"Ethical dilemmas in times of COVID 19: Screening and tracing methods in the Zambian context"

Please detail your project under the following headings 1) Project background, context and needs addressed Early this year, a novel zoonotic infection by the coronavirus (SARS-CoV-2) began causing COVID-19 across continents, leading the World Health Organization (WHO) to declare it a pandemic on 11th March 2020(1). This third zoonotic coronavirus, after SARS-CoV and MERS-CoV, is widely believed to have emanated from bats and the source is linked to the seafood market in Wuhan, China with a few studies suggesting otherwise (2). While "infection is normally characterized by respiratory symptoms, which indicates droplet transmission," some patients present with gastrointestinal symptoms and/or shed viral RNA or live infectious virus in faeces suggestive of faecal-oral transmission (3). Worryingly, some patients presented with symptoms after exposure to pre-symptomatic COVID19 cases. Given the implications of human interactions for the spread of infectious diseases, preventive measures include early case detection and quarantine even if asymptomatic (4). Since its first confirmed COVID19 cases in mid-March, Zambia has recorded a total of 88 confirmed cases (as at 26th April, 2020), with a surge in the number of cases after the death of a patient posthumously diagnosed with COVID-19 (5). Based on the public health Act, the government is mandated to impose measures to enhance health security and further statutory instruments have been invoked to empower officials to "intrude" the privacy of citizens and limit social interactions(6). With evidence that even one case can lead to a significant increase in the number of infected persons, the government has embarked on phone surveillance on persons who may have travelled or been in contact with a Covid19 patient. People have been requested to call a toll-free number to report not just themselves but also other persons suspected to be exposed to, or having signs of, COVID-19. We propose to study the "limitation" of individual rights and choices in times of pandemics through the lens provided by the theories of harm and rational egoism. The principle of harm contends that the actions of individuals should only be limited to prevent harm to other individuals (7). While the theory of rational egoism centres upon the idea that the rational thing to do must be to pursue one's own self-interest or that each person has but one ultimate aim, their own welfare (8, 9). These theories are used in understanding actions towards individuals and choices that individuals are likely to make and for whose benefit. For example, Everett et al reported that, despite strong heterogeneity in response, perceived benefit to others rather than 1) for the self or 2) for the innate virtue of recommended behaviours, motivated their U.S.-based sample to consider taking up preventive practices. This finding led to their suggestion that public messaging that emphasizes duty and responsibility to significant others. Thus, such information is useful to inform public health interventions and motivate desirable behaviours during emergency and pandemic situations. 2) Aims or research questions being addressed Aim: To identify the ethical dilemmas in times of COVID 19 concerning the screening and tracing methods in the Zambian context This research raises two primary ethical questions 1. What is the greater good in this pandemic? 2. What are the ethics of collecting information from patients? More specifically: a. What are the consequences of sharing the names of those with COVID-19 so that people who were in contact with them in the previous 7 days can seek testing services? b. What the implications of people refusing to give information regarding the people they have been in contact with forced to give this information against their will? c. What if persons with COVID-19 and/or their contacts knowingly give you inaccurate or incomplete information, for example, to conceal their whereabouts from significant others? d. What if they unknowingly provide inaccurate or incomplete information, for example, due to recall bias? e. What lessons can be learnt from the Zambian experience during the COVID19 pandemic? 3) Study design We propose a qualitative exploratory study. The philosophical principle of harm and theory of rational egoism and the ethical Delphi method will be used as basis for the inquiry. The ethical Delphi method is a method of inquiry, usually used in mixed methods, but in this case will be used qualitatively to get iterative participatory exchange of views and arguments on ethical issues by experts on the topic. An open-ended questionnaire will be sent to 20 different experts individually and their views will be used as basis for further study activities. 10 bio-scientists and frontline personnel in the fight against Covid19 will be interviewed and 8 ethicists will be invited to 5 Focus Group Discussions (FGDs) using zoom video conferencing. The recordings will be kept on a password protected computer and only be available to the research team. 10 Patients and those interviewed for contact tracing after travel or close intraction with a known case will also be interviewed by phone to get their perspective. The data will be analyzed using thematic analysis, where common themes will be drawn from the data and explained. A total of 20 In-depth interviews (IDIs) and 5FGDs will be conducted virtually. The participants will be purposively sampled for their expertise in research ethics and their experience in dealing with the COVID 19 cases and the whole process of screening for cases and planning to combat the pandemic. 4) Approach used to maximise the impact of research outputs, to improve health, and to the research community In order to maximize the impact of our research outputs, we will publish research findings in an open access journal for a wider coverage. This will help disseminate findings and lessons learnt from the Zambian perspective that may apply in similar settings for better health outcomes and community health. Recommendations will be drawn and shared with the Ministry of Health (MOH) through Zambia National Public Health Institute (ZNPHI) to improve emergency epidemic and pandemic case management with regard to ethics. 5) Expected outcomes 1. The project is expected to provide exploratory findings that may produce new comprehension or lead to other form of research inquiry 2. Ethical dilemmas in times of pandemics like COVID19 and some possible ways to deal with them will be identified 3. Detailed scrutiny of ethical implications of the Zambian Public Health Act and the relevant statutory instruments invoked to facilitate health security. 6) Your role in the project I will be the Principle Investigator in the project. My role will include overseeing all research activities including but not limited to collecting and analyzing the data, and dissemination of the findings. It will be my role to ensure the smooth and timely running of the whole project from inception and ensuring that the funds are being used as per budget. 1. Cucinotta D, Vanelli M. WHO Declares COVID-19 a Pandemic. Acta bio-medica : Atenei Parmensis. 2020;91(1):157-60. 2. Mackenzie JS, Smith DW. COVID-19: a novel zoonotic disease caused by a coronavirus from China: what we know and what we don't. Microbiology Australia. 2020:Ma20013. 3. Hindson J. COVID-19: faecal-oral transmission? Nature reviews Gastroenterology & hepatology. 2020. 4. Read JM, Eames KT, Edmunds WJ. Dynamic social networks and the implications for the spread of infectious disease. Journal of the Royal Society, Interface. 2008;5(26):1001-7. 5. Institute ZNPH. COVID19 updates. 2020. 6. Ministry of Legal Affairs GotRoZ. The Public Health Act: Chapter 295 of the lwas of Zambia. 2013. 7. Turner PN. "Harm" and Mill's Harm Principle. Ethics. 2014;124(2):299-326. 8. Cholbi M. The Moral Conversion of Rational Egoists. Social Theory and Practice. 2011;37(4):533-56. 9. Shaver R. Rational Egoism: A Selective and Critical History. Cambridge University Press 2009.