79C3C34C52B45572883A05D425EB0F82

Managing Ethical Issues in Infectious Disease Outbreaks: Guidance Document

https://apps.who.int/iris/bitstream/handle/10665/250580/9789241549837-eng.pdf?sequence=1

http://leaux.net/URLS/ConvertAPI Text Files/1179BFAE6BECF21B470CF44E1CC7CDD1.en.txt

Examining the file media/Synopses/1179BFAE6BECF21B470CF44E1CC7CDD1.html:

This file was generated: 2020-12-01 09:27:53

Indicators in focus are typically shown highlighted in yellow; Peer Indicators (that share the same Vulnerability association) are shown highlighted in pink; "Outside" Indicators (those that do NOT share the same Vulnerability association) are shown highlighted in green; Trigger Words/Phrases are shown highlighted in gray.

Link to Orphaned Trigger Words (Appendix (Indicator List, Indicator Peers, Trigger Words, Type/Vulnerability/Indicator Overlay)


Applicable Type / Vulnerability / Indicator Overlay for this Input

Vulnerability TypeVulnerabilityIndicator# Matches
Politicalpolitical affiliationpolitical4
Politicalvulnerablevulnerable15
Politicalvulnerablevulnerability10
HealthCognitive Impairmentcognitive1
HealthCognitive Impairmentimpaired1
HealthDrug Usagedrug10
HealthDrug Usageinfluence1
HealthHIV/AIDSHIV2
HealthHIV/AIDShiv/aids0
HealthHealthy Peoplevolunteers1
HealthMentally Disabledmentally2
HealthMentally Disableddisability1
HealthMotherhood/Familyfamily13
HealthPhysically Disabledillness4
HealthPhysically Illsick4
HealthPregnantpregnant5
HealthUnconscious Peopleunconscious1
Healthillill2
Healthof childbearing age/fertilechildbearing age1
Healthpatients in emergency situationsemergencies7
SocialAccess to Social Goodsaccess27
SocialAccess to informationaccess to information1
SocialChildchild1
SocialChildchildren3
SocialEthnicityethnicity1
SocialFetus/Neonatefetus1
SocialIncarceratedliberty8
SocialIncarceratedrestricted6
SocialLinguistic Proficiencylanguage2
SocialLinguistic Proficiencylinguistic3
SocialMarital Statussingle1
SocialMothersmothers1
SocialOccupationjob5
SocialPolice Officerofficer13
SocialProperty Ownershiphome6
SocialProperty Ownershipproperty1
SocialRacial Minorityminority2
SocialReligionreligion1
SocialReligionreligious2
SocialSoldiermilitary2
SocialThreat of Stigmastigma2
SocialThreat of Stigmathreat1
SocialThreat of Stigmastigmatization9
SocialThreat of Violenceviolence7
SocialTrade Union Membershipunion1
SocialWomenwomen8
Socialeducationeducation3
Socialemployeesemployees2
Socialgendergender21
Socialparentsparents1
Socialphilosophical differences/differences of opinionopinion3
Socialphilosophical differences/differences of opinionphilosophy1
EconomicEconomic/Povertypoor2
EconomicEconomic/Povertypoverty1
EconomicEconomic/Povertysocial status2
General/OtherDependentdependent1
General/OtherDeveloping Countryunderdeveloped1
General/OtherImpaired Autonomyautonomy2
General/OtherPublic Emergencyemergency26
General/OtherRelationship to Authorityauthority5
General/Othercioms guidelinescioms1
General/Othercultural differenceculturally2
General/Otherdeclaration of helsinkihelsinki2
General/Otherparticipants in a control groupplacebo1

Political / political affiliation

Searching for indicator political:

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p.000006: decreasing needed resources and access to health care. Moreover, infectious disease outbreaks can generate or
p.000006: exacerbate social crises that can weaken already fragile health systems. Within such contexts, it
p.000006: is not possible to satisfy all urgent needs simultaneously, forcing decision-makers to weigh and prioritize potentially
p.000006: competing ethical values. Time pressures and resource constraints may force action without
p.000006: the thorough deliberation, inclusiveness and transparency that a robust ethical decision-making process demands.
p.000006:
p.000006: This guidance document on ethical issues that arise specifically in the context of infectious disease outbreaks aims to
p.000006: complement existing guidance on ethics in public health. It should therefore be read in conjunction with more general
p.000006: guidance on issues such as public health surveillance,
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006: research with human participants, and addressing the needs of vulnerable populations.
p.000006:
p.000006: Setting up decision-making systems and procedures in advance is the best way to ensure that ethically appropriate
p.000006: decisions will be made if an outbreak
p.000006: 8 occurs. Countries, health-care institutions,
p.000006: international organizations and others involved in epidemic response efforts are encouraged to develop practical
p.000006: strategies and tools to apply the principles in this guidance document to their specific settings, taking into account
p.000006: local social, cultural, and political contexts. WHO is committed to providing countries with technical assistance in
p.000006: support of these efforts.
p.000006:
p.000006:
p.000006: Relevant ethical principles
p.000006:
p.000006: Ethics involves judgements about “the way we ought to live our lives, including our actions, intentions, and our
p.000006: habitual behaviour.”3 The process of ethical analysis involves identifying relevant principles, applying them to a
p.000006: particular situation, and making judgements about how to weigh competing principles when it is not possible to satisfy
p.000006: them all. This guidance document draws on a variety of ethical principles, which are grouped below into seven general
p.000006: categories. These categories are presented merely for the convenience
p.000006: of the reader; other ways of grouping them are equally legitimate.
p.000006:
p.000006: Justice — As used in this document, justice, or fairness, encompasses two different concepts. The first is equity,
p.000006: which refers to fairness in the distribution of resources, opportunities and outcomes. Key elements of equity include
p.000006: treating like
p.000006: cases alike, avoiding discrimination and exploitation, and being sensitive to persons who are especially vulnerable to
p.000006: harm or injustice. The second aspect of justice is procedural justice, which refers to a fair process for making
p.000006: important decisions.
...

p.000006: Respect for persons — The term “respect for persons” refers to treating individuals in ways that are fitting to and
p.000006: informed by a recognition of our common humanity, dignity and inherent rights. A central
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006: aspect of respect for persons is respect for autonomy, which requires letting individuals make their own choices based
p.000006: on their values and preferences. Informed consent, a process in which a competent individual authorizes a course of
p.000006: action based on sufficient relevant information, without coercion or undue inducement, is one
p.000006: way to operationalize this concept. Where individuals lack decision-making capacity, it may be necessary for others to
p.000006: be charged with protecting their interests. Respect for persons also includes paying attention to values such as
p.000006: privacy and confidentiality, as well as social, religious and cultural beliefs and important relationships, including
p.000006: family bonds. Finally, respect for persons requires transparency and truth-telling in the context of carrying out
p.000006: public health and research activities.
p.000006:
p.000006: LibertyLiberty includes a broad range of social, religious and political freedoms, such as freedom of movement,
p.000006: freedom of peaceful assembly, and freedom of speech. Many aspects of liberty are protected as fundamental human rights.
p.000006:
p.000006: Reciprocity — Reciprocity consists of making a “fitting and proportional return” for contributions that people have
p.000006: made.6 Policies that encourage reciprocity can
p.000006: be an important means of promoting the principle of justice, as they can correct unfair disparities in the distribution
p.000006: of the benefits and burdens of epidemic response efforts.
p.000006:
p.000006: Solidarity — Solidarity is a social relation in which a group, community, nation
p.000006: or, potentially, global community stands together.7 The principle of solidarity justifies collective action in the
p.000006: face of common threats. It also supports efforts to overcome inequalities that undermine the welfare
p.000006: of minorities and groups that suffer from discrimination.
p.000006:
p.000006:
p.000006: Practical applications
p.000006:
p.000006: The application of ethical principles should be informed by evidence as far as it is
p.000006: available. For example, in determining 9
p.000006: whether a particular action contributes to utility, decision-makers should be guided by any available scientific
p.000006: evidence about the action’s expected benefits and harms.
p.000006: The more intrusive the proposed action, the greater the need for robust evidence that what is being proposed is likely
p.000006: to achieve its desired aim. When specific evidence is not available, decisions should be based
p.000006: on reasoned, substantive arguments and informed by evidence from analogous situations, to the extent possible.
p.000006:
p.000006: In balancing competing principles during infectious disease outbreaks, countries must respect their obligations under
p.000006: international human rights agreements. The Siracusa Principles on the Limitation and Derogation Provisions in the
p.000006: International Covenant on Civil and Political Rights
p.000006: (the “Siracusa Principles”)8 are a widely accepted framework for evaluating
p.000006: the appropriateness of limiting certain fundamental human rights in emergency situations. The Siracusa Principles
p.000006: provide that any restrictions on human rights must be carried out in accordance with the law and in pursuit of a
p.000006: legitimate objective of general interest. In addition, such restrictions must be strictly necessary and there must
p.000006: be no other, less intrusive means available to reach the same objective. Finally, any restrictions must be based on
p.000006: scientific evidence and not imposed in an arbitrary, unreasonable, or discriminatory manner.
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
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p.000006:
p.000006: For both pragmatic and ethical reasons, maintaining the population’s trust in epidemic response efforts is of
p.000006: fundamental importance. This is possible only if
p.000006: policy-makers and response workers act in a trustworthy manner by applying
p.000006: procedural principles fairly and consistently, being open to review based on new
p.000006: 10 relevant information, and acting with the
p.000006: genuine input of affected communities.
p.000006: In addition, a synchronized approach is indispensable to the success of any
p.000006: response effort. All members of the global community need to act in solidarity, since all countries share a common
p.000006: vulnerability to the threat of infectious disease.
p.000006:
p.000006:
p.000006: How the Guidance was developed
...

p.000050: 2008 (WHO/HSE/EPR/GIP/2008.2, WHO/IER/ETH/2008.1;
p.000050: http://apps.who.int/iris/bitstream/10665/69902/1/WHO_IER_ETH_2008.1_eng.pdf?ua=1, accessed 23 July 2016).
p.000050:
p.000050: 3 Guidance on ethics of tuberculosis prevention, care and control. Geneva: World Health Organization; 2010
p.000050: (WHO/HTM/TB/2010.16, http://apps.who.int/iris/ bitstream/10665/44452/1/9789241500531_eng.pdf?ua=1, accessed 23 July
p.000050: 2016).
p.000050:
p.000050: 4 Ethics of using convalescent whole blood and convalescent plasma during the Ebola epidemic. Geneva: World Health
p.000050: Organization; 2015 (WHO/HIS/KER/GHE/15.1; http://apps.who.int/iris/bitstream/10665/161912/1/WHO_HIS_KER_GHE_15.1_eng.
p.000050: pdf?ua=1&ua=1, accessed 23 July 2016).
p.000050:
p.000050: 5 Ethical considerations for use of unregistered interventions for Ebola viral disease. Geneva: World Health
p.000050: Organization; 2014 (WHO/HIS/KER/GHE/14.1, http://apps.who.
p.000050: int/iris/bitstream/10665/130997/1/WHO_HIS_KER_GHE_14.1_eng.pdf?ua=1, accessed 23 July 2016).
p.000050:
p.000050: 6 Becker L. Reciprocity, justice, and disability. Ethics. 2005;116(1):9–39.
p.000050:
p.000050: 7 Dawson A, Jennings B. The place of solidarity in public health ethics. Public Health Reviews. 2012;34(1):65–79.
p.000050:
p.000050: 8 Siracusa Principles on the Limitation and Derogation Provision in the International Covenant on Civil and
p.000050: Political Rights. Geneva: American Association for the International Commission of Jurists; 1985
p.000050: (http://icj.wpengine.netdna-cdn.com/wp-content/uploads/1984/07/Siracusa-
p.000050: principles-ICCPR-legal-submission-1985-eng.pdf, accessed 23 July 2016).
p.000050:
p.000050: 9 United Nations Economic and Social Council. General Comment No. 14: The right to Highest Attainable Standard of
p.000050: Health (Art. 12 of the International Covenant on Economic, Social and Cultural Rights). New York: United Nations
p.000050: Committee on Economic, Social and Cultural Rights (E/C. 12/2000/4 – 2000; www1.umn.edu/
p.000050: humanrts/gencomm/escgencom14.htm, accessed 23 July 2016).
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050: 10 Parpia AS, Ndeffo-Mbah ML, Wenzel NS, Galvani AP. Effects of response to the 2014–2015 Ebola outbreak on deaths
p.000050: from malaria, HIV/AIDS, and tuberculosis, West Africa. Emerg Infect Dis. 2016;22(3)
p.000050: (http://dx.doi.org/10.3201/eid2203.150977, accessed 23 July 2016).
p.000050:
p.000050: 11 Declaration of Helsinki – Ethical principles for medical research involving human subjects, revised October 2013
p.000050: Ferney-Voltaire: World Medical Association; 2013 (www.wma.net/ en/30publications/10policies/b3/index.html, accessed 23
p.000050: July 2016).
p.000050:
p.000050: 12 International ethical guidelines for biomedical research involving human subjects.
p.000050: Geneva: Council for International Organizations of Medical Sciences; 2002 (www.cioms. 51
p.000050: ch/publications/guidelines/guidelines_nov_2002_blurb.htm, accessed 23 July 2016).
...

Political / vulnerable

Searching for indicator vulnerable:

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p.000006: Invariably,
p.000006: the countries most affected by outbreaks have limited resources, underdeveloped legal and regulatory structures, and
p.000006: health systems that lack the resilience to deal with crisis situations. Countries that experience natural disasters and
p.000006: armed conflicts are particularly at risk, as these circumstances simultaneously increase the risk of infectious disease
p.000006: outbreaks while
p.000006: decreasing needed resources and access to health care. Moreover, infectious disease outbreaks can generate or
p.000006: exacerbate social crises that can weaken already fragile health systems. Within such contexts, it
p.000006: is not possible to satisfy all urgent needs simultaneously, forcing decision-makers to weigh and prioritize potentially
p.000006: competing ethical values. Time pressures and resource constraints may force action without
p.000006: the thorough deliberation, inclusiveness and transparency that a robust ethical decision-making process demands.
p.000006:
p.000006: This guidance document on ethical issues that arise specifically in the context of infectious disease outbreaks aims to
p.000006: complement existing guidance on ethics in public health. It should therefore be read in conjunction with more general
p.000006: guidance on issues such as public health surveillance,
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006: research with human participants, and addressing the needs of vulnerable populations.
p.000006:
p.000006: Setting up decision-making systems and procedures in advance is the best way to ensure that ethically appropriate
p.000006: decisions will be made if an outbreak
p.000006: 8 occurs. Countries, health-care institutions,
p.000006: international organizations and others involved in epidemic response efforts are encouraged to develop practical
p.000006: strategies and tools to apply the principles in this guidance document to their specific settings, taking into account
p.000006: local social, cultural, and political contexts. WHO is committed to providing countries with technical assistance in
p.000006: support of these efforts.
p.000006:
p.000006:
p.000006: Relevant ethical principles
p.000006:
p.000006: Ethics involves judgements about “the way we ought to live our lives, including our actions, intentions, and our
p.000006: habitual behaviour.”3 The process of ethical analysis involves identifying relevant principles, applying them to a
p.000006: particular situation, and making judgements about how to weigh competing principles when it is not possible to satisfy
p.000006: them all. This guidance document draws on a variety of ethical principles, which are grouped below into seven general
p.000006: categories. These categories are presented merely for the convenience
p.000006: of the reader; other ways of grouping them are equally legitimate.
p.000006:
p.000006: Justice — As used in this document, justice, or fairness, encompasses two different concepts. The first is equity,
p.000006: which refers to fairness in the distribution of resources, opportunities and outcomes. Key elements of equity include
p.000006: treating like
p.000006: cases alike, avoiding discrimination and exploitation, and being sensitive to persons who are especially vulnerable to
p.000006: harm or injustice. The second aspect of justice is procedural justice, which refers to a fair process for making
p.000006: important decisions.
p.000006: Elements of procedural justice include due process (providing notice to interested persons and an opportunity to be
p.000006: heard), transparency (providing clear and accurate information about the basis for decisions and the process by which
p.000006: they are made), inclusiveness/community engagement (ensuring all relevant stakeholders are able to participate in
p.000006: decisions), accountability (allocating and enforcing responsibility
p.000006: for decisions), and oversight (ensuring appropriate mechanisms for monitoring and review).
p.000006:
p.000006: Beneficence — Beneficence refers to acts that are done for the benefit of others, such as efforts to relieve
p.000006: individuals’ pain and suffering. In the public health context, the principle of beneficence underlies society’s
p.000006: obligation to meet the basic needs of individuals and communities, particularly humanitarian needs such as nourishment,
p.000006: shelter, good health, and security.
p.000006:
p.000006: Utility — The principle of utility states that actions are right insofar as they promote the well-being of individuals
p.000006: or communities. Efforts to maximize utility require consideration of proportionality (balancing the potential benefits
p.000006: of an activity against any risks of harm) and
p.000006: efficiency (achieving the greatest benefits at the lowest possible cost).
p.000006:
...

