients and trauma care

ABSTRACT

Trauma patients are particularly vulnerable to the impact of preexisting social and legal determinants of health postinjury. Trauma patients have a wide range of legal needs, including housing, employment, debt, insurance coverage, and access to federal and state benefits. Legal support could provide vital assistance to address the social determinants of health for injured patients. Medical legal partnerships (MLPs) embed legal professionals within health care teams to improve health by addressing legal needs that affect health. Medical legal partnerships have a successful track record in oncology, human immunodeficiency virus/acquired immune deficiency syndrome, and pediatrics, but have been little used in trauma. We conducted a scoping review to describe the role of MLPs and their potential to improve health outcomes for patients with traumatic injuries. We found that MLPs use legal remedies to address a variety of social and structural conditions that could affect patient health across several patient populations, such as children with asthma and patients with cancer. Legal intervention can assist patients in obtaining stable and healthy housing, employment opportunities, debt relief, access to public benefits, and immigration assistance. Medical legal partnership structure varies across institutions. In some, MLP lawyers are employed directly by a health care institution. In others, MLPs function as partnerships between a health system and an external legal organization. Medical legal partnerships have been found to reduce hospital readmissions, increase treatment utilization by patients, decrease patient stress levels, and benefit health systems financially. This scoping review outlines the potential of MLPs to improve outcomes for injured patients. Establishing trauma-focused MLPs could be a feasible intervention for trauma centers around the country seeking to improve health outcomes and reduce disparities for injured patients.

Navigating the uncertainty: A novel taxonomy of vaccine hesitancy in the context of COVID-19

Vaccine hesitancy remains a significant and evolving public health challenge. The COVID-19 pandemic has created a unique decision context with significant uncertainty caused by the novelty of the disease being targeted, unfamiliarity with the vaccines being offered, misinformation, and strong handed government measures. In an effort to extend our understanding of vaccine hesitancy to the high uncertainty decision environment presented by COVID-19, we present a novel taxonomy of the determinants of vaccine hesitancy, based on an inductive analysis of qualitative data gathered during the COVID-19 pandemic. We report on focus group data from a purposive sample of 18 Canadians with varying sociodemographic characteristics and COVID-19 vaccination attitudes. An inductive thematic analysis of this data reveals eight core themes related to vaccine hesitancy: values, trust, social environment, personal anecdotes, environmental fluctuation, prior knowledge, perceived risk & systems of care. We explore these core themes as well as 25 sub-themes, contrasting them with previous models of vaccine hesitancy and suggesting potential strategies for public health professionals.

Institutional trust is a distinct construct related to vaccine hesitancy and refusal

BACKGROUND

Vaccine hesitancy is driven by a heterogeneous and changing set of psychological, social and historical phenomena, requiring multidisciplinary approaches to its study and intervention. Past research has brought to light instances of both interpersonal and institutional trust playing an important role in vaccine uptake. However, no comprehensive study to date has specifically assessed the relative importance of these two categories of trust as they relate to vaccine behaviors and attitudes.

METHODS

In this paper, we examine the relationship between interpersonal and institutional trust and four measures related to COVID-19 vaccine hesitancy and one measure related to general vaccine hesitancy. We hypothesize that, across measures, individuals with vaccine hesitant attitudes and behaviors have lower trust-especially in institutions-than those who are not hesitant. We test this hypothesis in a sample of 1541 Canadians.

RESULTS

A deficit in both interpersonal and institutional trust was associated with higher levels of vaccine hesitant attitudes and behaviors. However, institutional trust was significantly lower than interpersonal trust in those with high hesitancy scores, suggesting that the two types of trust can be thought of as distinct constructs in the context of vaccine hesitancy.

CONCLUSIONS

Based on our findings, we suggest that diminished institutional trust plays a crucial role in vaccine hesitancy. We propose that this may contribute to a tendency to instead place trust in interpersonally propagated belief systems, which may be more strongly misaligned with mainstream evidence and thus support vaccine hesitancy attitudes. We offer strategies rooted in these observations for creating public health messages designed to enhance vaccine uptake.

Data Sharing During Pandemics: Reciprocity, Solidarity, and Limits to Obligations

South Africa shared with the world the warning of a new strain of SARS-CoV2, Omicron, in November 2021. As a result, many high-income countries (HICs) instituted complete travel bans on persons leaving South Africa and other neighbouring countries. These bans were unnecessary from a scientific standpoint, and they ran counter to the International Health Regulations. In short, South Africa was penalized for sharing data. Data sharing during pandemics is commonly justified by appeals to solidarity. In this paper, we argue that solidarity is, at best, an aspirational ideal to work toward but that it cannot ground an obligation to share data. Instead, low-and-middle income countries (LIMCs) should be guided by the principle of reciprocity, which states that we ought to return good for good received. Reciprocity is necessarily a conditional principle. LMICs, we argue, should only share data during future pandemics on the condition that HICs provide enforceable assurances that the benefits of data sharing will be equitably distributed and that LMICs won't be penalized for sharing information.

