Based on the document by The Johns Hopkins Berman Institute of Bioethics

1. Ethics Guidance for the Public Health Containment of Serious Infectious Disease Outbreaks in Low Income Settings: Lessons from Ebola Based on the document by The Johns Hopkins Berman Institute of Bioethics (Add date & name of presenter here)

2. Organization of presentation Introduction: What do we mean by an ethically optimal response? How do we incorporate ethics into response activities? • Preparing for and Initiating Public Health Response Activities with Local Communities • Interacting with Local Communities During Public Health Containment • Outbreak Communication and Messaging • Special Considerations for Isolation, Quarantine and Social Distancing • Supporting and Protecting Outbreak Responders • Providing Care during Outbreaks • Supporting Survivors • Outbreak Recovery

3. Introduction: Ethically optimal public health response The goal of a public health response to a serious infectious disease outbreak is to prevent disease transmission and minimize illness and death, guided throughout by commitments to support local ownership of the response, and to treat individuals and communities with respect, fairness, and compassion.Community buy-inand community collaboration are critical to an effective and ethically optimal response.

4. Introduction: Guiding Ethics Principles • Respect: all actions reflect recognition of the inherent and equal moral worth of all individuals. Value on honesty, transparency, self-determination, and recognition of norms and culture. • Justice:programs are implemented fairly; benefits and burdens are distributed equitably. • Promoting good & preventing harm: applies to both individuals and communities. Show compassion, dis-allow stigma, safeguard well-being of those who are socially or financially disadvantaged.

5. Please note: • This presentation contains several recommendations to help assure an ethically optimal response.  • It is understood that lack of adequate resources often precludes full implementation of all these measures, even when they feel urgent, necessary and right.  • Doing what one can, in the spirit of these recommendations, may also be helpful, for example, in continuing to be respectful even when resources or staffing are inadequate. Scarcity of resources will greatly increase the challenges in responding.  But scarcity does not justify acting at the cost of ethics considerations. 

6. 1. Preparing for and Initiating Public Health Response Activities with Local Communities • Learn what you can about prevailing culture, norms, attitudes and traditions ahead of implementation. • Collaborate with local, national, and foreign leaders to identify if, which, and how containment strategies are needed. • Enter into communities demonstrating respect. • Identify and take steps to include and protect populations at heightened risk, and do so equitably. • Continually identify and synthesize best available evidence.

7. 1. Preparing for and Initiating Public Health Response Activities with Local Communities • Identify community leaders and local community groups to accompany or “host” response teams. • Identify and discuss local practices that may need to be modified due to transmission riskwhile considering which can be maintained. • Educate and include traditional healers. • Take steps to ensure potential benefits and burdens of proposed containment activities will be distributed equitably and fairly.

8. Example: By creating an open and interactive dialogue with community leadership during the Ebola outbreak in Liberia, responders learned that the burial teams working in Muslim communities must be comprised of Muslims, so that bodies would not be touched by non-Muslims. The creation of Muslim burial teams greatly reduced resistance to body collection in these communities. Lesson: Keep an open dialogue with community leadership

9. 2. Interacting with Local Communities During Public Health Containment • Demonstrate respect with everyday acts of respect, kindness, courtesy, and empathy. • Promote transparency about when, why, and how containment activities will be implemented and for how long. • Ensure outbreak response workers clearly distinguish their role and scope of authority. • Provide resources and information to act.

10. 2. Interacting with Local Communities During Public Health Containment • Respect privacy and confidentiality before, during, and after conducting frontline containment activities. • Include psychosocial support for all involved in the response. • Support two-way communication and feedback between managers and affected communities. • Support resolutions between responders at all levels as disagreements arise.

11. Example: During an outbreak of H1N1 flu in Guatemala, role playing exercises were facilitated between responders and stakeholders during which participants were paired and took turns assuming the other’s role in the outbreak response. Lesson: Be creative

12. 3. Outbreak Communication and Messaging • Communication and messages should reach all individuals and communities at risk, in a language and format they can understand. • Consider communication and messaging during outbreaks as a “dialogue,” and prioritize mechanisms of supporting two-way communication and feedback from affected communities. • Messages should be honest, transparent, evidence-based, actionable, and updated as more evidence becomes available.

13. 3. Outbreak Communication and Messaging • Communication campaigns should make a deliberate effort to ensure that messages do not perpetuate stigma or single out groups unfairly. • Pilot-test messages before broadcast, even in urgent situations – even with 2-3 local coworkers if needed. Ask a few people what they think the message means. • Listen to and counteract rumors – ask people what they are hearing, and why they think the outbreak is happening. • Craft messages to avoid instilling fear by using expressions of empathy, honesty, truthfulness, and refraining from over-assurances.  Give people actionable things to do, and use positive terms.

14. 4. Isolation, Quarantine, & Social Distancing Definitions • Isolation: separating people who are sick with a contagious disease from people who are not sick to protect uninfected people from exposure to the illness. • Quarantine: separating and restricting the movement of an individual who is not known to be sick, but who may have been exposed to a contagious disease.  The goal is to more closely observe the exposed person to see if he or she becomes sick in order to avoid spread to others. Community quarantine applies to restricting movement of a geographically defined group of people.  • Social distancing: community level efforts to restrict when and where people gather together in order to prevent or slow the spread of a contagious disease, may also refer to personal distancing directives that establish a minimum distance between individuals.

15. 4. Isolation, Quarantine, & Social Distancing • These are highly effective public health strategies to prevent disease transmission. • Implement only when epidemiologic evidence shows significant public health benefits. • Implement when there are no feasible alternative or less restrictive approach to achieve benefits. • Those in isolation or quarantine must have access to basic materials and communication. • Implement only if fairness is practiced and existing inequities are not aggravated.