p.000015: and conveyed to the public.
p.000015:
p.000015: • Accountability — The public should know who is responsible for making
p.000015: and implementing decisions in relation to the outbreak response, and how they can challenge decisions they believe are
p.000015: inappropriate.
p.000015:
p.000015: The media will play an important role in any infectious disease outbreak response effort. It is therefore important to
p.000015: ensure that the media has access to accurate and timely information about the disease and its management. Governments,
p.000015: nongovernmental organizations, and
p.000015: academic institutions should make efforts to support media training in relevant scientific concepts and techniques for
p.000015: communicating risk information without raising unnecessary alarm. Media training is important for public health sector
p.000015: employees who may interact with media covering public health issues.
p.000015: In turn, the media has a responsibility to provide accurate, factual, and balanced reporting. This is an important
p.000015: component of media ethics.
p.000015:
p.000015:
p.000015: Cholera outbreak in Sierra Leone
p.000015: Source: Fid Thompson
p.000015:
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p.000015:
p.000015: 3. Situations of particular vulnerability
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000017: 17
p.000017: Questions addressed:
p.000017:
p.000017: • Why are some individuals and groups considered particularly vulnerable during infectious disease outbreaks?
p.000017: • How can vulnerability affect a person’s ability to access services during infectious disease outbreaks?
p.000017: • How can vulnerability affect a person’s willingness and ability to share and receive information during an
p.000017: infectious disease outbreak?
p.000017: • Why are stigmatization and discrimination particular risks during infectious disease outbreaks?
p.000017: • In what ways might vulnerable persons suffer disproportionate burdens from infectious disease response efforts,
p.000017: or have a greater need for resources?
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017: Some individuals and groups face heightened susceptibility to harm or injustice during infectious disease outbreaks.
p.000017: Policy-makers and epidemic responders should develop plans to address the needs of such individuals and groups in
p.000017: advance of an outbreak and,
p.000017: if an outbreak occurs, make reasonable efforts to ensure that these needs are actually met. Doing this requires ongoing
p.000017: attention to community engagement and the development of active social networks between community representatives and
p.000017: government actors.
p.000017:
p.000017: Efforts to address the ways in which individuals and groups may be vulnerable should take into account the following:
p.000017: • Difficulty accessing services and resources — Many of the
p.000017: characteristics that contribute to social vulnerability can make it difficult
p.000017: for individuals to access necessary services. For example, persons with physical disabilities may have mobility
p.000017: impairments that make travelling even short distances difficult or impossible.
p.000017: Other socially vulnerable persons may lack access to safe and reliable transportation or have caregiving
p.000017: responsibilities that make it difficult for them to leave their homes. In addition, vulnerable persons may lack access
p.000017: to necessary resources such as clean water or bednets to reduce the risk of contracting a mosquito-borne disease.
p.000017:
p.000017:
p.000017:
p.000017:
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p.000017:
p.000017:
p.000017:
p.000017:
p.000017: • Need for effective alternative communication strategies — Some types of vulnerability can impede
p.000017: an individual’s ability to transmit or receive information. Communication barriers can stem from a wide range of
p.000017: factors including, but not limited to, illiteracy, unfamiliarity with the
p.000017: 18 local or official language(s), vision or
p.000017: hearing impairments, social isolation, or lack of access to Internet and other communication services. These barriers
p.000017: make it difficult for individuals to receive necessary public health messages
p.000017: or to participate fully in community engagement activities. To overcome these barriers, messages should be delivered in
p.000017: multiple formats (e.g. radio, text messages, billboards, cartoons) as well as direct oral communication with key
p.000017: stakeholders. Health authorities should not assume that the public will search for information; instead, they should
p.000017: proactively reach out to the concerned population wherever they are.
p.000017:
p.000017: • Impact of stigmatization and discrimination — Members of socially disadvantaged groups often face considerable
p.000017: stigma and discrimination, which can be exacerbated in public health emergencies characterized by fear and distrust.
p.000017: Those responsible for infectious disease outbreak response should ensure that all individuals are treated fairly and
p.000017: equitably regardless of their social status or perceived “worth” to society. They should also take measures to prevent
p.000017: stigmatization and social violence.
p.000017:
p.000017: • Disproportionate burdens of outbreak response measures — Even when public health measures
p.000017: are designed with the best of intentions, they can inadvertently place a disproportionate burden on particular
p.000017: populations. For example, quarantine orders that require individuals to stay
p.000017: in their homes can have devastating consequences for persons who need to leave their homes to obtain basic
p.000017: necessities such as clean water or food. Similarly, social distancing measures such as school closures can place
p.000017: disproportionate burdens on children who depend on going to school to access regular meals, as well as on working
p.000017: parents who may have no one available to provide child care.
p.000017:
p.000017: • Greater need for resources — Accommodating the needs of individuals whose situation makes them particularly
p.000017: vulnerable sometimes requires the use of additional resources.
p.000017: In some cases, additional resources are relatively minimal, such as when an interpreter is hired to make
p.000017: a community engagement forum accessible to members of a linguistic minority group. In other cases, they may be more
p.000017: substantial, such as when mobile health teams are assembled to dispatch vaccines and treatments to hard-to-reach rural
p.000017: areas. It is legitimate to take costs into consideration in determining whether a particular accommodation is
p.000017: warranted; indeed, the goal of maximizing utility demands that such assessments be made.
p.000017: However, despite the importance of conserving limited resources, the ethical principle of equity may sometimes justify
p.000017: providing greater resources to persons who have greater needs.
p.000017:
p.000017: • Heightened risk of violence — Infectious disease outbreaks can
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017: exacerbate social unrest, increase criminality, and induce violent behaviour, especially against vulnerable groups such
p.000017: as minority populations
p.000017: or migrants. In addition, public health measures such as home isolation, quarantine, or closure of schools and work
p.000017: facilities can induce violence, particularly against women and children. Officials involved in outbreak planning and
p.000017: response efforts should be prepared for the possibility that
p.000017: specific populations may be targeted as being the cause of the outbreak or provoking transmission; strategies should be
p.000017: proactively designed to
p.000017: protect members of such groups from a heightened risk of violence.
p.000017:
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p.000019:
p.000019: A doctor inspects patients in an MSF supported hospital in Aweil,
p.000019: Northern Bar El Ghazal in South Sudan, 2011
p.000019: Source: Siegfried Modola/IRIN
p.000019:
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p.000019: 4. Allocating scarce resources
p.000019:
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p.000020: 20
p.000020: Questions addressed:
p.000020:
...

p.000020: of health-care workers. As
p.000020: a result, deaths from tuberculosis, human immunodeficiency virus (HIV), and malaria increased dramatically during this
p.000020: period.10
p.000020:
p.000020: Governments, health-care facilities, and others involved in response efforts should
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020: prepare for such situations by developing guidelines on the allocation of scarce resources in outbreak situations. Such
p.000020: guidelines should be developed through an open and transparent process involving broad stakeholder input and, to the
p.000020: extent
p.000020: possible, should be incorporated into formal written documents that establish clear priorities and procedures. Those
p.000020: involved
p.000020: in developing these guidelines should be guided by the following considerations:
p.000020:
p.000020: • Balancing considerations of utility and equity — Resource allocation decisions should be guided by the ethical
p.000020: principles of utility and equity. The principle of utility requires allocating resources to maximize benefits and
p.000020: minimize burdens, while the principle of equity requires attention to the fair distribution of benefits
p.000020: and burdens. In some cases, an equal distribution of benefits and burdens may be considered fair, but in others, it may
p.000020: be fairer to give preference to groups that are worse off, such as the poor, the sick, or the vulnerable. It is not
p.000020: always be possible to achieve fully both utility and equity. For example, establishing treatment centres in large urban
p.000020: settings promotes the value of utility because it makes it possible to treat a large number of people with relatively
p.000020: few resources. However, such
p.000020: an approach may be in tension with the principle of equity if it means that fewer resources will be directed to
p.000020: isolated communities in remote rural areas.
p.000020: There is no single correct way to resolve potential tensions between utility
p.000020: and equity; what is important is that decisions are made through an inclusive and transparent process that takes into
p.000020: account local circumstances.
p.000020: • Defining utility on the basis of health-related considerations —
p.000020: In order to apply the ethical principle of utility, it is first necessary to identify the type of outcomes that will be
p.000020: counted as improvements to welfare. In general, the focus should be on the health-related benefits of allocation
p.000020: mechanisms, whether defined in terms 21
p.000020: of the total number of lives saved, the total number of life years saved, or the total number of quality-adjusted life
p.000020: years saved. For this reason,
p.000020: while it might be ethical to prioritize persons who are essential to manage an outbreak, it is not appropriate to
p.000020: prioritize persons based on social value considerations unrelated to carrying out critical services necessary for
p.000020: society.
p.000020:
p.000020: • Paying attention to the needs of vulnerable populations — In applying the ethical principle of equity, special
p.000020: attention should be given to individuals and groups that are the most vulnerable to discrimination, stigmatization, or
p.000020: isolation, as discussed in Guideline 3.
p.000020: Particular consideration must be given to individuals who are confined in institutional settings, where they are highly
p.000020: dependent on others and
p.000020: potentially exposed to much higher risks of infection than persons living in the community.
p.000020:
p.000020: • Fulfilling reciprocity-based obligations to those who contribute to infectious disease outbreak response efforts
p.000020: — The ethical principle of reciprocity implies that society should support persons who face a disproportionate burden
p.000020: or risk in protecting the public good. This principle justifies giving priority access to scarce resources to persons
p.000020: who
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020: assume risks to their own health or life to contribute to outbreak response efforts.
p.000020:
p.000020: • Providing supportive and palliative care to persons unable to access life- saving resources — Even when it is not
p.000020: possible to provide life-saving medical
p.000020: 22 resources to all who could benefit from
p.000020: them, efforts should be made to ensure that no patients are abandoned. One way to do this is to ensure that adequate
p.000020: resources are directed to providing supportive and palliative care.
p.000020:
p.000020: The application of allocation principles should take into account the following considerations:
p.000020:
p.000020: • Consistent application — Allocation principles should be applied in
...

p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000023: 23
p.000023: Questions addressed:
p.000023:
p.000023: • What role does surveillance play in infectious disease outbreak response efforts?
p.000023: • Should surveillance activities be subject to ethical review?
p.000023: • What obligations do entities conducting surveillance activities have to protect the confidentiality of
p.000023: information collected?
p.000023: • Are there any circumstances under which individuals should be asked for consent to, or given the opportunity to
p.000023: opt out of, surveillance activities?
p.000023: • What obligations do those conducting surveillance activities have to disclose information they collect to the
p.000023: affected individuals and communities?
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023: Systematic observation and data collection are essential components of emergency response measures, both to guide the
p.000023: management of the current outbreak and to help prevent and respond to outbreaks in the future. Even if these activities
p.000023: are not characterized as research for regulatory purposes, an ethical analysis should
p.000023: be undertaken to ensure that personal information is protected from physical, legal, psychological, and other harm.
p.000023: Countries should consider organizing systems for ethical oversight of public health activities, commensurate with the
p.000023: activity objectives, methods, risks and benefits, as well as the extent to which the activity involves individuals or
p.000023: groups whose situation may make them vulnerable.
p.000023: Regardless of whether such systems are adopted, ethical analysis of public
p.000023: health activities should be consistent with accepted norms of public health ethics and conducted by individuals or
p.000023: entities that can be held accountable for their decisions.
p.000023:
p.000023: Ensuring high-quality, ethically appropriate surveillance is complicated by at least
p.000023: two factors. First, the law surrounding surveillance across jurisdictions may be unnecessarily complex or inconsistent.
p.000023: Second, surveillance activities will occur across jurisdictions with varying levels of resources, thus placing strains
p.000023: on the quality and reliability of the data. These
p.000023: issues are likely to be exacerbated during an infectious disease outbreak, creating an urgent need for careful planning
p.000023: and international collaboration. Specific issues that should be addressed include the following:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023: • Protecting the confidentiality of personal information — The
p.000023: unauthorized disclosure of personal information collected during an infectious disease outbreak (including name,
p.000023: address, diagnosis, family history, etc.) can expose individuals to significant risk. Countries should
p.000023: 24 ensure that adequate protection exists
p.000023: against these risks, including laws that safeguard the confidentiality of information generated through
p.000023: surveillance activities, and that strictly limit the circumstances in which such information may be used or disclosed
...

p.000025: should be backed up with sufficient resources to ensure that those subject to the restrictions do not experience undue
p.000025: burdens. For example, individuals whose mobility is restricted (whether through confinement at home or
p.000025: in institutional settings) should be ensured access to food, drinking water, sanitary facilities, shelter, clothing,
p.000025: and medical care. It is also important to ensure that individuals have adequate physical space, opportunities to engage
p.000025: in activities, and the means
p.000025: to communicate with their loved ones and the outside world. Fulfilling these needs is essential to respect individual
p.000025: dignity and address the significant psychosocial burden of confinement on individuals and their loved ones. Mechanisms
p.000025: should be put in place to minimize the risk of violence (including sexual assault) and local disease
p.000025: transmission, especially when individuals are confined in institutional settings
p.000025: or when communities are under mass quarantine. At a minimum, persons who
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025: are quarantined because they have been exposed to the pathogen responsible for the outbreak should not be put at
p.000025: heightened risk of infection because of the manner in which they are confined. (Decisions on the circumstances and
p.000025: conditions of confinement should consider the heightened needs of vulnerable populations, as discussed
p.000025: in Guideline 3.)
p.000025:
p.000025: • Addressing financial and social consequences — Even short-term restrictions on freedom of movement can have
p.000025: significant — and possibly devastating —financial and social consequences for individuals, their families, and their
p.000025: communities. Countries should provide assistance to households that suffer financial
p.000025: losses as a result of inability to conduct business, loss of a job, damage to crops, or other consequences of
p.000025: restrictions on freedom of movement. In some cases, this support may need to continue
p.000025: for a period following the end of confinement. In addition, efforts should be made to support the social and
p.000025: professional reintegration of individuals for whom confinement is no longer necessary, including measures to reduce
p.000025: stigmatization and discrimination.
p.000025:
p.000025: • Due process protections — Mechanisms should be in place to allow individuals whose liberty has been restricted to
p.000025: challenge the appropriateness of those restrictions, the way they are enforced, and the conditions under which the
p.000025: restrictions are carried out. If it is not feasible to provide full due process protection before the restrictions are
p.000025: implemented in an emergency scenario, mechanisms for review and appeal should be made
p.000025: available without excessive delay. All persons involved in decisions to restrict individuals’ freedom of movement
p.000025: should be accountable for any abuses of authority.
p.000025:
p.000025: • Equitable application — Restrictions on freedom of movement should be
p.000025: applied in the same manner to all 27
p.000025: persons posing a comparable public health risk. Thus, individuals should not be subject to greater or lesser
p.000025: restrictions for reasons unrelated to the
p.000025: risks they may pose to others, including membership in any disfavoured or favoured social group or class (for example,
p.000025: groups defined by gender, ethnicity, or religion). In addition, policy- makers should seek to ensure that restrictions
p.000025: are not applied in a manner that imposes a disproportionate burden on vulnerable segments of society.
p.000025:
p.000025: • Communication and transparency —
p.000025: Policy-makers and public health officials should engage communities in a dialogue about any restrictions on freedom of
p.000025: movement and solicit community members’ views on how restrictions can be carried out with the least possible burden.
p.000025: They should also provide regular updates on the implementation of such measures,
p.000025: both to the public at large and to those whose movement has been restricted. Communication strategies should be
p.000025: designed to avoid the stigmatization
p.000025: of individuals whose liberty has been restricted and to protect their privacy and confidentiality, particularly in the
p.000025: media.
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025: 7. Obligations related to medical interventions for the diagnosis, treatment, and prevention of infectious disease
p.000028: 28
p.000028:
p.000028:
p.000028: Questions addressed:
p.000028:
p.000028: • What quality and safety standards should govern the administration of medical interventions offered during
p.000028: infectious disease outbreaks?
p.000028: • What rights do patients (or their authorized proxy decision-makers) have to receive information about the risks
p.000028: and benefits of, and alternatives to, medical interventions during infectious disease outbreaks?
p.000028: • Under what circumstances, if any, might it be appropriate to override an individual’s refusal of diagnostic,
p.000028: therapeutic, or preventive measures during an infectious disease outbreak?
...