Bridging ethics and epidemiology: Modelling ethical standards of health equity

Health inequities are differences in health that are 'unjust'. Yet, despite competing ethical views about what counts as an 'unjust difference in health', theoretical insights from ethics have not been systematically integrated into epidemiological research. Using diabetes as an example, we explore the impact of adopting different ethical standards of health equity on population health outcomes. Specifically, we explore how the implementation of population-level weight-loss interventions using different ethical standards of equity impacts the intervention's implementation and resultant population health outcomes. We conducted a risk prediction modelling study using the nationally representative 2015-16 Canadian Community Health Survey (n = 75,044, 54% women). We used the Diabetes Population Risk Tool (DPoRT) to calculate individual-level 10-year diabetes risk. Hypothetical weight-loss interventions were modelled in individuals with overweight or obesity based on each ethical standard: 1) health sufficiency (reduce DPoRT risk below a high-risk threshold (16.5%); 2) health equality (equalize DPoRT risk to the low risk group (5%)); 3) social-health sufficiency (reduce DPoRT risk <16.5 in individuals with lower education); 4) social-health equality (equalize DPoRT risk to the level of individuals with high education). For each scenario, we calculated intervention impacts, diabetes cases prevented or delayed, and relative and absolute educational inequities in diabetes. Overall, we estimated that achieving health sufficiency (i.e., all individuals below the diabetes risk threshold) was more feasible than achieving health equality (i.e., diabetes risk equalized for all individuals), requiring smaller initial investments and fewer interventions; however, fewer diabetes cases were prevented or delayed. Further, targeting only diabetes inequalities related to education reduced the target population size and number of interventions required, but consequently resulted in even fewer diabetes cases prevented or delayed. Using diabetes as an example, we found that an explicit, ethically-informed definition of health equity is essential to guide population-level interventions that aim to reduce health inequities.

The importance of getting the ethics right in a pandemic treaty

The COVID-19 pandemic revealed numerous weaknesses in pandemic preparedness and response, including underfunding, inadequate surveillance, and inequitable distribution of countermeasures. To overcome these weaknesses for future pandemics, WHO released a zero draft of a pandemic treaty in February, 2023, and subsequently a revised bureau's text in May, 2023. COVID-19 made clear that pandemic prevention, preparedness, and response reflect choices and value judgements. These decisions are therefore not a purely scientific or technical exercise, but are fundamentally grounded in ethics. The latest treaty draft reflects these ethical considerations by including a section entitled Guiding Principles and Approaches. Most of these principles are ethical-they establish core values that undergird the treaty. Unfortunately, the treaty draft's set of principles are numerous, overlapping, and show inadequate coherence and consistency. We propose two improvements to this section of the draft pandemic treaty. First, key guiding ethical principles should be clearer and more precise than they currently are. Second, the link between ethical principles and policy implementation should be clearly established and define boundaries on acceptable interpretation, ensuring that signatories abide by these principles.

Artificial intelligence and the work-health interface: A research agenda for a technologically transforming world of work

The labor market is undergoing a rapid artificial intelligence (AI) revolution. There is currently limited empirical scholarship that focuses on how AI adoption affects employment opportunities and work environments in ways that shape worker health, safety, well-being and equity. In this article, we present an agenda to guide research examining the implications of AI on the intersection between work and health. To build the agenda, a full day meeting was organized and attended by 50 participants including researchers from diverse disciplines and applied stakeholders. Facilitated meeting discussions aimed to set research priorities related to workplace AI applications and its impact on the health of workers, including critical research questions, methodological approaches, data needs, and resource requirements. Discussions also aimed to identify groups of workers and working contexts that may benefit from AI adoption as well as those that may be disadvantaged by AI. Discussions were synthesized into four research agenda areas: (1) examining the impact of stronger AI on human workers; (2) advancing responsible and healthy AI; (3) informing AI policy for worker health, safety, well-being, and equitable employment; and (4) understanding and addressing worker and employer knowledge needs regarding AI applications. The agenda provides a roadmap for researchers to build a critical evidence base on the impact of AI on workers and workplaces, and will ensure that worker health, safety, well-being, and equity are at the forefront of workplace AI system design and adoption.

Neurologic Physiology after Removal of Therapy (NeuPaRT) study: study protocol of a multicentre, prospective, observational, pilot feasibility study of neurophysiology after withdrawal of life-sustaining measures

INTRODUCTION

In donation after circulatory determination of death, death is declared 5 min after circulatory arrest. This practice assumes, but does not explicitly confirm, permanent loss of brain activity. While this assumption is rooted a strong physiological rationale, paucity of direct human data regarding temporal relationship between cessation of brain activity and circulatory arrest during the dying process threatens public and healthcare provider trust in deceased organ donation.

METHODS AND ANALYSIS

In this cohort study, we will prospectively record cerebral and brainstem electrical activity, cerebral blood flow velocity and arterial blood pressure using electroencephalography (EEG), brainstem evoked potentials, transcranial doppler and bedside haemodynamic monitors in adult patients undergoing planned withdrawal of life sustaining measures in the intensive care units at five hospital sites for 18 months. We will use MATLAB to synchronise waveform data and compute the time of cessation of each signal relative to circulatory arrest. Our primary outcome is the feasibility of patient accrual, while secondary outcomes are (a) proportion of patients with complete waveform recordings and data transfer to coordinating site and (b) time difference between cessation of neurophysiological signals and circulatory arrest. We expect to accrue 1 patient/site/month for a total of 90 patients.

