Diagnostic testing
The beginning of the COVID-19 pandemic was marked by an absence of diagnostic tests in some countries. Ethical questions were raised, but there has been too little time for consensus guidance to emerge. We present here (1) the concerns raised in the media, (2) general ethical consensus principles that apply, and (3) when available, examples of recommendations and practices some have put in place, although they do not necessarily reflect ethical considerations.
Concerns
- There are too few diagnostics kits for widespread testing. The Washington Post
- There are too few testing materials (e.g., PPE, nasal swabs) for testing. Stat News
- There are too few trained technicians to process the tests. The Atlantic
- On whom should a limited supply of tests be used? The Washington Post
- How does a limited supply of tests affect the ability to effectively contain the epidemic? The New York Times
Ethical principles
- See ethics guidelines on this Dashboard for the allocation of scarce resources in the community and in hospitals.
Recommendations and practices
- Focus asymptomatic testing on persons with an increased likelihood of infection and on settings with particularly vulnerable populations. Evaluating and Testing Persons for Coronavirus Disease, CDC
- Where supplies are limited, the top priority for testing is those hospitalized with symptoms, healthcare workers, and residents in long-term care or congregate living settings. Evaluating and Testing Persons for Coronavirus Disease, CDC
- During the Ebola outbreak, the CDC recommended testing only be conducted for persons who meet the criteria for persons under investigation for Ebola Virus Disease. Guidance for Collection, Transport and Submission of Specimens for Ebola Virus Testing, CDC
Concerns
- Are poor neighborhoods being neglected? The Washington Post
- Are undocumented immigrants being neglected? Time Magazine
Ethical principles
- Policymakers should ensure that criteria for priority setting do not discriminate against individuals based on inappropriate characteristics, including but not limited to: gender, race and ethnicity, religion, political affiliation, national origin, or social or economic status. WHO Ethics in Pandemic Flu
- Recognize and act upon the fact that the ethical obligation to provide access to health care is not limited to persons with citizen status only. APHA Code of Ethics, 4.7.1.
- See ethics principles on this Dashboard for implementing control measures equitably.
Recommendations and practices
- When conducting health surveillance, collect information on sex, gender, and pregnancy status to identify differential risks and monitor differential impact WHO Ethics in an Outbreak
- Use testing to monitor outbreak control, particularly among vulnerable populations and high-risk populations Guidance on Reopening, CDC
Concerns
- Tests for employee health can create a false sense of security. The New York Times
- Several antibody tests are accurate. CNN, Center for Infectious Diseases Research and Practice
- Antigen tests are quick and inexpensive, but less accurate than tests for the virus. Science Magazine
Ethical principles
- Ensure data validity, account for the limitations of available data, determine statistical thresholds for defining significance, and take steps to assist others who use the data, including the media and policymakers, so they will not draw inappropriate conclusions regarding cause and effect. APHA Code of Ethics, 4.2.4.
- Employ the best available evidence to guide public health work. APHA Code of Ethics, 4.10.1.
Recommendations and practices
- Encourage sharing of data on test accuracy to help develop safe and accurate tests. Health Affairs
- Antibody testing is not recommended for diagnosing acute infection. Evaluating and Testing Persons fro Coronavirus Disease, CDC
- Antibody test results should not be used to determine if a person can return to work or whether to group people in settings such as schools, dormitories, and correctional facilities. Using Antibody Tests for COVID-19, CDC
Concerns
- It is important to collect hospital, race, and ethnicity data. CovidTracking.com
- The number of positive cases alone doesn’t provide the full story without a report of total tests administered CovidTracking.com
Ethical principles
- Sound guidelines should be based on the best available scientific evidence. CDC Ethics in Pandemic Flu
- Ensure data validity, account for the limitations of available data, determine statistical thresholds for defining significance, and take steps to assist others who use the data, including the media and policymakers, so they will not draw inappropriate conclusions regarding cause and effect. APHA Code of Ethics, 4.2.4.
- Recognize and acknowledge when evidence is changing or incomplete and when assumptions or contexts change the relevance of evidence. APHA Code of Ethics, 4.10.5
Concerns
- Immunity certificates will create a new class of employment. The New York Times
- Workers fear company refusal to share positive tests will put them in danger. The Washington Post
- Aggregate collected data on vulnerable populations are not being made publicly available. Newsy
Ethical principles
- Have safeguards in place so that public health information does not harm individuals or communities. APHA Code of Ethics, 4.1.5
- Give special attention to protecting the privacy and confidentiality of individuals when gathering data, collect only data elements and specimens necessary for disease control or protection, and remove personal identifying information from the data set as soon as it is no longer needed. APHA Code of Ethics, 4.2.5
- Require reporting of findings promptly, especially to individuals and community partners who contributed data to the investigation. APHA Code of Ethics, 4.2.7.
Recommendations and practices
- Privacy and security policies should be in place to protect patients and providers, and inform patients about how their data are being used Association of State and Territorial Health Officials
- After the Ebola outbreak, Bill Gates stated that systematic disease surveillance linked with national public health libraries and public access testing data are necessary in epidemics The New England Journal of Medicine