Searching for indicator vulnerability:

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p.000001: approximate border lines for which there may not yet be full agreement.
p.000001: The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or
p.000001: recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors
p.000001: and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
p.000001: All reasonable precautions have been taken by the World Health Organization to verify the information contained in this
p.000001: publication. However, the published material is being
p.000001: distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and
p.000001: use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising
p.000001: from its use.
p.000001:
p.000001: Printed in Spain
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001: Table of Contents
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001: Foreword ............................................................................................................ 3
p.000001: 1
p.000001: Acknowledgements 4
p.000001: Introduction 7
p.000001: Guidelines 12
p.000001: 1. Obligations of governments and the international community 13
p.000001: 2. Involving the local community
p.000015: 15
p.000015: 3. Situations of particular vulnerability
p.000017: 17
p.000017: 4. Allocating scarce resources
p.000020: 20
p.000020: 5. Public health surveillance
p.000023: 23
p.000023: 6. Restrictions on freedom of movement 25
p.000023: 7. Obligations related to medical interventions for the diagnosis, treatment,
p.000023: and prevention of infectious disease
p.000028: 28
p.000028: 8. Research during infectious disease outbreaks 30
p.000028: 9. Emergency use of unproven interventions outside of research 35
p.000028: 10. Rapid data sharing
p.000038: 38
p.000038: 11. Long-term storage of biological specimens collected during infectious
p.000038: disease outbreaks
p.000039: 39
p.000039: 12. Addressing sex- and gender-based differences 41
p.000039: 13. Frontline response workers’ rights and obligations 43
p.000039: 14. Ethical issues in deploying foreign humanitarian aid workers 47
p.000039: References 50
p.000039: Annex 1. Ethics guidance documents consulted in developing Guidance for managing ethical issues in infectious disease
p.000039: outbreaks 52
p.000039: Annex 2. Participants at meetings to formulate Guidance for managing ethical issues in infectious disease outbreaks
p.000055: 55
p.000055:
p.000055:
p.000055:
p.000055:
...

p.000006: international human rights agreements. The Siracusa Principles on the Limitation and Derogation Provisions in the
p.000006: International Covenant on Civil and Political Rights
p.000006: (the “Siracusa Principles”)8 are a widely accepted framework for evaluating
p.000006: the appropriateness of limiting certain fundamental human rights in emergency situations. The Siracusa Principles
p.000006: provide that any restrictions on human rights must be carried out in accordance with the law and in pursuit of a
p.000006: legitimate objective of general interest. In addition, such restrictions must be strictly necessary and there must
p.000006: be no other, less intrusive means available to reach the same objective. Finally, any restrictions must be based on
p.000006: scientific evidence and not imposed in an arbitrary, unreasonable, or discriminatory manner.
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006: For both pragmatic and ethical reasons, maintaining the population’s trust in epidemic response efforts is of
p.000006: fundamental importance. This is possible only if
p.000006: policy-makers and response workers act in a trustworthy manner by applying
p.000006: procedural principles fairly and consistently, being open to review based on new
p.000006: 10 relevant information, and acting with the
p.000006: genuine input of affected communities.
p.000006: In addition, a synchronized approach is indispensable to the success of any
p.000006: response effort. All members of the global community need to act in solidarity, since all countries share a common
p.000006: vulnerability to the threat of infectious disease.
p.000006:
p.000006:
p.000006: How the Guidance was developed
p.000006: Many individuals have helped shape this guidance document, directly or indirectly, starting with the Ethics Panel that
p.000006: was convened by the Director-General on
p.000006: 11 August 2014, and the ad-hoc ethics working groups that met in Geneva, Switzerland between August and October 2014 to
p.000006: provide guidance on the use of untested interventions during the Ebola outbreak in West Africa. Subsequently,
p.000006: in May 2015, a group of experts and stakeholders met in Dublin, Ireland to review existing ethical statements on
p.000006: infectious disease outbreaks and
p.000006: develop a methodology to create a more comprehensive document. To assist this process, an analysis and synthesis of all
p.000006: existing guidance documents relevant
p.000006: to ethical considerations in infectious disease outbreaks was prepared (Annex 1). Reflecting on lessons learnt from
p.000006: previous outbreaks, particularly the recent experiences with Ebola, participants emphasized the need for
p.000006: guidance that could be tailored to different epidemiological, social, and economic contexts. They also discussed the
p.000006: importance of focusing on broader questions of global health governance, community engagement, knowledge generation,
p.000006: and priority setting. Finally,
p.000006: participants emphasized the urgent need to develop concrete operational tools to help individuals involved in epidemic
p.000006: response efforts to incorporate ethical guidance into practical decision-making. The group met again in November 2015
p.000006: in Prato, Italy
...

p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014: Avian Influenza in Indonesia
p.000014: Source: Gary Hampton, WHO
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014: 2. Involving the local community
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000015: 15
p.000015: Questions addressed:
p.000015:
p.000015: • Why is community engagement a critical component of infectious disease outbreak response efforts?
p.000015: • What are the hallmarks of a community-centred approach to infectious disease outbreak response?
p.000015: • What should decision-makers do with input they receive during community engagement activities?
p.000015: • What is the media’s role in infectious disease outbreak response efforts?
p.000015:
p.000015:
p.000015:
p.000015:
p.000015: All aspects of infectious disease outbreak response efforts should be supported
p.000015: by early and ongoing engagement with the affected communities. In addition to being ethically important in its own
p.000015: right, community engagement is essential to establishing and maintaining trust and preserving social order.
p.000015:
p.000015: Involving communities fully in infectious disease outbreak planning and response efforts requires attention to the
p.000015: following issues:
p.000015:
p.000015: • Inclusiveness — All persons who could potentially be affected should have opportunities to make their voices
p.000015: heard in all stages of infectious disease outbreak planning and response, either directly or through legitimate
p.000015: representatives. Adequate communication platforms and tools should be put in place to facilitate
p.000015:
p.000015: public communication with health authorities.
p.000015:
p.000015: • Situations of particular vulnerability — As discussed further in Guideline 3, special attention should be given
p.000015: to ensuring that persons who face heightened susceptibility to harm or injustice during infectious disease outbreaks
p.000015: are able to contribute to decisions about infectious disease outbreak planning and response. Public health officials
p.000015: should recognize that such persons might be distrustful of government and other institutions, and make special efforts
p.000015: to include them in community engagement plans.
p.000015:
p.000015: • Openness to diverse perspectives — Communication efforts should be designed to facilitate a genuine
p.000015: two-way dialogue, rather than as merely a means to announce decisions
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015: that have already been made. Decision-makers should be prepared to recognize and debate alternative approaches and
p.000015: revise their decisions based on information they receive. Reaching out to the community early, and allowing for
p.000015: consideration of
p.000015: the interests of all people who will
p.000015: 16 potentially be affected, can play an important role in building trust and empowering communities to
p.000015: be involved in a genuine dialogue.
p.000015:
p.000015: • Transparency — The ethical principle of transparency requires that decision-makers publicly explain the basis for
p.000015: decisions in language that is
p.000015: linguistically and culturally appropriate.
p.000015: When decisions must be made in the face of uncertain information, the uncertainties should be explicitly acknowledged
p.000015: and conveyed to the public.
p.000015:
p.000015: • Accountability — The public should know who is responsible for making
p.000015: and implementing decisions in relation to the outbreak response, and how they can challenge decisions they believe are
p.000015: inappropriate.
p.000015:
p.000015: The media will play an important role in any infectious disease outbreak response effort. It is therefore important to
p.000015: ensure that the media has access to accurate and timely information about the disease and its management. Governments,
p.000015: nongovernmental organizations, and
p.000015: academic institutions should make efforts to support media training in relevant scientific concepts and techniques for
p.000015: communicating risk information without raising unnecessary alarm. Media training is important for public health sector
p.000015: employees who may interact with media covering public health issues.
p.000015: In turn, the media has a responsibility to provide accurate, factual, and balanced reporting. This is an important
p.000015: component of media ethics.
p.000015:
p.000015:
p.000015: Cholera outbreak in Sierra Leone
p.000015: Source: Fid Thompson
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015: 3. Situations of particular vulnerability
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000017: 17
p.000017: Questions addressed:
p.000017:
p.000017: • Why are some individuals and groups considered particularly vulnerable during infectious disease outbreaks?
p.000017: • How can vulnerability affect a person’s ability to access services during infectious disease outbreaks?
p.000017: • How can vulnerability affect a person’s willingness and ability to share and receive information during an
p.000017: infectious disease outbreak?
p.000017: • Why are stigmatization and discrimination particular risks during infectious disease outbreaks?
p.000017: • In what ways might vulnerable persons suffer disproportionate burdens from infectious disease response efforts,
p.000017: or have a greater need for resources?
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017: Some individuals and groups face heightened susceptibility to harm or injustice during infectious disease outbreaks.
p.000017: Policy-makers and epidemic responders should develop plans to address the needs of such individuals and groups in
p.000017: advance of an outbreak and,
p.000017: if an outbreak occurs, make reasonable efforts to ensure that these needs are actually met. Doing this requires ongoing
p.000017: attention to community engagement and the development of active social networks between community representatives and
p.000017: government actors.
p.000017:
p.000017: Efforts to address the ways in which individuals and groups may be vulnerable should take into account the following:
p.000017: • Difficulty accessing services and resources — Many of the
p.000017: characteristics that contribute to social vulnerability can make it difficult
p.000017: for individuals to access necessary services. For example, persons with physical disabilities may have mobility
p.000017: impairments that make travelling even short distances difficult or impossible.
p.000017: Other socially vulnerable persons may lack access to safe and reliable transportation or have caregiving
p.000017: responsibilities that make it difficult for them to leave their homes. In addition, vulnerable persons may lack access
p.000017: to necessary resources such as clean water or bednets to reduce the risk of contracting a mosquito-borne disease.
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017: • Need for effective alternative communication strategies — Some types of vulnerability can impede
p.000017: an individual’s ability to transmit or receive information. Communication barriers can stem from a wide range of
p.000017: factors including, but not limited to, illiteracy, unfamiliarity with the
p.000017: 18 local or official language(s), vision or
p.000017: hearing impairments, social isolation, or lack of access to Internet and other communication services. These barriers
p.000017: make it difficult for individuals to receive necessary public health messages
p.000017: or to participate fully in community engagement activities. To overcome these barriers, messages should be delivered in
p.000017: multiple formats (e.g. radio, text messages, billboards, cartoons) as well as direct oral communication with key
p.000017: stakeholders. Health authorities should not assume that the public will search for information; instead, they should
p.000017: proactively reach out to the concerned population wherever they are.
p.000017:
p.000017: • Impact of stigmatization and discrimination — Members of socially disadvantaged groups often face considerable
p.000017: stigma and discrimination, which can be exacerbated in public health emergencies characterized by fear and distrust.
p.000017: Those responsible for infectious disease outbreak response should ensure that all individuals are treated fairly and
p.000017: equitably regardless of their social status or perceived “worth” to society. They should also take measures to prevent
...

p.000041:
p.000041:
p.000041:
p.000041:
p.000041: disease creates special risks for pregnant women or their fetus, both men and women should be informed of these risks
p.000041: and have access to safe methods to minimize them, along with reproductive counselling services.
p.000041:
p.000041: • Sex- and gender-inclusive research
p.000041: 42 strategies — Researchers should make efforts to ensure that studies do not disproportionately
p.000041: favour a particular sex or gender, and that women who are or might become pregnant are not inappropriately excluded
p.000041: from research participation. During an outbreak, research on experimental treatments and preventive measures should
p.000041: seek to identify any sex- or gender-related differences in outcomes.
p.000041:
p.000041: • Attention to social and cultural practices — Gender-related roles and practices can affect all aspects of
p.000041: infectious disease outbreaks, including
p.000041: individuals’ risk of becoming infected, the consequences of infection, their use of health services and other
p.000041: health-seeking behaviours, and their vulnerability to interpersonal violence.
p.000041: Policy-makers and outbreak responders should identify and respond to these factors, drawing when possible
p.000041: on relevant anthropological and sociological research.
p.000041:
p.000041: • Sex- and gender-sensitive communication strategies —
p.000041: Entities responsible for developing and implementing communication strategies should be sensitive to sex- and gender-
p.000041: based differences in how individuals have access to and respond to health- related information. Separate messages and
p.000041: communication strategies may be needed to provide relevant information to particular subgroups, such as pregnant women
p.000041: or nursing mothers.
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: Influenza in India
p.000041: Source: Tom Pietrasik, WHO
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: 13. Frontline response workers’ rights and obligations
p.000041:
p.000041:
p.000041:
p.000043: 43
p.000043: Questions addressed:
p.000043:
...

p.000043: maximum extent compatible with legitimate public health interests.
p.000043:
p.000043: • Provide accurate information to the public — During an infectious disease outbreak, public health officials have
p.000043: the primary responsibility to communicate information about the outbreak pathogen, including how
p.000043: it is transmitted, how infection can be prevented, and what treatments or preventive measures may be effective. Those
p.000043: responsible for designing communication strategies should anticipate and respond to misinformation, exaggeration, and
p.000043: mistrust, and should seek (without
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: withholding key information) to minimize the risk that information about risk factors will lead to stigmatization and
p.000043: discrimination. If persons working in the health sector are asked medical questions about the outbreak by patients or
p.000043: the general public, they should not spread
p.000043: 46 unsubstantiated rumours or suspicion
p.000043: and ensure that information they provide comes from reliable sources.
p.000043:
p.000043: • Avoiding exploitation — In the context of a rapidly spreading life- threatening illness with no proven
p.000043: treatment, desperate individuals may be willing to try any intervention offered, regardless of the expected risks or
p.000043: benefits. Health-care workers have a duty not to exploit individuals’ vulnerability by offering treatments or
p.000043: preventive measures for which
p.000043: there is no reasonable basis to believe that the potential benefits outweigh the uncertainties and risks. This duty
p.000043: does not preclude the appropriate use of unproven interventions on an
p.000043: experimental basis, consistent with the guidelines set forth in Guideline 9.
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: Earthquake Haiti 2010
p.000043: Source: Victor Ariscain, PAHO/WHO
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: 14. Ethical issues in deploying foreign humanitarian aid workers
p.000043:
p.000043:
p.000043:
p.000047: 47
p.000047: Questions addressed:
p.000047:
p.000047: • What ethical issues arise in assigning foreign workers for deployment during infectious disease outbreaks?
p.000047: • What obligations do sponsoring organizations have to prepare foreign aid workers adequately for their missions?
p.000047: • What obligations do sponsoring organizations have regarding the conditions of deployment?
p.000047: • What obligations do sponsoring organizations have to coordinate with local officials?
p.000047: • What obligations do foreign aid workers have before, during, and after deployment?
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047: Foreign governments and humanitarian aid organizations that deploy workers in infectious disease outbreaks have ethical
p.000047: obligations to both the workers themselves and the affected communities. These obligations include the following:
p.000047:
...

Health / Cognitive Impairment

Searching for indicator cognitive:

(return to top)
p.000030: Despite such efforts, some prospective participants may still not fully appreciate the difference between research and
p.000030: ordinary medical care, and this should not in itself preclude their enrolment.
p.000030:
p.000030: • Addressing other barriers to informed consent — In addition to the impact of fear and desperation,
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030: other factors can challenge researchers’ ability to obtain informed consent to research; these range from cultural and
p.000030: linguistic differences between foreign researchers and local participants, to the fact that prospective participants in
p.000030: quarantine or isolation may be cut off from their families and other support
p.000030: systems and feel powerless to decline an invitation to participate in research. To the extent possible, consent
p.000030: processes compatible with international research ethics guidelines should be developed
p.000030: in consultation with local communities and implemented by locally recruited personnel. In addition, researchers should
p.000030: be well informed about the medical, psychological and social support systems available locally so that they can guide
p.000030: participants in need towards these services. In some situations, it may be necessary to develop rapid mechanisms for
p.000030: appointing proxy decision-makers, such as during outbreaks of diseases that affect cognitive abilities, or when
p.000030: an outbreak leaves a large number of children as orphans.
p.000030:
p.000030: • Gaining and maintaining trust — Failure to build and maintain community trust during the process of research
p.000030: design and implementation, or when disclosing preliminary results, will not only impede study recruitment and
p.000030: completion but may also undermine
p.000030: the uptake of any interventions proven to be efficacious. Engaging with affected communities before, during, and after
p.000030: a study is essential to build and maintain trust. In environments in which the public’s trust in government is fragile,
p.000030: researchers should remain as independent as possible from official public health activities. If government workers are
p.000030: themselves involved in
p.000030: conducting research, they should inform participants of this fact. Individuals who observe unethical practices carried
p.000030: out in the name of public health or emergency response efforts should promptly report them to ethics committees or
p.000030: other independent bodies.
p.000030: • Selecting an appropriate research 33
p.000030: methodology — Exposing research participants to risk is ethically unacceptable if the study is not designed in a manner
p.000030: capable of providing valid results. It is therefore imperative that all research be designed and conducted in a
p.000030: methodologically rigorous manner. In clinical trials,
p.000030: the appropriateness of features such as randomization, placebo controls, blinding or masking should be determined on a
...

Searching for indicator impaired:

(return to top)
p.000035:
p.000035: • Collection and sharing of meaningful data — Physicians overseeing MEURI have the same moral
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035: obligation to collect all scientifically relevant data on the safety and efficacy of the intervention as researchers
p.000035: overseeing a clinical trial. Knowledge generated through MEURI should be aggregated across patients if possible and
p.000035: shared transparently, completely and rapidly with the MEURI scientific advisory committee, public health authorities,
p.000035: physicians and researchers in the country, and the international medical and scientific community.
p.000035: Information should be described accurately, without overstating benefits or understating uncertainties or risks.
p.000035:
p.000035: • Importance of informed consent — Individuals who are offered MEURI should be made aware that the intervention
p.000035: might not benefit
p.000035: them and might even harm them. The process of obtaining informed consent to MEURI should be carried out in a
p.000035: culturally and linguistically sensitive manner, with an emphasis on the content and understandability of the
p.000035: information conveyed and the voluntariness of the patient’s decision.
p.000035: The ultimate choice of whether to receive the unproven intervention must rest with the patient, if the patient is
p.000035: in a condition to make the choice. If the patient is unconscious, cognitively impaired, or too sick to understand the
p.000035: information, proxy consent should be obtained from a family member or other authorized decision-maker.
p.000035:
p.000035: • Need for community engagement —
p.000035: MEURI must be sensitive to local norms and practices. One way to try to ensure such sensitivity is to use rapid
p.000035: “community engagement
p.000035: teams” to promote dialogue about the potential benefits and risks of receiving
p.000035: interventions that have not yet been tested in clinical trials.
p.000035:
p.000035: • Fair distribution in the face of scarcity — Compounds qualifying for MEURI may not be available in large
p.000035: quantities. In this situation, choices will have to be made about who receives
p.000035: each intervention. Countries should 37
p.000035: establish mechanisms for making these allocation decisions, taking into account the assessment of the MEURI Scientific
p.000035: Advisory Committee and the principles discussed in Guideline 4.
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035: 10. Rapid data sharing
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000038: 38
p.000038: Questions addressed:
p.000038:
p.000038: • Why is rapid data sharing essential during an infectious disease outbreak?
p.000038: • What are the key ethical issues related to rapid data sharing?
p.000038:
p.000038:
p.000038:
p.000038:
p.000038:
p.000038: The collection and sharing of data are essential parts of ordinary public health practice. During an infectious disease
...