ETHICS AND DISSEMINATION

We have ethics approval from Clinical Trials Ontario (protocol #3862, version 1.0, date 19 January 2022.) and the relevant Research Ethics Board for each site. We will obtain written informed consent from legal substitute decision makers. We will present study results at research conferences including donor family partner forum and in peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT05306327.

Complexities and benefits of adopting next-generation sequencing-based tuberculosis diagnostics: a qualitative study among stakeholders in low and high-income countries

OBJECTIVES

To clarify perceived benefits, barriers and facilitators of Mycobacterium tuberculosis next-generation sequencing implementation in Madagascar and Canada, towards informing implementation of this diagnostic technology in public health agencies and clinical settings in and beyond these settings.

DESIGN

This qualitative study involved conducting semistructured interviews with key stakeholders engaged with next-generation sequencing implementation in Madagascar and Canada. Team-based descriptive analysis supported by Nvivo V.12.0 was used to identify key themes.

SETTING

The study was conducted with participants involved at the clinical, diagnostic and surveillance levels of tuberculosis (TB) management from Madagascar and Canada.

PARTICIPANTS

Eighteen participants were interviewed (nine Madagascar and nine Canada) and included individuals purposively sampled based on involvement with TB surveillance, laboratory diagnosis and clinical management.

RESULTS

The following five themes emerged in the analysis of Malagasy and Canadian interviews: (1) heterogeneity in experience with established TB diagnostics, (2) variable understanding of new sequencing-based diagnostics potential; (3) further evidence as being key to expand adoption; (4) ethical arguments and concerns; (5) operational and system-level considerations.

CONCLUSION

There persists important lack of familiarity with TB next-generation sequencing (TB NGS) applications among stakeholders in Canada and Madagascar. This translates into skepticism on the evidence underlying its use and its true potential value added within global public health systems. If deployed, TB NGS testing should be integrated with clinical and surveillance programmes. Although this is perceived as a priority, leadership and funding responsibilities for this integration to happen remains unclear to clinical, laboratory and public health stakeholders.

Addressing Legal Needs as Violence Prevention: A National Survey of Legal Services Offered through Hospital-based Violence Intervention Programs

Hospital-based violence intervention programs (HVIPs) provide comprehensive services to survivors of community violence to address social determinants of health (SDOH) as risks factors for future violence. Medical-legal partnerships (MLPs) integrate lawyers into health care teams to address SDOH through the application of the law. Despite shared purposes, it is unknown if HVIP-MLPs exist. We sought to quantify the existing landscape of legal services provided by HVIPs, identify HVIP-MLPs, and characterize barriers to formation. Surveys and interviews were conducted in 2020 with 35 HVIPs of the Health Alliance for Violence Intervention (HAVI) concerning civil legal services. Most HVIPs screened for civil legal needs though none had an official MLP. Common civil legal needs included housing, mental health, and education. Barriers included no memorandum of understanding, legal confusion, funding, and overwhelming need. In 2021, no HVIP-MLP partnerships existed within HAVI. Establishing HVIP-MLPs may further support survivors of violence and address health inequity.

Use of digital technologies for public health surveillance during the COVID-19 pandemic: A scoping review

Throughout the COVID-19 pandemic, a variety of digital technologies have been leveraged for public health surveillance worldwide. However, concerns remain around the rapid development and deployment of digital technologies, how these technologies have been used, and their efficacy in supporting public health goals. Following the five-stage scoping review framework, we conducted a scoping review of the peer-reviewed and grey literature to identify the types and nature of digital technologies used for surveillance during the COVID-19 pandemic and the success of these measures. We conducted a search of the peer-reviewed and grey literature published between 1 December 2019 and 31 December 2020 to provide a snapshot of questions, concerns, discussions, and findings emerging at this pivotal time. A total of 147 peer-reviewed and 79 grey literature publications reporting on digital technology use for surveillance across 90 countries and regions were retained for analysis. The most frequently used technologies included mobile phone devices and applications, location tracking technologies, drones, temperature scanning technologies, and wearable devices. The utility of digital technologies for public health surveillance was impacted by factors including uptake of digital technologies across targeted populations, technological capacity and errors, scope, validity and accuracy of data, guiding legal frameworks, and infrastructure to support technology use. Our findings raise important questions around the value of digital surveillance for public health and how to ensure successful use of technologies while mitigating potential harms not only in the context of the COVID-19 pandemic, but also during other infectious disease outbreaks, epidemics, and pandemics.