16. 4. Isolation, Quarantine, & Social Distancing • Emphasize maintaining local courtesies and practices unless they pose a threat to public health. • Implement restrictive measures in collaboration with community leaders and local authorities, always demonstrating dignity and respect as possible. • Implement such that local stigmas and existing inequities are not exacerbated. • Restrictive measures should only be implemented with a plan to monitor their effectiveness and acceptability and reverse them as soon as possible. • Isolation/quarantine cannot be instilled unless provisions can be made for food, water, and communication for those restricted.

17. Example: During the 2014-2015 Ebola outbreak in West Africa, community members suggested turning off the siren on the ambulance because people in the community were frightened by the sound.  Lessons: Remain flexible, ask others for suggestions

18. 5. Supporting and Protecting Outbreak Responders • Outbreak responders must be trained and given appropriate personal protective equipment. • Governments’ and employers’ obligations extend to all response workers who put their own health at risk for the public good. • Governments and employers must prioritize making working conditions for responders as safe as possible; hazard pay cannot substitute for unsafe working conditions. • Governments and employers should uphold reasonable limits on healthcare workers’ risks when they can be no further minimized.

19. 5. Supporting and Protecting Outbreak Responders • Governments and employers should prepare and support outbreak responders regarding the psychosocial challenges of participating in the response. • Outbreak responders from international agencies should be prepared for the reality that they will likely have access to more advanced care and support than their local country counterparts. • Advocate for special considerations for hiring survivors as outbreak response workers or other jobs once outbreak is over.

20. 6. Providing Care and Treatment During Outbreaks • Provide evidence-based care and treatment (if available) to patients and their families. • Invest in strategies to improve equitable access to care and treatment if available. • Approach care with a commitment to transparency in decision-making and even in equipment. • Prioritize communication and feedback between patients in treatment facilities and their families.

21. 6. Providing Care and Treatment During Outbreaks • Balance outbreak care and treatment with other health needs. • Minimize psychological triggers of fear. • Respect the privacy and protect confidentiality of those who are ill in all aspects of care. • Show respect for basic human dignity in the provision of care; try to ‘humanize’ the care experience; facilitate communication and demonstrate kindness wherever possible. 

22. 7. Supporting Survivors • Refer survivors to clinical follow-up services. • Refer survivors to on-going social and psychological support; consider assistance in job-finding. • If possible, replace property of survivors (e.g., clothes, utensils) that may have been destroyed to reduce contagion.  • Prepare communities for and reduce stigma towards survivors who have returned home from isolation and care facilities. • Collaboratively develop a plan to provide supports to survivors and affected communities.

23. 8. Outbreak Recovery • Collectively develop benchmarks for when to re-open schools, borders, markets, hospitals, businesses, etc. • Suggest ways to respectfully recognize and remember those who were lost in the outbreak. • Consider long-term recovery goals and community perception of dismantling infrastructure built during the response.

24. 8. Outbreak Recovery • Consider how lessons learned during the outbreak can inform local preparedness planning. • Develop a multi-sectoral development plan. • Think about ways an outbreak could be leveraged for broader system strengthening initiatives.

25. Quick Review of Ethics Principles • Justice:programs are implemented fairly; benefits and burdens are distributed equitably. • Respect: all actions reflect recognition of the inherent and equal moral worth of all individuals. Value on honesty, transparency, self-determination, equal treatment of all. • Promoting good & preventing harm: applies to both individuals and communities. Show compassion, dis-allow stigma, protect rights of those who are socially or financially disadvantaged.

26. What would you do if… Why? Which ethics principles are applicable? (Please note that each case in this presentation is hypothetical but based on real circumstances.)

27. Village health workers have been instructed to conduct house-to-house visits in an effort to control a local outbreak of pneumonic plague. Their job is to identify and monitor close contacts of pneumonic plague patients and to make sure they get a seven-day course of antibiotics as chemoprophylaxis.

28. Following an outbreak of severe cholera, food baskets of rice, oil, lentils, fortified cereal, and water purifier are being provided to those who recovered but remain debilitated and wasted. Others in the community are demanding the same basket saying that they can’t afford those items and their families also need food. Should they also be provided food?

29. A highly respected village elder has just died from Ebola. Close relatives and other villagers feel it would be unacceptably disrespectful to the deceased elder and their ancestors if they did not wash his body before burial.

30. A young woman has been diagnosed with extremely drug resistant pulmonary tuberculosis. There are no beds available in the hospital ward for such cases, and besides, all the other cases are men. The health care staff say she needs to be isolated as soon as possible. What should they do? 

31. A breastfeeding woman with three children has tested positive for the Ebola virus. The status of her children is unknown. There is an Ebola Treatment Unit (ETU) three kilometers from her village, but if she goes to the ETU it will mean her children other than her baby cannot go with her. Should she be transported to the ETU?

32. Country X experienced an outbreak of measles in three of six provinces two years ago. Currently there is not enough vaccine in-country to fully implement the next round of MMR (measles, mumps, and rubella) vaccinations. On what basis should the decision of where to vaccinate be made?

33. The Zika virus has been linked to the birth defect microcephaly (infants are born with smaller-than-normal heads). Although it can be sexually transmitted, Zika is primarily mosquito-borne. You have been asked to organize and manage a Ministry of Health program for widespread spraying of insecticide because of an outbreak of Zika. The Permanent Secretary has ordered his entire district to be sprayed first, however the outbreak is concentrated in a much poorer district on the outskirts of the capital. What should you do?

34. Thank you! For the complete guidance document & related tools: http://bioethics.jhu.edu/outbreak_guidance