Health / Drug Usage

Searching for indicator drug:

(return to top)
p.000038: regarding data sharing to ensure that they adequately protect the confidentiality of personal information and address
p.000038: other relevant ethical questions like managing incidental findings, and dealing with disputes over the ownership or
p.000038: control of information.
p.000038:
p.000038:
p.000038:
p.000038:
p.000038:
p.000038:
p.000038:
p.000038:
p.000038: 11. Long-term storage of biological specimens collected during infectious disease outbreaks
p.000038:
p.000038:
p.000039: 39
p.000039: Questions addressed:
p.000039:
p.000039: • What are the benefits and risks associated with the long-term storage of biological specimens collected during
p.000039: infectious disease outbreaks?
p.000039: • What obligations do entities involved in the long-term storage of biological specimens collected during
p.000039: infectious disease outbreaks have to consult with the community?
p.000039: • Are there any circumstances under which individuals should be asked for consent to, or given the opportunity to
p.000039: opt out of, the long-term storage of biological specimens collected during an infectious disease outbreak?
p.000039: • What considerations should be taken into account in transferring biospecimens outside the institutions that
p.000039: collected them, whether domestically or internationally?
p.000039:
p.000039:
p.000039:
p.000039:
p.000039:
p.000039: Biological specimens are often collected during an infectious disease outbreak in the context of diagnosis (e.g. to
p.000039: determine who has been infected with or exposed to a novel pathogen), surveillance (e.g. to identify the incidence of
p.000039: drug-resistant bacteria), or research (e.g. during clinical trials of new diagnostics, vaccines or interventions). Such
p.000039: samples are sent to laboratories on site or other laboratories, either domestically or internationally, for analysis.
p.000039:
p.000039: Biospecimens collected during the management of an infectious disease outbreak offer researchers important
p.000039: opportunities to understand the outbreak pathogen better and to develop diagnostic, therapeutic, and preventive
p.000039: measures that
p.000039:
p.000039: may mitigate the harm of similar outbreaks in the future. At the same time, long-term storage of biospecimens involves
p.000039: potential risks to individuals and communities.
p.000039: Risks to individuals primarily relate to the unwanted disclosure of personal information. This can be minimized by
p.000039: protecting the confidentiality of individuals’ identities, but confidentiality may be difficult to protect when only a
p.000039: small number of people are being tested. Moreover, even when individual confidentiality can be adequately protected,
p.000039: some individuals or communities might still be uncomfortable making their biospecimens available for future use,
p.000039: especially if such use is not subject to community control. Particular concerns can arise when specimens are
p.000039:
p.000039:
p.000039:
p.000039:
p.000039:
p.000039:
p.000039:
p.000039:
p.000039:
p.000039: transferred abroad without the originating country’s prior agreement. Addressing these concerns requires time-consuming
p.000039: but necessary relationship-building, consultation, and education, as well as the establishment of policies, practices,
p.000039: and institutions capable of commanding public confidence and trust.
...

p.000054:
p.000054: Stand on guard for thee: Ethical considerations in preparedness planning for pandemic influenza. Toronto: University of
p.000054: Toronto Joint Centre for Bioethics; 2005 (www.jcb. utoronto.ca/people/documents/upshur_stand_guard.pdf).
p.000054:
p.000054: Swiss Federal Office of Public Health. Swiss Influenza Pandemic Plan. Bern; 2013
p.000054: (www.bag.admin.ch/influenza/01120/01132/10097/10104/index.html?lang=en&download=
p.000054: NHzLpZeg7t,lnp6I0NTU042l2Z6ln1ad1IZn4Z2qZpnO2Yuq2Z6gpJCGenx6gWym162epYb g2c_JjKbNoKSn6A--).
p.000054:
p.000054: Venkat A, Wolf L, Geiderman JM, Asher SL, Marco CA, McGreevy J et al. Ethical issues in the response to Ebola virus
p.000054: disease in US emergency departments: a position paper of the American College of Emergency Physicians, the Emergency
p.000054: Nurses Association and the Society for Academic Emergency Medicine. J Emerg Nurs. 2015; Mar;41(2):e5-e16. doi:
p.000054: 10.1016/j.jen.2015.01.012 (www.ncbi.nlm.nih.gov/pubmed/25770003).
p.000054:
p.000054:
p.000054:
p.000054:
p.000054:
p.000054:
p.000054:
p.000054: Annex 2. Participants at meetings to formulate Guidance for managing ethical issues in infectious disease outbreaks
p.000054:
p.000054:
p.000054:
p.000054: Panel discussion: Ethical considerations for use of unregistered interventions
p.000054: for Ebola viral disease, World Health Organization, Geneva, 11 August 2014 55
p.000054:
p.000054: Advisors
p.000054: Dr Juan Pablo Beca, Professor, Bioethics Center, Universidad del Desarrollo, Chile
p.000054: Dr Helen Byomire Ndagije, Head, Drug Information Department, Ugandan National Drug Authority, Uganda
p.000054: Dr Philippe Calain (Chair), Senior Researcher, Unit of Research on Humanitarian Stakes and Practices, Médecins Sans
p.000054: Frontières, Switzerland
p.000054: Dr Marion Danis, Head, Ethics and Health Policy and Chief, Bioethics Consultation Service, National Institutes of
p.000054: Health, United States of America
p.000054: Professor Jeremy Farrar, Director, Wellcome Trust, United Kingdom Professor Ryuichi Ida, Chair, National Bioethics
p.000054: Advisory Committee, Japan
p.000054: Professor Tariq Madani, infectious diseases physician and clinical academic researcher, Saudi Arabia
p.000054: Professor Michael Selgelid, Director, Centre for Human Bioethics, Monash University, Australia
p.000054: Professor Peter Smith, Professor of Tropical Epidemiology, London School of Tropical Medicine and Hygiene, United
p.000054: Kingdom
p.000054: Ms Jeanine Thomas, Patient Safety Champion, United States of America
p.000054: Professor Aisssatou Touré, Head, Immunology Department, Institut Pasteurde Dakar,,Senegal Professor Ross Upshur, Chair
p.000054: in Primary Care Research; Professor, Department of Family and Community Medicine and Dalla Lana School of Public
p.000054: Health, University of Toronto; Canada
p.000054:
p.000054: Resource persons
p.000054: Dr Daniel Bausch, Head, Virology and Emerging Infections Department, US Naval Medical Research Unit No. 6, Peru
p.000054: Professor Luciana Borio, Assistant Commissioner for Counterterrorism Policy; Director, Office of Counterterrorism and
p.000054: Emerging Threats, Food and Drug Administration, United States of America
p.000054: Dr Frederick Hayden, Professor of Clinical Virology and Professor of Medicine, University of Virginia School of
p.000054: Medicine, United States of America
p.000054: Dr Stephan Monroe, Deputy Director, National Centre for Emerging and Zoonotic Infectious Diseases, Centers for Disease
p.000054: Control and Prevention, United States of America
p.000054:
p.000054:
p.000054:
p.000054:
p.000054:
p.000054:
p.000054:
p.000054:
p.000054: WHO Secretariat
p.000054:
p.000054: WHO headquarters, Geneva, Switzerland
p.000054: Dr Margaret Chan, Director-General
p.000054: Dr Marie-Paule Kieny, Assistant Director-General, Health Systems and Innovation Dr Marie-Charlotte Bouesseau, Ethics
p.000054: Advisor, Service Delivery and Safety
p.000054: Dr Pierre Formenty, Scientist, Control of Epidemic Diseases, Department of Pandemic and Epidemic Diseases
p.000054: 56 Dr Margaret Harris, Communication Officer, Department of Pandemic and Epidemic
p.000054: Diseases
p.000054: Mr Gregory Hartl, Coordinator, Department of Communications Dr Rüdiger Krech, Director, Health Systems and Innovation
p.000054: Dr Andreas Reis, Technical Officer, Global Health Ethics, Department of Knowledge, Ethics and Research
p.000054: Dr Cathy Roth, Adviser, Office of the Assistant Director-General, Health Systems and Innovation
p.000054: Dr Vasee Sathyamoorthy, Technical Officer, Initiative for Vaccine Research, Department of Immunization, Vaccines and
p.000054: Biologicals
...

p.002014: Dr Amar Jesani, Independent Researcher and Teacher, Bioethics and Public Health; Editor, Indian Journal of Medical
p.002014: Ethics; Visiting Professor, Centre for Ethics, Yenepoya University, India Dr Dan O’Connor, Head, Medical Humanities,
p.002014: Wellcome Trust, United Kingdom
p.002014: Dr Lisa Schwartz, Arnold L. Johnson Chair in Health Care Ethics, McMaster Ethics in Healthcare, McMaster University,
p.002014: Canada
p.002014: Professor Michael Selgelid, Director, Centre for Human Bioethics, Monash University, Australia Dr Paulina Tindana,
p.002014: Ethicist and Senior Researcher, Navrongo Health Research Centre, Ghana Professor Ross Upshur, Chair in Primary Care
p.002014: Research; Professor, Department of Family and Community Medicine and Dalla Lana School of Public Health, University of
p.002014: Toronto, Canada
p.002014:
p.002014:
p.002014:
p.002014:
p.002014:
p.002014:
p.002014:
p.002014:
p.002014: Invited participants
p.002014: Dr Enrica Alteri, Head, Human Medicines Evaluation Division, European Medicines Agency, United Kingdom
p.002014: Dr Nicholas Andrews, Statistics Modelling and Economics Department, Centre for Infectious Disease Surveillance and
p.002014: Control, Public Health England, United Kingdom
p.002014: Professor Oumou Younoussa Bah-Sow, Head of Pneumophtisiology, Ignace Deen National Hospital, Guinea
p.002014: Dr Luciana Borio, Assistant Commissioner for Counterterrorism Policy; Director, Office of
p.002014: 58 Counterterrorism and Emerging Threats, Food and Drug Administration, United States of Ameria
p.002014: Dr Jacob Thorup Cohn; Vice President, Governmental Affairs, Bavarian Nordic, Denmark Dr Edward Cox, Director, Office of
p.002014: Antimicrobial Products, Office of New Drugs Center for Drug Evaluation and Research, Food and Drug Administration,
p.002014: Silver Spring MD, United States of America
p.002014: Dr Nicolas Day, Director, Thailand/Laos Wellcome Trust Major Overseas Programme Mahidol-Oxford Tropical Medicine
p.002014: Research Unit, Thailand
p.002014: Dr Matthias Egger, Professor, Clinical Epidemiology, Department of Social Medicine, University of Bristol, United
p.002014: Kingdom; Epidemiology and Public Health, Institute for Social and Preventive Medicine, University of Bern, Switzerland
p.002014: Dr Elizabeth Higgs, Global Health Science Advisor, Office of the Director, Division of Clinical Research, National
p.002014: Institute of Allergy and Infectious Diseases, National Institutes of Health, United States of America
p.002014: Dr Nadia Khelef, Senior Advisor, Global Affairs, Institut Pasteur, France
p.002014: Professor Trudie Lang, Lead Professor, Global Health Network, Nuffield Department of Medicine, University of Oxford,
p.002014: United Kingdom
p.002014: Dr Matthew Lim, Senior Advisor, Global Health Security, Department of Health and Human Services, United States of
p.002014: America
p.002014: Professor Ira Longini, Professor of Biostatistics, Department of Biostatistics, College of Public Health and College of
p.002014: Medicine, University of Florida, United States of America
p.002014: Colonel Scott Miller, Director, Infectious Disease Clinical Research Program, Department of Preventive Medicine,
p.002014: Uniformed Services University, United States of America
p.002014: Ms Adeline Osakwe, Head, National Pharmacovigilance Centre, National Agency for Food and Drug Administration and
p.002014: Control, Nigeria
p.002014: Ms Virginie Pirard, Member, Belgian Advisory Committee on Bioethics; Ethics Advisor, Institut Pasteur, France
p.002014: Dr Micaela Serafini, Medical Director, Médecins Sans Frontières, Switzerland
p.002014: Mr Jemee Tegli, Institutional Review Board Administrator, University of Liberia–Pacific Institute for Research and
p.002014: Evaluation Institutional Review Board, Liberia
p.002014: Dr Gervais Tougas, Representative, International Federation of Pharmaceutical Manufacturers & Associations, Chief
p.002014: Medical Officer, Novartis, Switzerland
p.002014: Dr Johan van Griensven, Department of Clinical Sciences, Institute of Tropical Medicine, Belgium
p.002014: Professor John Whitehead, Emeritus Professor, Department of Mathematics and Statistics, Fylde College, Lancaster
p.002014: University, United Kingdom
p.002014:
p.002014:
p.002014:
p.002014:
p.002014:
p.002014:
p.002014:
p.002014:
p.002014: WHO Secretariat
p.002014: Dr Marie-Paule Kieny, Assistant Director-General, Health Systems and Innovation Dr Marie-Charlotte Bouesseau, Advisor,
p.002014: Department of Service Delivery and Safety Dr Vânia de la Fuente-Núñez,Technical Officer, Global Health Ethics,
p.002014: Department of Knowledge, Ethics and Research
p.002014: Dr Martin Friede, Scientist, Public Health, Innovation and Intellectual Property, Department of Essential Medicines and
p.002014: Health Products
...

p.000059: Dr Selena Knight, Intern, Global Health Ethics, Department of Knowledge, Ethics and Research Dr Nicola Magrini,
p.000059: Scientist, Policy, Access and Use, Department of Essential Medicines and Health Products
p.000059: Dr Cathy Roth, Adviser, Office of the Assistant Director-General, Health Systems and Innovation Dr Vasee
p.000059: Sathiyamoorthy, Technical Officer, Initiative for Vaccine Research, Department of Immunization, Vaccines and
p.000059: Biologicals
p.000059: Dr Abha Saxena, Coordinator, Global Health Ethics, Department of Knowledge, Ethics and Research
p.000059: Dr David Wood, Coordinator, Technologies, Standards and Norms, Department of Essential Medicines and Health Products
p.000059:
p.000059: Developing ethics guidelines for public health responses during epidemics, including for the conduct of related
p.000059: research, Dublin, Ireland, 25–26 May 2015
p.000059:
p.000059: Participants
p.000059: Dr Annick Antierens, Manager, Investigational Platform for Experimental Ebola Products, Médecins Sans Frontières,
p.000059: Switzerland
p.000059: Dr Philippe Calain, Senior Researcher, Unit of Research on Humanitarian Stakes and Practices, Médecins Sans Frontières,
p.000059: Switzerland
p.000059: Dr Edward Cox, Director, Office of Antimicrobial Products, Food and Drug Administration, United States of America
p.000059: Professor Heather Draper, Professor of Biomedical Ethics, University of Birmingham, United Kingdom
p.000059: Dr Sarah Edwards, Senior Lecturer in Research Ethics and Governance, University College London, United Kingdom
p.000059: Professor Jónína Einarsdóttir, Medical Anthropology, School of Social Sciences, University of Iceland, Iceland
p.000059: Professor Jeremy Farrar, Director, Wellcome Trust, United Kingdom
p.000059: Dr Margaret Fitzgerald, Public Health Specialist, Irish Health Service Executive, Ireland Dr Gabriel Fitzpatrick,
p.000059: Médecins Sans Frontières, Ireland
p.000059: Ms Lorraine Gallagher, Development Specialist, Irish Aid, Department of Foreign Affairs, Ireland Professor Jennifer
p.000059: Gibson, Sun Life Financial Chair in Bioethics; Director, Joint Centre for Bioethics; Associate Professor, Institute of
p.000059: Health Policy, Management and Evaluation, University of Toronto, Canada
p.000059:
p.000059:
p.000059:
p.000059:
p.000059:
p.000059:
p.000059:
p.000059:
p.000059: Professor Frederick G Hayden, Professor of Medicine and Pathology, University of Virginia School of Medicine, Unites
p.000059: States of America
p.000059: Dr Rita Helfand, Centers for Disease Control and Prevention, United States of America Dr Simon Jenkins, Research
p.000059: Fellow, University of Birmingham Project on the ethical challenges experienced by British military healthcare
p.000059: professionals in the Ebola region, United Kingdom
p.000059: Dr Pretesh Kiran, Assistant Professor, Community Health; Convener, Disaster Management Unit, St Johns National Academy
p.000059: of Health Sciences, India
p.000059: 60 Dr Markus Kirchner, Department for Infectious Disease Epidemiology, Robert Koch Institute,
p.000059: Germany
p.000059: Dr Katherine Littler, Senior Policy Adviser, Wellcome Trust, United Kingdom
p.000059: Professor Samuel McConkey, Head, International Health and Tropical Medicine, Royal College of Surgeons, Ireland
p.000059: Dr Farhat Moazam, Founding Chairperson, Center of Biomedical Ethics and Culture, Sindh Institute of Urology and
p.000059: Transplantation, Pakistan
p.000059: Dr Robert Nelson, Deputy Director and Senior Pediatric Ethicist, Office of Pediatric Therapeutics, Food and Drug
p.000059: Administration, United States of America
p.000059: Professor Alistair Nichol, Consultant Anaesthetist, School of Medicine and Medical Sciences, and EU projects,
p.000059: University College Dublin, Ireland
p.000059: Professor Lisa Schwartz, Arnold Johnson Chair in Health Care Ethics, Ethics in Health Care, McMaster University, Canada
p.000059: Professor Michael Selgelid, Director, Centre for Human Bioethics, Monash University, Australia Dr Kadri Simm, Associate
p.000059: Professor of Practical Philosophy, University of Tartu, Estonia
p.000059: Dr Aissatou Touré, Head, Immunology Department, Institut Pasteur de Dakar and Member, National Ethics Committee,
p.000059: Senegal
p.000059: Professor Ross Upshur, Canada Research Chair in Primary Care Research; Professor, Department of Family and Community
p.000059: Medicine and Dalla Lana School of Public Health, University of Toronto, Canada
p.000059: Dr Maria Van Kerkhove, Centre for Global Health, Institut Pasteur, France
p.000059: Dr Aminu Yakubu, Department of Health Planning and Research, Federal Ministry of Health, Nigeria
p.000059:
p.000059: Resource person
p.000059: Professor Carl Coleman (Rapporteur), Professor of Law and Academic Director, Division of Online Learning, Seton Hall
p.000059: University, New Jersey, United States of America
p.000059:
p.000059: WHO headquarters Secretariat, Geneva, Switzerland
...