Between rules and resistance: moving public health emergency responses beyond fear, racism and greed

In times of a public health emergency, lawyers and ethicists play a key role in ensuring that government responses, such as travel restrictions, are both legally and ethically justified. However, when travel bans were imposed in a broadly discriminatory manner against southern African countries in response to the Omicron SARS-CoV-2 variant in late 2021, considerations of law, ethics or science did not appear to guide politicians' decisions. Rather, these bans appeared to be driven by fear of contagion and electoral blowback, economic motivations and inherently racist assumptions about low-income and middle-income countries (LMICs). With a new pandemic treaty and amendments to the WHO's International Health Regulations (IHR) on the near-term horizon, ethics and international law are at a key inflection point in global health governance. Drawing on examples of bordering practices to contain contagion in the current pandemic and in the distant past, we argue that the current IHR is not adequately constructed for a just and equitable international response to pandemics. Countries impose travel restrictions irrespective of their need or of the health and economic impact of such measures on LMICs. While the strengthening and reform of international laws and norms are worthy pursuits, we remain apprehensive about the transformative potential of such initiatives in the absence of collective political will, and suggest that in the interim, LMICs are justified in seeking strategic opportunities to play the same stark self-interested hardball as powerful states.

Is the Cure Worse than the Disease? The Ethics of Imposing Risk in Public Health

Efforts to improve public health, both in the context of infectious diseases and non-communicable diseases, will often consist of measures that confer risk on some persons to bring about benefits to those same people or others. Still, it is unclear what exactly justifies implementing such measures that impose risk on some people and not others in the context of public health. Herein, we build on existing autonomy-based accounts of ethical risk imposition by arguing that considerations of imposing risk in public health should be centered on a relational autonomy and relational justice approach. Doing so better captures what makes some risk permissible and others not by exploring the importance of power and context in such deliberations. We conclude the paper by applying a relational account of risk imposition in the cases of (a) COVID-19 measures and (b) the regulation of sugar-sweetened beverages to illustrate its explanatory power.

Why we should not 'just use age' for COVID-19 vaccine prioritisation

Older age is one of the greatest risk factors for severe outcomes from COVID-19. If we believe it is important to use limited supplies of COVID-19 vaccines to protect the most vulnerable and prevent deaths, then available doses should be allocated with significant priority to older adults. Yet, we should resist the conclusion that age should be the sole criterion for COVID-19 vaccine prioritisation or that no younger populations (eg, those under the age of 60) should be prioritised until all older adults have been vaccinated. This article examines arguments that are commonly presented to abandon 'complex' vaccine prioritisation schemes in favour of 'just using age' (eg, prioritising those 80 years of age and older and then decreasing in a 5-year age bands until the entire population has had the opportunity to be vaccinated), and articulates the ethical reasons why these arguments are not persuasive.

Percutaneous cryoablation for desmoid fibromatosis: initial experience at a UK centre

AIM

To report the first UK experience of cryoablation in desmoid fibromatosis (DF) with particular focus on technique, safety, and efficacy.

MATERIALS AND METHODS

Patients were selected at multidisciplinary tumour board meetings at a specialist cancer hospital. Radiation dose, procedure duration, and number of cryoprobes were compared for small versus large tumours (>10 cm long axis). Response at magnetic resonance imaging (MRI) was evaluated using different criteria, and percentage agreement with clinical response as assessed in oncology clinic calculated.

RESULTS

Thirteen procedures were performed in 10 patients (eight women, median age 51 years, IQR 42-69 years) between February 2019 and August 2021. Procedures for large tumours had higher radiation dose (2,012 ± 1,012 versus 1,076 ± 519 mGy·cm, p=0.048) used more cryoprobes (13 ± 7 versus 4 ± 2, p=0.009), and were more likely to have residual unablated tumour (38 ± 37% versus 7.5 ± 10%, p=0.045). Adverse events were minor apart from one transient radial nerve palsy. Eight of 10 patients had symptomatic benefit at clinical follow-up (median 353 days, IQR 86-796 days), and three started systemic therapy mean 393 days later. All patients who had complete ablation demonstrated symptomatic response, with no instances of repeat treatment, recurrence, or need for systemic therapy during the study period. All progression occurred outside ablation zones.

CONCLUSION

Cryoablation for symptomatic DF is a reproducible technique with low, transient toxicity, where one or two treatments can achieve a meaningful response. Where possible, the ablation ice ball should fully cover DF tumours.

A framework for critical care triage during a major surge in critical illness

During the COVID-19 pandemic, many jurisdictions experienced surges in demand for critical care that strained or overwhelmed their healthcare system's ability to respond. A major surge necessitates a deviation from usual practices, including difficult decisions about how to allocate critical care resources. We present a framework to guide these decisions in the hope of saving the most lives as ethically as possible, while concurrently respecting, protecting, and fulfilling legal and human rights obligations. It was developed in Ontario in 2020-2021 through an iterative consultation process with diverse participants, but was adopted in other jurisdictions with some modifications. The framework features three levels of triage depending on the degree of the surge, and a system for prioritizing patients based on their short-term mortality risk following the onset of critical illness. It also includes processes aimed at promoting consistency and fairness across a region where many hospitals are expected to apply the same framework. No triage framework should ever be considered "final," and there is a need for further research to examine ethical issues related to critical care triage and to increase the extent and quality of evidence to inform critical care triage.