Searching for indicator influence:

(return to top)
p.000040: specimens will be shared with the communities from which the samples were obtained. Material transfer agreements should
p.000040: be developed with the involvement of persons responsible for the care of patients and the taking of samples,
p.000040: representatives of affected communities and patients, and relevant government officials and ethics committees.
p.000040:
p.000040:
p.000040:
p.000040:
p.000040:
p.000040:
p.000040:
p.000040:
p.000040: 12. Addressing sex- and gender-based differences
p.000040:
p.000040:
p.000040:
p.000041: 41
p.000041: Questions addressed:
p.000041:
p.000041: • How are sex and gender relevant to infectious disease outbreaks?
p.000041: • How can sex and gender be incorporated into public health and surveillance?
p.000041: • How can social and cultural practices relevant to gender roles affect infectious disease outbreaks?
p.000041: • How should appropriate reproductive health-care services be safely provided during an infectious disease
p.000041: outbreak?
p.000041: • How are sex and gender relevant to communication strategies during outbreaks?
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: Sex (biological and physiological characteristics) and gender (socially constructed roles, behaviours, activities, and
p.000041: attributes)20 can influence the spread, containment, course, and consequences of infectious disease outbreaks. Sex and
p.000041: gender differences have been associated with differences in susceptibility to infection, levels of health care
p.000041: received, and in the course and outcome of illness.21 Addressing sex and gender differences in infectious disease
p.000041: outbreak planning and response efforts requires attention to the following considerations:
p.000041:
p.000041: • Sex- and gender-inclusive surveillance programmes — Public health surveillance should systematically collect
p.000041: disaggregated information on sex, gender, and pregnancy status, both to identify differential risks and
p.000041: modes of transmission, and to monitor any differential impact of an infectious disease outbreak and the interventions
p.000041: used to control it. This information is particularly important for pregnant women and their offspring.
p.000041:
p.000041: • Ensuring the availability of high- quality reproductive health-care services — Whether or not they are currently
p.000041: pregnant, women of childbearing age should have access to the full range of high-quality
p.000041: reproductive health-care services during an infectious disease outbreak. These services should be organized and
...

Health / HIV/AIDS

Searching for indicator HIV:

(return to top)
p.000020: disease outbreaks?
p.000020: • What procedural considerations apply to decisions about resource allocation during infectious disease outbreaks?
p.000020: • What obligations do health-care providers have towards persons who are not able to access life-saving resources
p.000020: during infectious disease outbreaks?
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020: Infectious disease outbreaks can quickly overwhelm the capacities of governments and health-care systems, requiring
p.000020: them to make difficult decisions about the allocation of limited resources. Some of these decisions may arise in the
p.000020: context of allocating medical interventions, such as hospital beds, medications, and medical equipment. Others may
p.000020: relate to broader questions about how public health resources should be utilized. For example, how should limited
p.000020: resources be allocated between activities such as surveillance, health promotion, and community engagement? Should
p.000020: human resources be devoted to contact tracing at the possible expense of patient management? Should
p.000020: limited funds be spent improving water and
p.000020: sanitation facilities or building quarantine facilities?
p.000020:
p.000020: Infectious disease outbreaks also compete with other important public health
p.000020: issues for attention and resources. For example, one of the consequences of the Ebola outbreak was a reduction in
p.000020: access to general health-care services due to a combination of a greater number of patients and the sickness and death
p.000020: of health-care workers. As
p.000020: a result, deaths from tuberculosis, human immunodeficiency virus (HIV), and malaria increased dramatically during this
p.000020: period.10
p.000020:
p.000020: Governments, health-care facilities, and others involved in response efforts should
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020: prepare for such situations by developing guidelines on the allocation of scarce resources in outbreak situations. Such
p.000020: guidelines should be developed through an open and transparent process involving broad stakeholder input and, to the
p.000020: extent
p.000020: possible, should be incorporated into formal written documents that establish clear priorities and procedures. Those
p.000020: involved
p.000020: in developing these guidelines should be guided by the following considerations:
p.000020:
p.000020: • Balancing considerations of utility and equity — Resource allocation decisions should be guided by the ethical
p.000020: principles of utility and equity. The principle of utility requires allocating resources to maximize benefits and
p.000020: minimize burdens, while the principle of equity requires attention to the fair distribution of benefits
p.000020: and burdens. In some cases, an equal distribution of benefits and burdens may be considered fair, but in others, it may
p.000020: be fairer to give preference to groups that are worse off, such as the poor, the sick, or the vulnerable. It is not
p.000020: always be possible to achieve fully both utility and equity. For example, establishing treatment centres in large urban
...

p.000050: Organization; 2014 (WHO/HIS/KER/GHE/14.1, http://apps.who.
p.000050: int/iris/bitstream/10665/130997/1/WHO_HIS_KER_GHE_14.1_eng.pdf?ua=1, accessed 23 July 2016).
p.000050:
p.000050: 6 Becker L. Reciprocity, justice, and disability. Ethics. 2005;116(1):9–39.
p.000050:
p.000050: 7 Dawson A, Jennings B. The place of solidarity in public health ethics. Public Health Reviews. 2012;34(1):65–79.
p.000050:
p.000050: 8 Siracusa Principles on the Limitation and Derogation Provision in the International Covenant on Civil and
p.000050: Political Rights. Geneva: American Association for the International Commission of Jurists; 1985
p.000050: (http://icj.wpengine.netdna-cdn.com/wp-content/uploads/1984/07/Siracusa-
p.000050: principles-ICCPR-legal-submission-1985-eng.pdf, accessed 23 July 2016).
p.000050:
p.000050: 9 United Nations Economic and Social Council. General Comment No. 14: The right to Highest Attainable Standard of
p.000050: Health (Art. 12 of the International Covenant on Economic, Social and Cultural Rights). New York: United Nations
p.000050: Committee on Economic, Social and Cultural Rights (E/C. 12/2000/4 – 2000; www1.umn.edu/
p.000050: humanrts/gencomm/escgencom14.htm, accessed 23 July 2016).
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050: 10 Parpia AS, Ndeffo-Mbah ML, Wenzel NS, Galvani AP. Effects of response to the 2014–2015 Ebola outbreak on deaths
p.000050: from malaria, HIV/AIDS, and tuberculosis, West Africa. Emerg Infect Dis. 2016;22(3)
p.000050: (http://dx.doi.org/10.3201/eid2203.150977, accessed 23 July 2016).
p.000050:
p.000050: 11 Declaration of Helsinki – Ethical principles for medical research involving human subjects, revised October 2013
p.000050: Ferney-Voltaire: World Medical Association; 2013 (www.wma.net/ en/30publications/10policies/b3/index.html, accessed 23
p.000050: July 2016).
p.000050:
p.000050: 12 International ethical guidelines for biomedical research involving human subjects.
p.000050: Geneva: Council for International Organizations of Medical Sciences; 2002 (www.cioms. 51
p.000050: ch/publications/guidelines/guidelines_nov_2002_blurb.htm, accessed 23 July 2016).
p.000050:
p.000050: 13 Standards and operational guidance for ethics review of health-related research with human participants. Geneva:
p.000050: World Health Organization; 2011 (www.who.int/ethics/ publications/9789241502948/en/, accessed 23 July 2016).
p.000050:
p.000050: 14 Ethics in epidemics, emergencies and disasters: Research, surveillance and patient care.
p.000050: Geneva: World Health Organization; 2015 (who.int/ethics/publications/epidemics- emergencies-research/en/, accessed 23
p.000050: July 2016).
p.000050:
p.000050: 15 Research ethics in international epidemic response. Geneva: World Health Organization; 2009 (WHO/HSE/GIP/ITP/10.1;
...

Searching for indicator hiv/aids:

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Health / Healthy People

Searching for indicator volunteers:

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p.000043: obligations to pay their employees and contractors. Fair remuneration for frontline workers includes the provision of
p.000043: financial support during periods in which workers are unable to carry out their normal responsibilities because of an
p.000043: infection acquired on the job.
p.000043:
p.000043: • Support for reintegrating into the community — Frontline workers may experience stigma and discrimination,
p.000043: particularly those involved in unpopular measures such as infection control or burials not conducted according to
p.000043: the traditional customs. Governments should make efforts to reduce the risk of stigmatization and discrimination and
p.000043: help such workers to reintegrate into the community, including by providing job placement assistance and relocation to
p.000043: other communities if needed.
p.000043:
p.000043: • Assistance to family members — Assistance should be provided to families of frontline workers who need to remain
p.000043: away from home in order
p.000043: to carry out their responsibilities or to recuperate from illness. Death benefits should be provided to family members
p.000043: of frontline workers who die in the line of duty, including those who were volunteers or “casual workers.”
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: As noted above, some workers may have a duty to work during an infectious
p.000043: disease outbreak. However, even for these individuals, the duty to assume risk is not unlimited. In determining the
p.000043: scope of workers’ duties to assume personal risks, the following factors should be taken into account:
p.000043:
p.000043: • Reciprocal obligations — Any professional or employment-based obligation to assume personal risk is contingent on
p.000043: society’s fulfilment of its reciprocal obligations to workers, as outlined above. If the reciprocal obligations are not
p.000043: met, frontline
p.000043: workers cannot legitimately be expected to assume a significant risk of harm to themselves and their families.
p.000043:
p.000043: • Risks and benefits — Frontline workers should not be expected to expose themselves to risks that are
p.000043: disproportionate to the public health
p.000043: benefits their efforts are likely to achieve.
p.000043:
p.000043: • Equity and transparency — Entities responsible for assigning frontline workers to specific tasks should ensure
p.000043: that risks are distributed among individuals and occupational categories in an equitable manner, and that the process
p.000043: of assigning workers is as transparent as possible.
p.000043:
p.000043: • Consequences for non- participation — Frontline workers should be informed of the risks they are being asked to
p.000043: assume. Insofar as possible, expectations should be made clear in written employment agreements. Workers who are
...

Health / Mentally Disabled

Searching for indicator mentally:

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p.000028:
p.000028:
p.000028: Any medical intervention for the diagnosis, treatment, or prevention of infectious disease should be provided in accord
p.000028: with professional medical standards, under conditions designed to ensure the highest attainable level of patient
p.000028: safety. Countries, with the support of international experts, should establish the minimum standards
p.000028: to be applied in the care and treatment of patients affected by an outbreak.
p.000028: These standards should apply not only to health-care institutions but also to home-based care, community activities
p.000028: (including health education sessions), and environmental decontamination efforts or the management of dead bodies.
p.000028:
p.000028: Individuals offered medical interventions for the diagnosis, treatment, or prevention of an infectious pathogen should
p.000028: be informed about the risks, benefits, and alternatives, just as they would be for other significant medical
p.000028: interventions. The presumption should be that the final decision about which medical interventions to accept, if any,
p.000028: belongs to the patient. For patients who lack the legal capacity to make health- care decisions for themselves,
p.000028: decisions should generally be made by appropriately authorized proxy decision-makers, with efforts made to solicit the
p.000028: patient’s assent whenever possible.
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028: Health-care providers should recognize that, in some situations, the refusal of diagnostic, therapeutic, or preventive
p.000028: measures might be a choice that is rational from the perspective of a mentally competent individual. If an individual
p.000028: is unwilling to accept an intervention, providers should engage the patient in an open and respectful dialogue, paying
p.000028: careful attention to the patient’s concerns, perceptions, and situational needs.
p.000028:
p.000028: In exceptional situations, there may be legitimate reasons to override an individual’s refusal of a diagnostic,
p.000028: therapeutic, or preventive measure that has proven to
p.000028: be safe and effective and is part of the accepted medical standard of care. Decisions on whether to override a refusal
p.000028: should be grounded in the following considerations:
p.000028:
p.000028: • Public health necessity of the proposed intervention — A mentally competent individual’s refusal of diagnostic,
p.000028: therapeutic, or preventive measures should only be overridden when there is substantial reason to believe that
p.000028: accepting the refusal would pose significant risks to public health, that the intervention is likely to
p.000028: ameliorate those risks, and that no other measures to protect public health — including isolating the patient — are
p.000028: feasible under the circumstances.
p.000028:
p.000028: • Existence of medical contraindications to the proposed intervention — Some interventions that may pose low risks
p.000028: for the majority of the population can pose heightened risks for individuals with particular medical conditions.
p.000028: Individuals should not be forced to undergo interventions that would expose them to significant risks in light of their
p.000028: personal medical circumstances.
p.000028: • Feasibility of providing interventions to an unwilling patient — In some cases, it may be impossible to provide
p.000028: an intervention to an individual who is unwilling to be an active participant in the process. For example, standard
p.000028: treatment for tuberculosis requires the patient to
p.000028: take medication on a regular basis for 29
p.000028: several months. Without the patient’s cooperation, it is unrealistic to expect that such a lengthy treatment regimen
p.000028: could successfully be completed. In such circumstances, the only realistic way to protect public health may be to
p.000028: isolate the patient until he or she is no longer infectious, assuming it is feasible to do so in a humane manner.
p.000028:
p.000028: • Impact on community trust — Overriding individuals’ refusal of diagnostic, therapeutic, or preventive measures
...

Searching for indicator disability:

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p.000047:
p.000047:
p.000047: References
p.000047:
p.000047:
p.000047: 1 Resolution WHA58.3. Revision of the International Health Regulations. In: Fifty-eighth World Health Assembly,
p.000047: Geneva, 16–25 May 2005. Resolutions and decisions, annex. Geneva: World Health Organization; 2005 (WHA58/2005/REC/1;
p.000047: http://apps.who.int/gb/ ebwha/pdf_files/WHA58-REC1/english/A58_2005_REC1-en.pdf, accessed 23 July 2016).
p.000050: 50
p.000050: 2 Addressing ethical issues in pandemic influenza planning: Discussion papers. Geneva: World Health Organization;
p.000050: 2008 (WHO/HSE/EPR/GIP/2008.2, WHO/IER/ETH/2008.1;
p.000050: http://apps.who.int/iris/bitstream/10665/69902/1/WHO_IER_ETH_2008.1_eng.pdf?ua=1, accessed 23 July 2016).
p.000050:
p.000050: 3 Guidance on ethics of tuberculosis prevention, care and control. Geneva: World Health Organization; 2010
p.000050: (WHO/HTM/TB/2010.16, http://apps.who.int/iris/ bitstream/10665/44452/1/9789241500531_eng.pdf?ua=1, accessed 23 July
p.000050: 2016).
p.000050:
p.000050: 4 Ethics of using convalescent whole blood and convalescent plasma during the Ebola epidemic. Geneva: World Health
p.000050: Organization; 2015 (WHO/HIS/KER/GHE/15.1; http://apps.who.int/iris/bitstream/10665/161912/1/WHO_HIS_KER_GHE_15.1_eng.
p.000050: pdf?ua=1&ua=1, accessed 23 July 2016).
p.000050:
p.000050: 5 Ethical considerations for use of unregistered interventions for Ebola viral disease. Geneva: World Health
p.000050: Organization; 2014 (WHO/HIS/KER/GHE/14.1, http://apps.who.
p.000050: int/iris/bitstream/10665/130997/1/WHO_HIS_KER_GHE_14.1_eng.pdf?ua=1, accessed 23 July 2016).
p.000050:
p.000050: 6 Becker L. Reciprocity, justice, and disability. Ethics. 2005;116(1):9–39.
p.000050:
p.000050: 7 Dawson A, Jennings B. The place of solidarity in public health ethics. Public Health Reviews. 2012;34(1):65–79.
p.000050:
p.000050: 8 Siracusa Principles on the Limitation and Derogation Provision in the International Covenant on Civil and
p.000050: Political Rights. Geneva: American Association for the International Commission of Jurists; 1985
p.000050: (http://icj.wpengine.netdna-cdn.com/wp-content/uploads/1984/07/Siracusa-
p.000050: principles-ICCPR-legal-submission-1985-eng.pdf, accessed 23 July 2016).
p.000050:
p.000050: 9 United Nations Economic and Social Council. General Comment No. 14: The right to Highest Attainable Standard of
p.000050: Health (Art. 12 of the International Covenant on Economic, Social and Cultural Rights). New York: United Nations
p.000050: Committee on Economic, Social and Cultural Rights (E/C. 12/2000/4 – 2000; www1.umn.edu/
p.000050: humanrts/gencomm/escgencom14.htm, accessed 23 July 2016).
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050: 10 Parpia AS, Ndeffo-Mbah ML, Wenzel NS, Galvani AP. Effects of response to the 2014–2015 Ebola outbreak on deaths
p.000050: from malaria, HIV/AIDS, and tuberculosis, West Africa. Emerg Infect Dis. 2016;22(3)
p.000050: (http://dx.doi.org/10.3201/eid2203.150977, accessed 23 July 2016).
p.000050:
p.000050: 11 Declaration of Helsinki – Ethical principles for medical research involving human subjects, revised October 2013
...