R&D during public health emergencies: the value(s) of trust, governance and collaboration

In January 2021, Dr Tedros Adhanom Ghebreyesus, director–general of the WHO, warned that the world was ‘on the brink of a catastrophic moral failure [that] will be paid with lives and livelihoods in the world’s poorest countries’. We are now past the brink. Many high-income countries have vaccinated their populations (which, in some cases, includes third and even fourth doses) and are loosening public health and social measures, while low-income and middle-income countries are struggling to secure enough supply of vaccines to administer first doses. While injustices abound in the deployment and allocation of COVID-19 vaccines, therapies and diagnostics, an area that has hitherto received inadequate ethical scrutiny concerns the upstream structures and mechanisms that govern and facilitate the research and development (R&D) associated with these novel therapies, vaccines and diagnostics. Much can be learnt by looking to past experiences with the rapid deployment of R&D in the context of public health emergencies. Yet, much of the ‘learning’ from past epidemics and outbreaks has largely focused on technical or technological innovations and overlooked the essential role of important normative developments; namely, the importance of fostering multiple levels of trust, strong and fair governance, and broad research collaborations. In this paper, we argue that normative lessons pertaining to the conduct of R&D during the 2014–2016 Ebola epidemic in West Africa provide important insights for how R&D ought to proceed to combat the current COVID-19 pandemic and future infectious disease threats.

WHO guidance on COVID-19 vaccine trial designs in the context of authorized COVID-19 vaccines and expanding global access: Ethical considerations

While the degree of COVID-19 vaccine accessibility and uptake varies at both national and global levels, increasing vaccination coverage raises questions regarding the standard of prevention that ought to apply to different settings where COVID-19 vaccine trials are hosted. A WHO Expert Group has developed guidance on the ethical implications of conducting placebo-controlled trials in the context of expanding global COVID-19 vaccine coverage. The guidance also considers alternative trial designs to placebo controlled trials in the context of prototype vaccines, modified vaccines, and next generation vaccines.

COVID-19 vaccination certificates and lifting public health and social measures: ethical considerations

Background: To reopen society, various countries are planning or have implemented differential public health and social measures (PHSMs) for COVID-19-vaccinated individuals, by exempting these individuals from some of these measures or restricting access to specific activities or services to them. Aims: To examine the ethical considerations raised by differential PHSMs in domestic contexts on the basis of individual vaccination status verified by vaccination certificates. Discussion: Decisions on whether and when measures should be lifted specifically for vaccinated individuals should be guided by scientific and ethical considerations. These considerations include the public health risks of differential lifting, particularly in a context where a substantial portion of society is not vaccinated; mitigation of inequities and unfair disadvantages for unvaccinated individuals; and whether to permit other health certificates or credentials besides proof of vaccination as alternative options to access specific activities or services, as a way to balance public health and freedom of movement. Conclusion: Vaccination certificates may undermine a population-based approach to COVID-19 vaccination to achieve and accelerate universal lifting of PHSMs, result in unfair and inequitable health and social outcomes, and generate social divisions at a time when solidarity within (and between) countries is necessary to navigate the pandemic and its burdens. Further research on the ethical acceptability and impact of COVID-19 vaccine certificates in countries that have implemented them should be carried out to inform future ethical considerations on this issue.

Governing the Access to COVID-19 Tools Accelerator: towards greater participation, transparency, and accountability

The Access to COVID-19 Tools Accelerator (ACT-A) is a multistakeholder initiative quickly constructed in the early months of the COVID-19 pandemic to respond to a catastrophic breakdown in global cooperation. ACT-A is now the largest international effort to achieve equitable access to COVID-19 health technologies, and its governance is a matter of broad public importance. We traced the evolution of ACT-A's governance through publicly available documents and analysed it against three principles embedded in the founding mission statement of ACT-A: participation, transparency, and accountability. We found three challenges to realising these principles. First, the roles of the various organisations in ACT-A decision making are unclear, obscuring who might be accountable to whom and for what. Second, the absence of a clearly defined decision making body; ACT-A instead has multiple centres of legally binding decision making and uneven arrangements for information transparency, inhibiting meaningful participation. Third, the nearly indiscernible role of governments in ACT-A, raising key questions about political legitimacy and channels for public accountability. With global public health and billions in public funding at stake, short-term improvements to governance arrangements can and should now be made. Efforts to strengthen pandemic preparedness for the future require attention to ethical, legitimate arrangements for governance.

Digital technology and disease surveillance in the COVID-19 pandemic: a scoping review protocol

INTRODUCTION

Infectious diseases pose a risk to public health, requiring efficient strategies for disease prevention. Digital health surveillance technologies provide new opportunities to enhance disease prevention, detection, tracking, reporting and analysis. However, in addition to concerns regarding the effectiveness of these technologies in meeting public health goals, there are also concerns regarding the ethics, legality, safety and sustainability of digital surveillance technologies. This scoping review examines the literature on digital surveillance for public health purposes during the COVID-19 pandemic to identify health-related applications of digital surveillance technologies, and to highlight discussions of the implications of these technologies.

METHODS AND ANALYSIS

The scoping review will be guided by the framework proposed by Arksey and O'Malley and the guidelines outlined by Colquhoun et al and Levac et al. We will search Medline (Ovid), PsycInfo, PubMed, Scopus, CINAHL (EBSCOhost), ACM Digital Library, Google Scholar and IEEE Explore for relevant studies published between December 2019 and December 2020. The review will also include grey literature. Data will be managed and analysed through an extraction table and thematic analysis.

ETHICS AND DISSEMINATION

Findings will be disseminated through traditional academic channels, as well as social media channels and research briefs and infographics. We will target our dissemination to provincial and federal public health organisations, as well as technology companies and community-based organisations managing the public response to the COVID-19 pandemic.

What do we mean by critical and ethical global engagement? Questions from a research partnership between universities in Canada and Rwanda

Language - the words we use - can play a key role in enabling or limiting transformation of inequalities in the field of global health. At the same time, given the interdisciplinary, intersectoral, and international nature of much global health work, intended meanings, commitments, and underlying values for words used cannot be taken for granted. This commentary sets out to clarify, and in this manner render available for further discussion and debate, the phrase 'critical and ethical global engagement' (CEGE). It derives from discussions between scholars and partners in research, education, and healthcare practice based at one Canadian and two Rwanda institutions. Initially, our aim was to conceptualise the term 'critical and ethical global engagement' in order to guide our own practices. As the complexity of the values, commitments, and considerations underlying our use of this phrase emerged, however, we realised these discussions merited being captured and shared, to facilitate further exploration and exchange on this phrase.

Informing 'good' global health research partnerships: A scoping review of guiding principles

Background: Several sets of principles have been proposed to guide global health research partnerships and mitigate inequities inadvertently caused by them. The existence of multiple sets of principles poses a challenge for those seeking to critically engage with and develop their practice. Which of these is best to use, and why? To what extent, if any, is there agreement across proposed principles?

Objective: The objectives of this review were to: (1) identify and consolidate existing documents and principles to guide global health research partnerships; (2) identify areas of overlapping consensus, if any, regarding which principles are fundamental in these partnerships; (3) identify any lack of consensus in the literature on core principles to support these partnerships.

Methods: A scoping review was conducted to gather documents outlining ‘principles’ of good global health research partnerships. A broad search of academic databases to gather peerreviewed literature was conducted, complemented by a hand-search of key global health funding institutions for grey literature guidelines.

Results: Our search yielded nine sets of principles designed to guide and support global health research partnerships. No single principle recurred across all documents reviewed. Most frequently cited were concerns with mutual benefits between partners (n = 6) and equity (n = 4). Despite a lack of consistency in the inclusion and definition of principles, all sources highlighted principles that identified attention to fairness, equity, or justice as an integral part of good global health research partnerships.

Conclusions: Lack of consensus regarding how principles are defined suggests a need for further discussion on what global health researchers mean by ‘core’ principles. Research partnerships should seek to interpret the practical meanings and requirements of these principles through international consultation. Finally, a need exists for tools to assist with implementation of these principles to ensure their application in research practice.

Should COVID-19 Vaccines Authorized for Emergency Use Be Considered "Essential" Medicines?

A critical debate in the race to develop, market, and distribute COVID-19 vaccines could define the future of this pandemic: How much evidence demonstrating a vaccine's safety and efficacy should be required before it is considered "essential"? If a COVID-19 vaccine were to be designated an essential medicine by the World Health Organization, this would invoke special "core" human rights duties for governments to provide the vaccine as a matter of priority irrespective of resource constraints. States would also have duties to make the vaccine available in adequate amounts, in the appropriate dosage forms, with assured quality and adequate information, and at an affordable price. This question is especially critical and unique given that COVID-19 vaccines have in many cases been authorized for use via national emergency use authorization processes-mechanisms that enable the public to gain access to promising medical products before they have received full regulatory approval and licensure. In this paper, we examine whether unlicensed COVID-19 vaccines authorized for emergency use should ever be considered essential medicines, thereby placing prioritized obligations on countries regarding their accessibility and affordability.

Top five ethical lessons of COVID-19 that the world must learn

As the world reflects upon one year since the first cases of coronavirus disease 2019 (COVID-19) and prepare for and experience surges in cases, it is important to identify the most crucial ethical issues that might lie ahead so that countries are able to plan accordingly. Some ethical issues are rather obvious to predict, such as the ethical issues surrounding the use of immunity certificates, contact tracing, and the fair allocation of vaccines globally. Yet, the most significant ethical challenge that the world must address in the next year and beyond is to ensure that we learn the ethical lessons of the first year of this pandemic. Learning from our collective experiences thus far constitutes our greatest moral obligation. Appreciating that decision-making in the context of a pandemic is constrained by unprecedented complexity and uncertainty, beginning in June 2020, an international group of 17 experts in bioethics spanning 15 countries (including low-, middle-, and high-income countries) met virtually to identify what we considered to be the most significant ethical challenges and accompanying lessons faced thus far in the COVID-19 pandemic. Once collected, the group met over the course of several virtual meetings to identify challenges and lessons that are analytically distinct in order to identify common ethical themes under which different challenges and lessons could be grouped. The result, described in this paper, is what this expert group consider to be the top five ethical lessons from the initial experience with COVID-19 that must be learned.