Health / Motherhood/Family

Searching for indicator family:

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p.000006:
p.000006: Utility — The principle of utility states that actions are right insofar as they promote the well-being of individuals
p.000006: or communities. Efforts to maximize utility require consideration of proportionality (balancing the potential benefits
p.000006: of an activity against any risks of harm) and
p.000006: efficiency (achieving the greatest benefits at the lowest possible cost).
p.000006:
p.000006: Respect for persons — The term “respect for persons” refers to treating individuals in ways that are fitting to and
p.000006: informed by a recognition of our common humanity, dignity and inherent rights. A central
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006: aspect of respect for persons is respect for autonomy, which requires letting individuals make their own choices based
p.000006: on their values and preferences. Informed consent, a process in which a competent individual authorizes a course of
p.000006: action based on sufficient relevant information, without coercion or undue inducement, is one
p.000006: way to operationalize this concept. Where individuals lack decision-making capacity, it may be necessary for others to
p.000006: be charged with protecting their interests. Respect for persons also includes paying attention to values such as
p.000006: privacy and confidentiality, as well as social, religious and cultural beliefs and important relationships, including
p.000006: family bonds. Finally, respect for persons requires transparency and truth-telling in the context of carrying out
p.000006: public health and research activities.
p.000006:
p.000006: LibertyLiberty includes a broad range of social, religious and political freedoms, such as freedom of movement,
p.000006: freedom of peaceful assembly, and freedom of speech. Many aspects of liberty are protected as fundamental human rights.
p.000006:
p.000006: Reciprocity — Reciprocity consists of making a “fitting and proportional return” for contributions that people have
p.000006: made.6 Policies that encourage reciprocity can
p.000006: be an important means of promoting the principle of justice, as they can correct unfair disparities in the distribution
p.000006: of the benefits and burdens of epidemic response efforts.
p.000006:
p.000006: Solidarity — Solidarity is a social relation in which a group, community, nation
p.000006: or, potentially, global community stands together.7 The principle of solidarity justifies collective action in the
p.000006: face of common threats. It also supports efforts to overcome inequalities that undermine the welfare
p.000006: of minorities and groups that suffer from discrimination.
p.000006:
p.000006:
p.000006: Practical applications
p.000006:
p.000006: The application of ethical principles should be informed by evidence as far as it is
p.000006: available. For example, in determining 9
...

p.000023: be undertaken to ensure that personal information is protected from physical, legal, psychological, and other harm.
p.000023: Countries should consider organizing systems for ethical oversight of public health activities, commensurate with the
p.000023: activity objectives, methods, risks and benefits, as well as the extent to which the activity involves individuals or
p.000023: groups whose situation may make them vulnerable.
p.000023: Regardless of whether such systems are adopted, ethical analysis of public
p.000023: health activities should be consistent with accepted norms of public health ethics and conducted by individuals or
p.000023: entities that can be held accountable for their decisions.
p.000023:
p.000023: Ensuring high-quality, ethically appropriate surveillance is complicated by at least
p.000023: two factors. First, the law surrounding surveillance across jurisdictions may be unnecessarily complex or inconsistent.
p.000023: Second, surveillance activities will occur across jurisdictions with varying levels of resources, thus placing strains
p.000023: on the quality and reliability of the data. These
p.000023: issues are likely to be exacerbated during an infectious disease outbreak, creating an urgent need for careful planning
p.000023: and international collaboration. Specific issues that should be addressed include the following:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023: • Protecting the confidentiality of personal information — The
p.000023: unauthorized disclosure of personal information collected during an infectious disease outbreak (including name,
p.000023: address, diagnosis, family history, etc.) can expose individuals to significant risk. Countries should
p.000023: 24 ensure that adequate protection exists
p.000023: against these risks, including laws that safeguard the confidentiality of information generated through
p.000023: surveillance activities, and that strictly limit the circumstances in which such information may be used or disclosed
p.000023: for purposes different from those for which it was initially collected. Use and sharing of non-aggregated surveillance
p.000023: data for research purposes must have the approval of a properly constituted and trained research ethics committee.
p.000023:
p.000023: • Assessing the importance of universal participation — Public health surveillance is typically conducted on a
p.000023: mandatory basis, without
p.000023: the possibility of individual refusal. Collecting surveillance information on a mandatory basis is ethically
p.000023: appropriate on the grounds of public
p.000023: interest if an accountable governmental authority has determined that universal participation is necessary to achieve
p.000023: compelling public health objectives.
p.000023: However, it should not be assumed that surveillance activities must always be carried out on a mandatory basis.
p.000023: Entities responsible for designing and approving surveillance programmes should consider the appropriateness of
p.000023: allowing individuals to opt out of particular surveillance activities, taking into account the nature and degree of
p.000023: individual risks involved and the extent to which allowing opt-outs
p.000023: would undermine the activity’s public health goals.
p.000023:
...

p.000025:
p.000025: about the outbreak pathogen, as determined in consultation with national and international public health officials. No
p.000025: such interventions should be implemented unless there is a reasonable basis to expect they will significantly reduce
p.000025: disease transmission. The rationale for relying
p.000025: 26 on these measures should be made
p.000025: explicit, and the appropriateness of any restrictions should be continuously re-evaluated in light of emerging
p.000025: scientific information about the outbreak. If the original rationale for
p.000025: imposing a restriction no longer applies, the restriction should be lifted without delay.
p.000025:
p.000025: • Least restrictive means — Any restrictions on freedom of movement should be designed and implemented in a manner
p.000025: that imposes the fewest constraints reasonably possible. Greater restrictions should be imposed only when there are
p.000025: strong grounds to believe that less restrictive measures are unlikely to achieve important
p.000025: public health goals. For example, requests for voluntary cooperation are generally preferable to public health mandates
p.000025: enforced by law or military authorities. Similarly, home-based quarantine should be considered before confining
p.000025: individuals in
p.000025: institutions. While isolation in a properly equipped health-care facility is usually recommended for individuals who
p.000025: are already symptomatic, especially for diseases with a high potential for contagiousness, home-based isolation may
p.000025: sometimes be appropriate, provided that adequate medical and
p.000025: logistical support can be organized and family attendants are willing and able to act under the oversight of trained
p.000025: public health staff. This is particularly true if the caseload overwhelms facility capacity.
p.000025:
p.000025: • Costs — In some cases, a less restrictive alternative may involve greater costs. This does not, in itself,
p.000025: justify more restrictive approaches. However, costs and other practical constraints (e.g. logistics, distance,
p.000025: available workforce) may legitimately be taken into account to determine whether a less restrictive alternative is
p.000025: feasible under the circumstances, particularly in settings with severe resource constraints.
p.000025:
p.000025: • Ensuring humane conditions — Any restrictions on freedom of movement, particularly those that are not voluntary,
p.000025: should be backed up with sufficient resources to ensure that those subject to the restrictions do not experience undue
p.000025: burdens. For example, individuals whose mobility is restricted (whether through confinement at home or
p.000025: in institutional settings) should be ensured access to food, drinking water, sanitary facilities, shelter, clothing,
p.000025: and medical care. It is also important to ensure that individuals have adequate physical space, opportunities to engage
p.000025: in activities, and the means
p.000025: to communicate with their loved ones and the outside world. Fulfilling these needs is essential to respect individual
p.000025: dignity and address the significant psychosocial burden of confinement on individuals and their loved ones. Mechanisms
...

p.000035: overseeing a clinical trial. Knowledge generated through MEURI should be aggregated across patients if possible and
p.000035: shared transparently, completely and rapidly with the MEURI scientific advisory committee, public health authorities,
p.000035: physicians and researchers in the country, and the international medical and scientific community.
p.000035: Information should be described accurately, without overstating benefits or understating uncertainties or risks.
p.000035:
p.000035: • Importance of informed consent — Individuals who are offered MEURI should be made aware that the intervention
p.000035: might not benefit
p.000035: them and might even harm them. The process of obtaining informed consent to MEURI should be carried out in a
p.000035: culturally and linguistically sensitive manner, with an emphasis on the content and understandability of the
p.000035: information conveyed and the voluntariness of the patient’s decision.
p.000035: The ultimate choice of whether to receive the unproven intervention must rest with the patient, if the patient is
p.000035: in a condition to make the choice. If the patient is unconscious, cognitively impaired, or too sick to understand the
p.000035: information, proxy consent should be obtained from a family member or other authorized decision-maker.
p.000035:
p.000035: • Need for community engagement —
p.000035: MEURI must be sensitive to local norms and practices. One way to try to ensure such sensitivity is to use rapid
p.000035: “community engagement
p.000035: teams” to promote dialogue about the potential benefits and risks of receiving
p.000035: interventions that have not yet been tested in clinical trials.
p.000035:
p.000035: • Fair distribution in the face of scarcity — Compounds qualifying for MEURI may not be available in large
p.000035: quantities. In this situation, choices will have to be made about who receives
p.000035: each intervention. Countries should 37
p.000035: establish mechanisms for making these allocation decisions, taking into account the assessment of the MEURI Scientific
p.000035: Advisory Committee and the principles discussed in Guideline 4.
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035: 10. Rapid data sharing
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000038: 38
p.000038: Questions addressed:
p.000038:
p.000038: • Why is rapid data sharing essential during an infectious disease outbreak?
p.000038: • What are the key ethical issues related to rapid data sharing?
p.000038:
p.000038:
p.000038:
p.000038:
p.000038:
p.000038: The collection and sharing of data are essential parts of ordinary public health practice. During an infectious disease
p.000038: outbreak, data sharing takes on increased urgency because of the uncertain and ever-changing scientific information;
p.000038: the compromised response capacity of local health systems; and the heightened role of cross-border collaboration. For
...

p.000041: Entities responsible for developing and implementing communication strategies should be sensitive to sex- and gender-
p.000041: based differences in how individuals have access to and respond to health- related information. Separate messages and
p.000041: communication strategies may be needed to provide relevant information to particular subgroups, such as pregnant women
p.000041: or nursing mothers.
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: Influenza in India
p.000041: Source: Tom Pietrasik, WHO
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: 13. Frontline response workers’ rights and obligations
p.000041:
p.000041:
p.000041:
p.000043: 43
p.000043: Questions addressed:
p.000043:
p.000043: • What obligations exist to protect the health of frontline workers who participate in infectious disease outbreak
p.000043: response efforts?
p.000043: • What obligations exist to provide material support to frontline workers who participate in infectious disease
p.000043: outbreak response efforts?
p.000043: • To what extent do these obligations extend to the workers’ family?
p.000043: • What should be taken into account in determining whether individuals have an obligation to serve as frontline
p.000043: workers during infectious disease outbreaks?
p.000043: • What special obligations do workers in the health-care sector have during infectious disease outbreaks?
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: An effective infectious disease outbreak response depends on the contribution of
p.000043: a diverse range of frontline workers, some of whom may be working on a volunteer basis. These workers often assume
p.000043: considerable personal risk to carry out their jobs. Within the health-care sector, frontline workers range from
p.000043: health-care professionals
p.000043: with direct patient care responsibilities to traditional healers, ambulance drivers,
p.000043: laboratory workers, and hospital ancillary staff. Outside the health sector, individuals such as sanitation workers,
p.000043: burial teams, domestic humanitarian aid workers, and persons who carry out contact-tracing also play critical roles.
p.000043: Some of these workers may be among the least advantaged members of society, and have little control over the type of
p.000043: duties they are asked to
p.000043: perform. It is essential that frontline workers’ rights and obligations be clearly established during the pre-outbreak
p.000043: planning period,
p.000043: in order to ensure that all actors are aware of what can reasonably be expected if an outbreak occurs.
p.000043:
p.000043: Workers with certain professional qualifications, such as physicians, nurses, and funeral directors, may have a duty to
...

p.000043:
p.000043: may have precarious employment contracts with no social protection, or work on
p.000043: a volunteer basis.
p.000043:
p.000043: Regardless of whether a particular individual has a pre-existing duty to assume
p.000043: heightened risks during an infectious disease outbreak, once a worker has taken on these
p.000043: 44 risks, society has a reciprocal obligation to
p.000043: provide necessary support. At a minimum, fulfilment of society’s reciprocal obligations to frontline workers requires
p.000043: the following actions:
p.000043:
p.000043: • Minimizing the risk of infection —
p.000043: Individuals should not be expected to take on risky work assignments
p.000043: during an infectious disease outbreak unless they are provided with
p.000043: the training, tools, and resources necessary to minimize the risks to the extent reasonably possible. This includes
p.000043: complete and accurate information known about the nature
p.000043: of the pathogen and infection control measures, updated information on the epidemiological situation at the local
p.000043: level, and the provision of personal protective equipment. Regular screening of frontline workers should be put
p.000043: in place to detect any infection as quickly as possible, in order to initiate immediate care and minimize the risk of
p.000043: transmission to colleagues, patients, families, and community members.
p.000043:
p.000043: • Priority access to health care — Frontline workers who become sick, as well as any immediate family members who
p.000043: become ill through contact with the worker, should be ensured access to the highest level of care reasonably available.
p.000043: In addition, countries should consider giving frontline workers and their families priority access to vaccines
p.000043: and other treatments as they become available.
p.000043:
p.000043: • Appropriate remuneration — Frontline workers should be given fair remuneration for their work. Governments should
p.000043: ensure that public sector workers are paid in
p.000043: a timely manner, and make efforts to ensure that actors in the private and nongovernmental sectors fulfil their own
p.000043: obligations to pay their employees and contractors. Fair remuneration for frontline workers includes the provision of
p.000043: financial support during periods in which workers are unable to carry out their normal responsibilities because of an
p.000043: infection acquired on the job.
p.000043:
p.000043: • Support for reintegrating into the community — Frontline workers may experience stigma and discrimination,
p.000043: particularly those involved in unpopular measures such as infection control or burials not conducted according to
p.000043: the traditional customs. Governments should make efforts to reduce the risk of stigmatization and discrimination and
p.000043: help such workers to reintegrate into the community, including by providing job placement assistance and relocation to
p.000043: other communities if needed.
p.000043:
p.000043: • Assistance to family members — Assistance should be provided to families of frontline workers who need to remain
p.000043: away from home in order
p.000043: to carry out their responsibilities or to recuperate from illness. Death benefits should be provided to family members
p.000043: of frontline workers who die in the line of duty, including those who were volunteers or “casual workers.”
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: As noted above, some workers may have a duty to work during an infectious
p.000043: disease outbreak. However, even for these individuals, the duty to assume risk is not unlimited. In determining the
p.000043: scope of workers’ duties to assume personal risks, the following factors should be taken into account:
p.000043:
p.000043: • Reciprocal obligations — Any professional or employment-based obligation to assume personal risk is contingent on
p.000043: society’s fulfilment of its reciprocal obligations to workers, as outlined above. If the reciprocal obligations are not
p.000043: met, frontline
p.000043: workers cannot legitimately be expected to assume a significant risk of harm to themselves and their families.
p.000043:
p.000043: • Risks and benefits — Frontline workers should not be expected to expose themselves to risks that are
p.000043: disproportionate to the public health
p.000043: benefits their efforts are likely to achieve.
p.000043:
p.000043: • Equity and transparency — Entities responsible for assigning frontline workers to specific tasks should ensure
p.000043: that risks are distributed among individuals and occupational categories in an equitable manner, and that the process
p.000043: of assigning workers is as transparent as possible.
p.000043:
p.000043: • Consequences for non- participation — Frontline workers should be informed of the risks they are being asked to
p.000043: assume. Insofar as possible, expectations should be made clear in written employment agreements. Workers who are
p.000043: unwilling to accept reasonable risks and work assignments may be subject to professional repercussions
p.000043: (for example, loss of their job), but additional punishments, such as fines or imprisonment, are generally unwarranted.
p.000043: Persons responsible for assessing the consequences for non- participation should recognize that
p.000043: workers may sometimes need to balance other obligations, such as duty to family,
p.000043: against job-related responsibilities. 45
p.000043:
p.000043: Additional obligations of those working in the health‑care sector:
p.000043:
p.000043: In addition to the issues addressed above, persons working in the health-care sector have obligations to the community
p.000043: during an infectious disease outbreak, including the following:
p.000043:
p.000043: • Participate in public health surveillance and reporting efforts — Persons working in the health sector have an
p.000043: obligation to participate in organized measures to respond to infectious disease outbreaks, including public health
p.000043: surveillance and reporting. Health-care providers should protect the confidentiality of patient information to the
p.000043: maximum extent compatible with legitimate public health interests.
p.000043:
p.000043: • Provide accurate information to the public — During an infectious disease outbreak, public health officials have
p.000043: the primary responsibility to communicate information about the outbreak pathogen, including how
p.000043: it is transmitted, how infection can be prevented, and what treatments or preventive measures may be effective. Those
p.000043: responsible for designing communication strategies should anticipate and respond to misinformation, exaggeration, and
p.000043: mistrust, and should seek (without
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: withholding key information) to minimize the risk that information about risk factors will lead to stigmatization and
...

p.000054:
p.000054:
p.000054:
p.000054: Panel discussion: Ethical considerations for use of unregistered interventions
p.000054: for Ebola viral disease, World Health Organization, Geneva, 11 August 2014 55
p.000054:
p.000054: Advisors
p.000054: Dr Juan Pablo Beca, Professor, Bioethics Center, Universidad del Desarrollo, Chile
p.000054: Dr Helen Byomire Ndagije, Head, Drug Information Department, Ugandan National Drug Authority, Uganda
p.000054: Dr Philippe Calain (Chair), Senior Researcher, Unit of Research on Humanitarian Stakes and Practices, Médecins Sans
p.000054: Frontières, Switzerland
p.000054: Dr Marion Danis, Head, Ethics and Health Policy and Chief, Bioethics Consultation Service, National Institutes of
p.000054: Health, United States of America
p.000054: Professor Jeremy Farrar, Director, Wellcome Trust, United Kingdom Professor Ryuichi Ida, Chair, National Bioethics
p.000054: Advisory Committee, Japan
p.000054: Professor Tariq Madani, infectious diseases physician and clinical academic researcher, Saudi Arabia
p.000054: Professor Michael Selgelid, Director, Centre for Human Bioethics, Monash University, Australia
p.000054: Professor Peter Smith, Professor of Tropical Epidemiology, London School of Tropical Medicine and Hygiene, United
p.000054: Kingdom
p.000054: Ms Jeanine Thomas, Patient Safety Champion, United States of America
p.000054: Professor Aisssatou Touré, Head, Immunology Department, Institut Pasteurde Dakar,,Senegal Professor Ross Upshur, Chair
p.000054: in Primary Care Research; Professor, Department of Family and Community Medicine and Dalla Lana School of Public
p.000054: Health, University of Toronto; Canada
p.000054:
p.000054: Resource persons
p.000054: Dr Daniel Bausch, Head, Virology and Emerging Infections Department, US Naval Medical Research Unit No. 6, Peru
p.000054: Professor Luciana Borio, Assistant Commissioner for Counterterrorism Policy; Director, Office of Counterterrorism and
p.000054: Emerging Threats, Food and Drug Administration, United States of America
p.000054: Dr Frederick Hayden, Professor of Clinical Virology and Professor of Medicine, University of Virginia School of
p.000054: Medicine, United States of America
p.000054: Dr Stephan Monroe, Deputy Director, National Centre for Emerging and Zoonotic Infectious Diseases, Centers for Disease
p.000054: Control and Prevention, United States of America
p.000054:
p.000054:
p.000054:
p.000054:
p.000054:
p.000054:
p.000054:
p.000054:
p.000054: WHO Secretariat
p.000054:
p.000054: WHO headquarters, Geneva, Switzerland
p.000054: Dr Margaret Chan, Director-General
p.000054: Dr Marie-Paule Kieny, Assistant Director-General, Health Systems and Innovation Dr Marie-Charlotte Bouesseau, Ethics
p.000054: Advisor, Service Delivery and Safety
p.000054: Dr Pierre Formenty, Scientist, Control of Epidemic Diseases, Department of Pandemic and Epidemic Diseases
p.000054: 56 Dr Margaret Harris, Communication Officer, Department of Pandemic and Epidemic
p.000054: Diseases
p.000054: Mr Gregory Hartl, Coordinator, Department of Communications Dr Rüdiger Krech, Director, Health Systems and Innovation
...