Learning Lessons from COVID-19 Requires Recognizing Moral Failures

The most powerful lesson learned from the 2013-2016 outbreak of Ebola in West Africa was that we do not learn our lessons. A common sentiment at the time was that Ebola served as a "wake-up call"-an alarm which signalled that an outbreak of that magnitude should never have occurred and that we are ill-prepared globally to prevent and respond to them when they do. Pledges were made that we must learn from the outbreak before we were faced with another. Nearly five years later the world is in the grips of a pandemic of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes coronavirus disease 2019 (COVID-19). It is therefore of no surprise that we are now yet again hearing that the COVID-19 pandemic serves as the "wake-up call" we need and that there are many lessons to be learned to better prepare us for future outbreaks. Will anything be different this time around? We argue that nothing will fundamentally change unless we truly understand and appreciate the nature of the lessons we should learn from these outbreaks. Our past failures must be understood as moral failures that offer moral lessons. Unless we appreciate that we have a defect in our collective moral attitude toward remediating the conditions that precipitate the emergence of outbreaks, we will never truly learn.

Immunity certification for COVID-19: ethical considerations

Restrictive measures imposed because of the coronavirus disease 2019 (COVID-19) pandemic have resulted in severe social, economic and health effects. Some countries have considered the use of immunity certification as a strategy to relax these measures for people who have recovered from the infection by issuing these individuals a document, commonly called an immunity passport. This document certifies them as having protective immunity against severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the virus that causes COVID-19. The World Health Organization has advised against the implementation of immunity certification at present because of uncertainty about whether long-term immunity truly exists for those who have recovered from COVID-19 and concerns over the reliability of the proposed serological test method for determining immunity. Immunity certification can only be considered if scientific thresholds for assuring immunity are met, whether based on antibodies or other criteria. However, even if immunity certification became well supported by science, it has many ethical issues in terms of different restrictions on individual liberties and its implementation process. We examine the main considerations for the ethical acceptability of immunity certification to exempt individuals from restrictive measures during the COVID-19 pandemic. As well as needing to meet robust scientific criteria, the ethical acceptability of immunity certification depends on its uses and policy objectives and the measures in place to reduce potential harms, and prevent disproportionate burdens on non-certified individuals and violation of individual liberties and rights.

Ethical conditions for accelerating COVID-19 vaccine research

There is a dire need to produce a safe and effective coronavirus disease 2019 (COVID-19) vaccine as quickly as possible to avert an enormous burden of morbidity and mortality. This need for speed has thus far resulted in significant deviations from standard approaches to vaccine research and regulatory approval. Yet, pandemics do not obviate the need for rigorous scientific evaluation of potential interventions and adherence to universal ethical standards. Consequently, steps taken to accelerate clinical research in the context of the current pandemic require an explicit ethical justification, particularly if we expect public trust in the vaccine. We argue that accelerating COVID-19 vaccine research can be ethically justified, but only if social value, scientific validity, and a favourable risk-benefit ratio can be maintained or enhanced when doing so.

Exploring the ethical issues in research using digital data collection strategies with minors: A scoping review

While emerging digital health technologies offer researchers new avenues to collect real-time data, little is known about current ethical dimensions, considerations, and challenges that are associated with conducting digital data collection in research with minors. As such, this paper reports the findings of a scoping review which explored existing literature to canvass current ethical issues that arise when using digital data collection in research with minors. Scholarly literature was searched using electronic academic databases for articles that provided explicit ethical analysis or presented empirical research that directly addressed ethical issues related to digital data collection used in research with minors. After screening 1,156 titles and abstracts, and reviewing 73 full-text articles, 20 articles were included in this review. Themes which emerged across the reviewed literature included: consent, data handling, minors' data rights, observing behaviors that may result in risk of harm to participants or others, private versus public conceptualizations of data generated through social media, and gatekeeping. Our findings indicate a degree of uncertainty which invariably exists with regards to the ethics of research that involves minors and digital technology. The reviewed literature suggests that this uncertainty can often lead to the preclusion of minors from otherwise important lines of research inquiry. While uncertainty warrants ethical consideration, increased ethical scrutiny and restricting the conduct of such research raises its own ethical challenges. We conclude by discussing and recommending the ethical merits of co-producing ethical practice between researchers and minors as a mechanism to proceed with such research while addressing concerns around uncertainty.

Social distancing, social justice, and risk during the COVID-19 pandemic

Social distancing is an important and necessary measure to help arrest the spread of SARS-CoV-2 during the COVID-19 pandemic. However, it does place persons who are socially or politically marginalized, including those who are of lower socio-economic status, at risk of further harms. In other words, marginalized or disadvantaged persons are at risk of both contracting SARS-CoV-2 and the risk of harms that may come about because of the social distancing measures themselves. Finally, a third layer of risk faced by marginalized persons would be the overuse of utility (i.e., maximize the benefit of resource x) as the primary ethics principle upon which to make allocation decisions, since oftentimes it is resource-intensive to help those in positions of social marginality. This three-fold risk of harm to which marginalized persons are subjected runs counter to the very notion of social justice that underpins public health. Social distancing in a socially just manner requires dialoguing with affected populations and providing social supports to marginalized persons, regardless of the associated costs.