p.000054:
p.000054: Ethical issues related to study design for trials on therapeutics, World Health Organization, Geneva, 20–21 October
p.002014: 2014
p.002014:
p.002014: Ethics Working Group
p.002014: Professor Arthur Caplan, Drs William F and Virginia Connolly Mitty; Director, Division of Medical Ethics, New York
p.002014: University Langone Medical Center’s Department of Population Health, United States of America
p.002014: Dr Clare Chandler, Senior Lecturer, Medical Anthropology, Department of Global Health and Development, London School of
p.002014: Hygiene and Tropical Medicine, United Kingdom
p.002014: Dr Alpha Ahmadou Diallo, Administrator, National Ethics Committee, Ministry of Health and Public Hygiene, Guinea
p.002014: Dr Amar Jesani, Independent Researcher and Teacher, Bioethics and Public Health; Editor, Indian Journal of Medical
p.002014: Ethics; Visiting Professor, Centre for Ethics, Yenepoya University, India Dr Dan O’Connor, Head, Medical Humanities,
p.002014: Wellcome Trust, United Kingdom
p.002014: Dr Lisa Schwartz, Arnold L. Johnson Chair in Health Care Ethics, McMaster Ethics in Healthcare, McMaster University,
p.002014: Canada
p.002014: Professor Michael Selgelid, Director, Centre for Human Bioethics, Monash University, Australia Dr Paulina Tindana,
p.002014: Ethicist and Senior Researcher, Navrongo Health Research Centre, Ghana Professor Ross Upshur, Chair in Primary Care
p.002014: Research; Professor, Department of Family and Community Medicine and Dalla Lana School of Public Health, University of
p.002014: Toronto, Canada
p.002014:
p.002014:
p.002014:
p.002014:
p.002014:
p.002014:
p.002014:
p.002014:
p.002014: Invited participants
p.002014: Dr Enrica Alteri, Head, Human Medicines Evaluation Division, European Medicines Agency, United Kingdom
p.002014: Dr Nicholas Andrews, Statistics Modelling and Economics Department, Centre for Infectious Disease Surveillance and
p.002014: Control, Public Health England, United Kingdom
p.002014: Professor Oumou Younoussa Bah-Sow, Head of Pneumophtisiology, Ignace Deen National Hospital, Guinea
p.002014: Dr Luciana Borio, Assistant Commissioner for Counterterrorism Policy; Director, Office of
p.002014: 58 Counterterrorism and Emerging Threats, Food and Drug Administration, United States of Ameria
p.002014: Dr Jacob Thorup Cohn; Vice President, Governmental Affairs, Bavarian Nordic, Denmark Dr Edward Cox, Director, Office of
p.002014: Antimicrobial Products, Office of New Drugs Center for Drug Evaluation and Research, Food and Drug Administration,
p.002014: Silver Spring MD, United States of America
p.002014: Dr Nicolas Day, Director, Thailand/Laos Wellcome Trust Major Overseas Programme Mahidol-Oxford Tropical Medicine
p.002014: Research Unit, Thailand
p.002014: Dr Matthias Egger, Professor, Clinical Epidemiology, Department of Social Medicine, University of Bristol, United
p.002014: Kingdom; Epidemiology and Public Health, Institute for Social and Preventive Medicine, University of Bern, Switzerland
p.002014: Dr Elizabeth Higgs, Global Health Science Advisor, Office of the Director, Division of Clinical Research, National
...

p.000059: of Health Sciences, India
p.000059: 60 Dr Markus Kirchner, Department for Infectious Disease Epidemiology, Robert Koch Institute,
p.000059: Germany
p.000059: Dr Katherine Littler, Senior Policy Adviser, Wellcome Trust, United Kingdom
p.000059: Professor Samuel McConkey, Head, International Health and Tropical Medicine, Royal College of Surgeons, Ireland
p.000059: Dr Farhat Moazam, Founding Chairperson, Center of Biomedical Ethics and Culture, Sindh Institute of Urology and
p.000059: Transplantation, Pakistan
p.000059: Dr Robert Nelson, Deputy Director and Senior Pediatric Ethicist, Office of Pediatric Therapeutics, Food and Drug
p.000059: Administration, United States of America
p.000059: Professor Alistair Nichol, Consultant Anaesthetist, School of Medicine and Medical Sciences, and EU projects,
p.000059: University College Dublin, Ireland
p.000059: Professor Lisa Schwartz, Arnold Johnson Chair in Health Care Ethics, Ethics in Health Care, McMaster University, Canada
p.000059: Professor Michael Selgelid, Director, Centre for Human Bioethics, Monash University, Australia Dr Kadri Simm, Associate
p.000059: Professor of Practical Philosophy, University of Tartu, Estonia
p.000059: Dr Aissatou Touré, Head, Immunology Department, Institut Pasteur de Dakar and Member, National Ethics Committee,
p.000059: Senegal
p.000059: Professor Ross Upshur, Canada Research Chair in Primary Care Research; Professor, Department of Family and Community
p.000059: Medicine and Dalla Lana School of Public Health, University of Toronto, Canada
p.000059: Dr Maria Van Kerkhove, Centre for Global Health, Institut Pasteur, France
p.000059: Dr Aminu Yakubu, Department of Health Planning and Research, Federal Ministry of Health, Nigeria
p.000059:
p.000059: Resource person
p.000059: Professor Carl Coleman (Rapporteur), Professor of Law and Academic Director, Division of Online Learning, Seton Hall
p.000059: University, New Jersey, United States of America
p.000059:
p.000059: WHO headquarters Secretariat, Geneva, Switzerland
p.000059: Dr Vânia de la Fuente-Núñez, Technical Officer, Global Health Ethics, Department of Knowledge, Ethics and Research
p.000059: Dr Andreas Reis, Technical Officer, Global Health Ethics, Department of Knowledge, Ethics and Research
p.000059: Dr Abha Saxena, Coordinator, Global Health Ethics, Department of Knowledge, Ethics and Research
p.000059:
p.000059:
p.000059:
p.000059:
p.000059:
p.000059:
p.000059:
p.000059:
p.000059: Meeting to develop WHO Guidance on ethics and epidemics. Prato, Italy, 22–24 November 2015
p.000059:
p.000059: Participants
p.000059: Dr Franklyn Prieto Alvarado, Universidad Nacional de Colombia, Colombia Dr Annick Antierens, Médecins Sans Frontières,
p.000059: Switzerland
p.000059: Professor Oumou Younoussa Bah-Sow, Ignace Deen National Hospital, Guinea Dr Ruchi Baxi, The Ethox Centre, United
...

p.000061: et de Formation sur le VIH et les Maladies Associées, Hôpital de Fann, Sénégal
p.000061: Dr Benedict Dossen, National Research Ethics Board, University of Liberia–Pacific Institute for Research and
p.000061: Evaluation, Africa Center Institutional Review Board, Liberia
p.000061: Dr Sarah Edwards, Research Ethics and Governance, University College London, United Kingdom
p.000061: Professor Amy F Fairchild, Mailman School of Public Health, United States of America Dr Eddy Foday, Ministry of Health
p.000061: and Sanitation, Sierra Leone
p.000061: Professor Frederick G Hayden, Mailman School of Public Health, United States of America Dr Amar Jesani, Yenepoya
p.000061: University, India
p.000061: Ms Rebecca Johnson, Ebola survivor, Sierra Leone
p.000061: Ms Robinah Kaitiritimba, Patient representative (Community representative, Makerere University Institutional Review
p.000061: Board; Uganda National Health Consumers’ Organisation, Uganda
p.000061: Dr Stephen Kennedy, Coordinator, Ebola Virus Disease Research, Incident Management System, Liberia
p.000061: Dr Pretesh Kiran, National Academy of Health Sciences, India
p.000061: Dr Bocar Kouyate, Special Advisor to the Minister of Health, Burkina Faso Professor Mark Leys, Vrije Universiteit
p.000061: Brussel,,Belgium
p.000061: Dr Farhat Moazam, Founding Chairperson of Center of Biomedical Ethics and Culture, Sindh Institute of Urology and
p.000061: Transplantation, Pakistan
p.000061: Dr Dónal O’Mathúna, Dublin City University, Ireland
p.000061: Professor Mahmudur Rahman, Director, Institute of Epidemiology, Disease Control and Research; National Influenza
p.000061: Center, Ministry of Health and Family Welfare, Bangladesh Professor Lisa Schwartz, Arnold Johnson Chair in Health Care
p.000061: Ethics, McMaster Ethics in Healthcare, McMaster University, Canada
p.000061: Professor Michael Selgelid, Director, Centre for Human Bioethics, Monash University, Australia Dr Aissatou Touré, Head,
p.000061: Immunology Unit, Institut Pasteur de Dakar, Senegal
p.000061: Dr Maria Van Kerkhove, Centre for Global Health, Institut Pasteur, France
p.000061:
p.000061:
p.000061:
p.000061:
p.000061:
p.000061:
p.000061:
p.000061:
p.000061: Observer
p.000061: Dr Katherine Littler, Senior Policy Adviser, Policy Department, Wellcome Trust, United Kingdom
p.000061:
p.000061: Resource consultants
p.000061: Professor Carl Coleman, Professor of Law and Academic Director, Division of Online Learning, Seton Hall University, New
p.000061: Jersey, United States of America
p.000061: Dr Michele Loi (Rapporteur), Post-doctoral research fellow, ETH Zürich, Switzerland
p.000061: Dr Diego Silva, Assistant Professor, Faculty of Health Sciences, Simon Fraser University, Canada
p.000062: 62
p.000062: WHO headquarters Secretariat, Geneva, Switzerland
p.000062: Dr Pierre Formenty, Scientist, Control of Epidemic Diseases, Department of Pandemic and Epidemic Diseases
p.000062: Dr Vânia de la Fuente-Núñez,Technical Officer, Global Health Ethics, Department of Knowledge, Ethics and Research
...

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p.000040:
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p.000040:
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p.000040:
p.000040:
p.000040: 12. Addressing sex- and gender-based differences
p.000040:
p.000040:
p.000040:
p.000041: 41
p.000041: Questions addressed:
p.000041:
p.000041: • How are sex and gender relevant to infectious disease outbreaks?
p.000041: • How can sex and gender be incorporated into public health and surveillance?
p.000041: • How can social and cultural practices relevant to gender roles affect infectious disease outbreaks?
p.000041: • How should appropriate reproductive health-care services be safely provided during an infectious disease
p.000041: outbreak?
p.000041: • How are sex and gender relevant to communication strategies during outbreaks?
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: Sex (biological and physiological characteristics) and gender (socially constructed roles, behaviours, activities, and
p.000041: attributes)20 can influence the spread, containment, course, and consequences of infectious disease outbreaks. Sex and
p.000041: gender differences have been associated with differences in susceptibility to infection, levels of health care
p.000041: received, and in the course and outcome of illness.21 Addressing sex and gender differences in infectious disease
p.000041: outbreak planning and response efforts requires attention to the following considerations:
p.000041:
p.000041: • Sex- and gender-inclusive surveillance programmes — Public health surveillance should systematically collect
p.000041: disaggregated information on sex, gender, and pregnancy status, both to identify differential risks and
p.000041: modes of transmission, and to monitor any differential impact of an infectious disease outbreak and the interventions
p.000041: used to control it. This information is particularly important for pregnant women and their offspring.
p.000041:
p.000041: • Ensuring the availability of high- quality reproductive health-care services — Whether or not they are currently
p.000041: pregnant, women of childbearing age should have access to the full range of high-quality
p.000041: reproductive health-care services during an infectious disease outbreak. These services should be organized and
p.000041: delivered in a manner that does not stigmatize persons who use them or expose them to a heightened risk of infection
p.000041: with the outbreak pathogen. If there is evidence that an infectious
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
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p.000043:
p.000043: • Appropriate remuneration — Frontline workers should be given fair remuneration for their work. Governments should
p.000043: ensure that public sector workers are paid in
p.000043: a timely manner, and make efforts to ensure that actors in the private and nongovernmental sectors fulfil their own
p.000043: obligations to pay their employees and contractors. Fair remuneration for frontline workers includes the provision of
p.000043: financial support during periods in which workers are unable to carry out their normal responsibilities because of an
p.000043: infection acquired on the job.
p.000043:
p.000043: • Support for reintegrating into the community — Frontline workers may experience stigma and discrimination,
p.000043: particularly those involved in unpopular measures such as infection control or burials not conducted according to
p.000043: the traditional customs. Governments should make efforts to reduce the risk of stigmatization and discrimination and
p.000043: help such workers to reintegrate into the community, including by providing job placement assistance and relocation to
p.000043: other communities if needed.
p.000043:
p.000043: • Assistance to family members — Assistance should be provided to families of frontline workers who need to remain
p.000043: away from home in order
p.000043: to carry out their responsibilities or to recuperate from illness. Death benefits should be provided to family members
p.000043: of frontline workers who die in the line of duty, including those who were volunteers or “casual workers.”
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: As noted above, some workers may have a duty to work during an infectious
p.000043: disease outbreak. However, even for these individuals, the duty to assume risk is not unlimited. In determining the
p.000043: scope of workers’ duties to assume personal risks, the following factors should be taken into account:
p.000043:
p.000043: • Reciprocal obligations — Any professional or employment-based obligation to assume personal risk is contingent on
p.000043: society’s fulfilment of its reciprocal obligations to workers, as outlined above. If the reciprocal obligations are not
p.000043: met, frontline
p.000043: workers cannot legitimately be expected to assume a significant risk of harm to themselves and their families.
p.000043:
p.000043: • Risks and benefits — Frontline workers should not be expected to expose themselves to risks that are
p.000043: disproportionate to the public health
p.000043: benefits their efforts are likely to achieve.
p.000043:
p.000043: • Equity and transparency — Entities responsible for assigning frontline workers to specific tasks should ensure
p.000043: that risks are distributed among individuals and occupational categories in an equitable manner, and that the process
p.000043: of assigning workers is as transparent as possible.
p.000043:
...

p.000043: obligation to participate in organized measures to respond to infectious disease outbreaks, including public health
p.000043: surveillance and reporting. Health-care providers should protect the confidentiality of patient information to the
p.000043: maximum extent compatible with legitimate public health interests.
p.000043:
p.000043: • Provide accurate information to the public — During an infectious disease outbreak, public health officials have
p.000043: the primary responsibility to communicate information about the outbreak pathogen, including how
p.000043: it is transmitted, how infection can be prevented, and what treatments or preventive measures may be effective. Those
p.000043: responsible for designing communication strategies should anticipate and respond to misinformation, exaggeration, and
p.000043: mistrust, and should seek (without
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: withholding key information) to minimize the risk that information about risk factors will lead to stigmatization and
p.000043: discrimination. If persons working in the health sector are asked medical questions about the outbreak by patients or
p.000043: the general public, they should not spread
p.000043: 46 unsubstantiated rumours or suspicion
p.000043: and ensure that information they provide comes from reliable sources.
p.000043:
p.000043: • Avoiding exploitation — In the context of a rapidly spreading life- threatening illness with no proven
p.000043: treatment, desperate individuals may be willing to try any intervention offered, regardless of the expected risks or
p.000043: benefits. Health-care workers have a duty not to exploit individuals’ vulnerability by offering treatments or
p.000043: preventive measures for which
p.000043: there is no reasonable basis to believe that the potential benefits outweigh the uncertainties and risks. This duty
p.000043: does not preclude the appropriate use of unproven interventions on an
p.000043: experimental basis, consistent with the guidelines set forth in Guideline 9.
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
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p.000043:
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p.000043:
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p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: Earthquake Haiti 2010
p.000043: Source: Victor Ariscain, PAHO/WHO
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: 14. Ethical issues in deploying foreign humanitarian aid workers
p.000043:
p.000043:
p.000043:
p.000047: 47
p.000047: Questions addressed:
p.000047:
p.000047: • What ethical issues arise in assigning foreign workers for deployment during infectious disease outbreaks?
p.000047: • What obligations do sponsoring organizations have to prepare foreign aid workers adequately for their missions?
p.000047: • What obligations do sponsoring organizations have regarding the conditions of deployment?
p.000047: • What obligations do sponsoring organizations have to coordinate with local officials?
p.000047: • What obligations do foreign aid workers have before, during, and after deployment?
p.000047:
...

p.000047: authorities and care providers to
p.000047: ensure that the foreign agency does not excessively draw resources away from other essential services.
p.000047:
p.000047: • Fairness in assigning foreign workers for deployment — Foreign aid workers should be deployed only if they are
p.000047: capable of providing necessary services not sufficiently available in the local setting. Assignment of foreign
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047: health workers should take into consideration their relevant skills and knowledge, as well as their linguistic and
p.000047: cultural competencies to meet mission objectives and understand and communicate with affected communities. It is
p.000047: inappropriate to deploy unqualified or unnecessary
p.000047: 48 workers solely to satisfy their personal
p.000047: or professional desire to be helpful (so-called “disaster tourism”).
p.000047:
p.000047: • Clarity about conditions of deployment — Prospective foreign aid workers should be given
p.000047: comprehensive information about the project’s expectations and risks so they can make informed decisions about whether
p.000047: or not they will be able to make appropriate contributions. In addition, foreign aid workers should be clearly
p.000047: informed of the conditions of their deployment, including the level of health care they can expect if they become ill,
p.000047: the circumstances under
p.000047: which they will be repatriated, available insurance, and whether benefits will
p.000047: be provided to their families in case of illness or death.
p.000047:
p.000047: • Provision of necessary training and resources — Aid workers must be provided with appropriate
p.000047: training, preparation, and equipment to ensure that they can effectively carry out their mission with the lowest risks
p.000047: practicable. Training should include preparation in psychosocial and communication skills, and in understanding and
p.000047: respecting the local culture and traditions. Managers and organizations have an obligation to provide adequate support
p.000047: and guidance to the staff, both during their activity in the field and following
p.000047: their mission. This should include training and resources for managing challenging ethical issues, such as resource
p.000047: allocation decisions, triage, and inequities.
p.000047:
p.000047: • Ensuring the security and safety of aid workers — Organizations that deploy foreign aid workers have an
p.000047: obligation to take all necessary measures to ensure the workers’ security, particularly in situations of crisis; this
p.000047: obligation includes the provision of measures to reduce risks of exposure to infectious agents, contamination and
p.000047: violence. A clear chain of authority must be in place to provide oversight and ongoing advice. Individuals who object
p.000047: to assigned duties should have an opportunity for review and appeal, according to the norms of the organizations for
p.000047: which they work.
p.000047:
p.000047: Aid workers also have their own ethical obligations to patients, affected communities, their sponsoring
p.000047: organizations, and themselves. In addition to the obligations described in other sections of this document, obligations
p.000047: of foreign aid workers include the following:
p.000047:
...