Adequate surgical margins for dermatofibrosarcoma protuberans - A multi-centre analysis

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a locally aggressive tumour. Adequate margins have a positive impact on recurrence rates. The aim of this study is to assess how adequate margins are achieved and secondly which additional treatment modalities might be necessary to achieve adequate margins.

MATERIAL & METHODS

Patients with DFSP treated between 1991 and 2016 at three tertiary centres were included. Patient- and tumour characteristics were obtained from a prospectively held database and patient files.

RESULTS

A total of 279 patients with a median age of 39 (Interquartile range [IQ], 31-50) years and a median follow-up of 50 (IQ, 18-96) months were included. When DFSP was preoperatively confirmed by biopsy and resected with an oncological operation in a tertiary centre, in 86% was had clear pathological margins after one excision. Wider resection margins were significantly correlated with more reconstructions (p = 0.002). A substantial discrepancy between the primary surgical macroscopic and the pathological margins was found with a median difference of 22 (range, 10-46) mm (Fig. 1). There was no significant influence of the width of the pathological clear margins (if > 1 mm) and the recurrence rate (p = 0.710).

CONCLUSION

The wider the resection margins, the more likely it is to obtain clear pathological margins, but the more likely patients will need any form of reconstruction after resection. The aim of the primary excision should be wide surgical resection, where the width of the margin should be balanced against the need for reconstructions and surgical morbidity.

Key Ethical Concepts and Their Application to COVID-19 Research

During the WHO-GloPID COVID-19 Global Research and Innovation Forum meeting held in Geneva on the 11th and 12th of February 2020 a number of different ethical concepts were used. This paper briefly states what a number of these concepts mean and how they might be applied to discussions about research during the COVID-19 pandemic and related outbreaks. This paper does not seek to be exhaustive and other ethical concepts are, of course, relevant and important.

Publication Ethics During Public Health Emergencies Such as the COVID-19 Pandemic

Public health emergencies require real-time, accurate information to guide effective responses. Rapid publication of information can, therefore, advance both the scientific validity and the social value of research conducted in these contexts. Consequently, medical journals place a high priority on rapidly publishing reports on these emergencies, which the media often report on to the public. Today, the focus is on the rapid publication of research related to the COVID-19 outbreak. Tomorrow, it might be an influenza pandemic or a crisis related to a vaping-related illness. (Am J Public Health. Published online ahead of print May 14, 2020: e1-e2. doi:10.2105/AJPH.2020.305686).

Point-of-care lung ultrasound in patients with COVID-19 - a narrative review

Ultrasound imaging of the lung and associated tissues may play an important role in the management of patients with COVID-19-associated lung injury. Compared with other monitoring modalities, such as auscultation or radiographic imaging, we argue lung ultrasound has high diagnostic accuracy, is ergonomically favourable and has fewer infection control implications. By informing the initiation, escalation, titration and weaning of respiratory support, lung ultrasound can be integrated into COVID-19 care pathways for patients with respiratory failure. Given the unprecedented pressure on healthcare services currently, supporting and educating clinicians is a key enabler of the wider implementation of lung ultrasound. This narrative review provides a summary of evidence and clinical guidance for the use and interpretation of lung ultrasound for patients with moderate, severe and critical COVID-19-associated lung injury. Mechanisms by which the potential lung ultrasound workforce can be deployed are explored, including a pragmatic approach to training, governance, imaging, interpretation of images and implementation of lung ultrasound into routine clinical practice.

Deploying the Precautionary Principle to Protect Vulnerable Populations in Canadian Post-Market Drug Surveillance

Drug regulatory bodies aim to ensure that patients have access to safe and effective drugs; however, no matter the quality of pre-licensure studies, uncertainty will remain regarding the safety and effectiveness of newly approved drugs until a large and diverse population uses those drugs. Recent analyses of Canada’s post-market drug surveillance (PMDS) system have found that Canada’s PMDS system requires strengthening and that efforts must be improved to monitor and address the safety and effectiveness of approved drugs among vulnerable populations. Given the uncertainty that exists when drugs enter the market, some have suggested that the precautionary principle is relevant to guiding decision-making in this context. This paper responds to recommendations that the Canadian PMDS system should be responsive to the health needs of vulnerable populations by assessing the utility of deploying the precautionary principle to guide a post-market strategy for vulnerable populations.

Systems thinking and ethics in public health: a necessary and mutually beneficial partnership

Systems thinking has emerged as a means of conceptualizing and addressing complex public health problems, thereby challenging more commonplace understanding of problems and corresponding solutions as straightforward explanations of cause and effect. Systems thinking tries to address the complexity of problems through qualitative and quantitative modeling based on a variety of systems theories, each with their own assumptions and, more importantly, implicit and unexamined values. To date, however, there has been little engagement between systems scientists and those working in bioethics and public health ethics. The goal of this paper is to begin to consider what it might mean to combine systems thinking with public health ethics to solve public health challenges. We argue that there is a role for ethics in systems thinking in public health as a means of elucidating implicit assumptions and facilitating ethics debate and dialogue with key stakeholders.