Health / Physically Ill

Searching for indicator sick:

(return to top)
p.000020: of health-care workers. As
p.000020: a result, deaths from tuberculosis, human immunodeficiency virus (HIV), and malaria increased dramatically during this
p.000020: period.10
p.000020:
p.000020: Governments, health-care facilities, and others involved in response efforts should
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020: prepare for such situations by developing guidelines on the allocation of scarce resources in outbreak situations. Such
p.000020: guidelines should be developed through an open and transparent process involving broad stakeholder input and, to the
p.000020: extent
p.000020: possible, should be incorporated into formal written documents that establish clear priorities and procedures. Those
p.000020: involved
p.000020: in developing these guidelines should be guided by the following considerations:
p.000020:
p.000020: • Balancing considerations of utility and equity — Resource allocation decisions should be guided by the ethical
p.000020: principles of utility and equity. The principle of utility requires allocating resources to maximize benefits and
p.000020: minimize burdens, while the principle of equity requires attention to the fair distribution of benefits
p.000020: and burdens. In some cases, an equal distribution of benefits and burdens may be considered fair, but in others, it may
p.000020: be fairer to give preference to groups that are worse off, such as the poor, the sick, or the vulnerable. It is not
p.000020: always be possible to achieve fully both utility and equity. For example, establishing treatment centres in large urban
p.000020: settings promotes the value of utility because it makes it possible to treat a large number of people with relatively
p.000020: few resources. However, such
p.000020: an approach may be in tension with the principle of equity if it means that fewer resources will be directed to
p.000020: isolated communities in remote rural areas.
p.000020: There is no single correct way to resolve potential tensions between utility
p.000020: and equity; what is important is that decisions are made through an inclusive and transparent process that takes into
p.000020: account local circumstances.
p.000020: • Defining utility on the basis of health-related considerations —
p.000020: In order to apply the ethical principle of utility, it is first necessary to identify the type of outcomes that will be
p.000020: counted as improvements to welfare. In general, the focus should be on the health-related benefits of allocation
p.000020: mechanisms, whether defined in terms 21
p.000020: of the total number of lives saved, the total number of life years saved, or the total number of quality-adjusted life
p.000020: years saved. For this reason,
p.000020: while it might be ethical to prioritize persons who are essential to manage an outbreak, it is not appropriate to
p.000020: prioritize persons based on social value considerations unrelated to carrying out critical services necessary for
p.000020: society.
p.000020:
...

p.000030: sites. Researchers have an obligation to share information collected as part of a study if it is important for the
p.000030: ongoing response efforts, such as information about hidden cases and transmission chains or resistance to response
p.000030: measures. Persons who share the information and those who receive it should protect the confidentiality of personal
p.000030: information to the maximum
p.000030: extent possible. As part of the informed consent process, researchers should inform potential participants about
p.000030: the circumstances under which their personal information might be shared with public health authorities.
p.000030:
p.000030: • Ensuring that research does not drain critical health-related resources — Research should not be done if it will
p.000030: excessively take
p.000030: away resources, including personnel, equipment, and health-care facilities, from other critical clinical and public
p.000030: health efforts. To the extent possible, research protocols should anticipate provisions for local capacity-building
p.000030: such as involving and training local contributors or, where possible, leaving behind any potentially useful tools or
p.000030: resources.
p.000030:
p.000030: • Confronting fear and desperation — The climate of fear and desperation typical of infectious disease outbreaks
p.000030: can make it difficult for ethics
p.000030: committees or prospective participants to engage in an objective assessment of the risks and benefits of research
p.000030: participation. In an environment where large numbers of individuals become sick and die, any potential intervention may
p.000030: be perceived to
p.000030: be better than nothing, regardless of the risks and potential benefits actually involved. Those responsible for
p.000030: approving research protocols
p.000030: should ensure that clinical trials are not initiated unless there is a reasonable scientific basis to believe that the
p.000030: experimental intervention is likely
p.000030: to be safe and efficacious, and that the risks have been minimized to the extent reasonably possible. In addition,
p.000030: researchers and ethics committees should recognize that, during an outbreak, prospective participants may be especially
p.000030: prone to the therapeutic misconception — that is, the mistaken view that the intervention is primarily designed to
p.000030: directly benefit the individual participants, as opposed to developing generalizable knowledge for the potential
p.000030: benefit of persons
p.000030: in the future. Indeed, researchers themselves, as well as humanitarian aid workers, may sometimes fail
p.000030: to distinguish between engaging in research and providing ordinary
p.000030: clinical care. Efforts should be made to dispel the therapeutic misconception to the extent reasonably possible.
p.000030: Despite such efforts, some prospective participants may still not fully appreciate the difference between research and
p.000030: ordinary medical care, and this should not in itself preclude their enrolment.
p.000030:
p.000030: • Addressing other barriers to informed consent — In addition to the impact of fear and desperation,
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
...

p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035: obligation to collect all scientifically relevant data on the safety and efficacy of the intervention as researchers
p.000035: overseeing a clinical trial. Knowledge generated through MEURI should be aggregated across patients if possible and
p.000035: shared transparently, completely and rapidly with the MEURI scientific advisory committee, public health authorities,
p.000035: physicians and researchers in the country, and the international medical and scientific community.
p.000035: Information should be described accurately, without overstating benefits or understating uncertainties or risks.
p.000035:
p.000035: • Importance of informed consent — Individuals who are offered MEURI should be made aware that the intervention
p.000035: might not benefit
p.000035: them and might even harm them. The process of obtaining informed consent to MEURI should be carried out in a
p.000035: culturally and linguistically sensitive manner, with an emphasis on the content and understandability of the
p.000035: information conveyed and the voluntariness of the patient’s decision.
p.000035: The ultimate choice of whether to receive the unproven intervention must rest with the patient, if the patient is
p.000035: in a condition to make the choice. If the patient is unconscious, cognitively impaired, or too sick to understand the
p.000035: information, proxy consent should be obtained from a family member or other authorized decision-maker.
p.000035:
p.000035: • Need for community engagement —
p.000035: MEURI must be sensitive to local norms and practices. One way to try to ensure such sensitivity is to use rapid
p.000035: “community engagement
p.000035: teams” to promote dialogue about the potential benefits and risks of receiving
p.000035: interventions that have not yet been tested in clinical trials.
p.000035:
p.000035: • Fair distribution in the face of scarcity — Compounds qualifying for MEURI may not be available in large
p.000035: quantities. In this situation, choices will have to be made about who receives
p.000035: each intervention. Countries should 37
p.000035: establish mechanisms for making these allocation decisions, taking into account the assessment of the MEURI Scientific
p.000035: Advisory Committee and the principles discussed in Guideline 4.
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035: 10. Rapid data sharing
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000038: 38
p.000038: Questions addressed:
p.000038:
p.000038: • Why is rapid data sharing essential during an infectious disease outbreak?
p.000038: • What are the key ethical issues related to rapid data sharing?
p.000038:
p.000038:
p.000038:
p.000038:
p.000038:
p.000038: The collection and sharing of data are essential parts of ordinary public health practice. During an infectious disease
p.000038: outbreak, data sharing takes on increased urgency because of the uncertain and ever-changing scientific information;
...

p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: may have precarious employment contracts with no social protection, or work on
p.000043: a volunteer basis.
p.000043:
p.000043: Regardless of whether a particular individual has a pre-existing duty to assume
p.000043: heightened risks during an infectious disease outbreak, once a worker has taken on these
p.000043: 44 risks, society has a reciprocal obligation to
p.000043: provide necessary support. At a minimum, fulfilment of society’s reciprocal obligations to frontline workers requires
p.000043: the following actions:
p.000043:
p.000043: • Minimizing the risk of infection —
p.000043: Individuals should not be expected to take on risky work assignments
p.000043: during an infectious disease outbreak unless they are provided with
p.000043: the training, tools, and resources necessary to minimize the risks to the extent reasonably possible. This includes
p.000043: complete and accurate information known about the nature
p.000043: of the pathogen and infection control measures, updated information on the epidemiological situation at the local
p.000043: level, and the provision of personal protective equipment. Regular screening of frontline workers should be put
p.000043: in place to detect any infection as quickly as possible, in order to initiate immediate care and minimize the risk of
p.000043: transmission to colleagues, patients, families, and community members.
p.000043:
p.000043: • Priority access to health care — Frontline workers who become sick, as well as any immediate family members who
p.000043: become ill through contact with the worker, should be ensured access to the highest level of care reasonably available.
p.000043: In addition, countries should consider giving frontline workers and their families priority access to vaccines
p.000043: and other treatments as they become available.
p.000043:
p.000043: • Appropriate remuneration — Frontline workers should be given fair remuneration for their work. Governments should
p.000043: ensure that public sector workers are paid in
p.000043: a timely manner, and make efforts to ensure that actors in the private and nongovernmental sectors fulfil their own
p.000043: obligations to pay their employees and contractors. Fair remuneration for frontline workers includes the provision of
p.000043: financial support during periods in which workers are unable to carry out their normal responsibilities because of an
p.000043: infection acquired on the job.
p.000043:
p.000043: • Support for reintegrating into the community — Frontline workers may experience stigma and discrimination,
p.000043: particularly those involved in unpopular measures such as infection control or burials not conducted according to
p.000043: the traditional customs. Governments should make efforts to reduce the risk of stigmatization and discrimination and
...

Health / Pregnant

Searching for indicator pregnant:

(return to top)
p.000041: • How should appropriate reproductive health-care services be safely provided during an infectious disease
p.000041: outbreak?
p.000041: • How are sex and gender relevant to communication strategies during outbreaks?
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: Sex (biological and physiological characteristics) and gender (socially constructed roles, behaviours, activities, and
p.000041: attributes)20 can influence the spread, containment, course, and consequences of infectious disease outbreaks. Sex and
p.000041: gender differences have been associated with differences in susceptibility to infection, levels of health care
p.000041: received, and in the course and outcome of illness.21 Addressing sex and gender differences in infectious disease
p.000041: outbreak planning and response efforts requires attention to the following considerations:
p.000041:
p.000041: • Sex- and gender-inclusive surveillance programmes — Public health surveillance should systematically collect
p.000041: disaggregated information on sex, gender, and pregnancy status, both to identify differential risks and
p.000041: modes of transmission, and to monitor any differential impact of an infectious disease outbreak and the interventions
p.000041: used to control it. This information is particularly important for pregnant women and their offspring.
p.000041:
p.000041: • Ensuring the availability of high- quality reproductive health-care services — Whether or not they are currently
p.000041: pregnant, women of childbearing age should have access to the full range of high-quality
p.000041: reproductive health-care services during an infectious disease outbreak. These services should be organized and
p.000041: delivered in a manner that does not stigmatize persons who use them or expose them to a heightened risk of infection
p.000041: with the outbreak pathogen. If there is evidence that an infectious
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: disease creates special risks for pregnant women or their fetus, both men and women should be informed of these risks
p.000041: and have access to safe methods to minimize them, along with reproductive counselling services.
p.000041:
p.000041: • Sex- and gender-inclusive research
p.000041: 42 strategies — Researchers should make efforts to ensure that studies do not disproportionately
p.000041: favour a particular sex or gender, and that women who are or might become pregnant are not inappropriately excluded
p.000041: from research participation. During an outbreak, research on experimental treatments and preventive measures should
p.000041: seek to identify any sex- or gender-related differences in outcomes.
p.000041:
p.000041: • Attention to social and cultural practices — Gender-related roles and practices can affect all aspects of
p.000041: infectious disease outbreaks, including
p.000041: individuals’ risk of becoming infected, the consequences of infection, their use of health services and other
p.000041: health-seeking behaviours, and their vulnerability to interpersonal violence.
p.000041: Policy-makers and outbreak responders should identify and respond to these factors, drawing when possible
p.000041: on relevant anthropological and sociological research.
p.000041:
p.000041: • Sex- and gender-sensitive communication strategies —
p.000041: Entities responsible for developing and implementing communication strategies should be sensitive to sex- and gender-
p.000041: based differences in how individuals have access to and respond to health- related information. Separate messages and
p.000041: communication strategies may be needed to provide relevant information to particular subgroups, such as pregnant women
p.000041: or nursing mothers.
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: Influenza in India
p.000041: Source: Tom Pietrasik, WHO
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: 13. Frontline response workers’ rights and obligations
p.000041:
p.000041:
p.000041:
p.000043: 43
p.000043: Questions addressed:
p.000043:
p.000043: • What obligations exist to protect the health of frontline workers who participate in infectious disease outbreak
p.000043: response efforts?
p.000043: • What obligations exist to provide material support to frontline workers who participate in infectious disease
p.000043: outbreak response efforts?
p.000043: • To what extent do these obligations extend to the workers’ family?
p.000043: • What should be taken into account in determining whether individuals have an obligation to serve as frontline
p.000043: workers during infectious disease outbreaks?
p.000043: • What special obligations do workers in the health-care sector have during infectious disease outbreaks?
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: An effective infectious disease outbreak response depends on the contribution of
p.000043: a diverse range of frontline workers, some of whom may be working on a volunteer basis. These workers often assume
...

Health / Unconscious People

Searching for indicator unconscious:

(return to top)
p.000035: according to good manufacturing practices should be used for MEURI.
p.000035:
p.000035: • Collection and sharing of meaningful data — Physicians overseeing MEURI have the same moral
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035: obligation to collect all scientifically relevant data on the safety and efficacy of the intervention as researchers
p.000035: overseeing a clinical trial. Knowledge generated through MEURI should be aggregated across patients if possible and
p.000035: shared transparently, completely and rapidly with the MEURI scientific advisory committee, public health authorities,
p.000035: physicians and researchers in the country, and the international medical and scientific community.
p.000035: Information should be described accurately, without overstating benefits or understating uncertainties or risks.
p.000035:
p.000035: • Importance of informed consent — Individuals who are offered MEURI should be made aware that the intervention
p.000035: might not benefit
p.000035: them and might even harm them. The process of obtaining informed consent to MEURI should be carried out in a
p.000035: culturally and linguistically sensitive manner, with an emphasis on the content and understandability of the
p.000035: information conveyed and the voluntariness of the patient’s decision.
p.000035: The ultimate choice of whether to receive the unproven intervention must rest with the patient, if the patient is
p.000035: in a condition to make the choice. If the patient is unconscious, cognitively impaired, or too sick to understand the
p.000035: information, proxy consent should be obtained from a family member or other authorized decision-maker.
p.000035:
p.000035: • Need for community engagement —
p.000035: MEURI must be sensitive to local norms and practices. One way to try to ensure such sensitivity is to use rapid
p.000035: “community engagement
p.000035: teams” to promote dialogue about the potential benefits and risks of receiving
p.000035: interventions that have not yet been tested in clinical trials.
p.000035:
p.000035: • Fair distribution in the face of scarcity — Compounds qualifying for MEURI may not be available in large
p.000035: quantities. In this situation, choices will have to be made about who receives
p.000035: each intervention. Countries should 37
p.000035: establish mechanisms for making these allocation decisions, taking into account the assessment of the MEURI Scientific
p.000035: Advisory Committee and the principles discussed in Guideline 4.
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035: 10. Rapid data sharing
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000038: 38
p.000038: Questions addressed:
p.000038:
p.000038: • Why is rapid data sharing essential during an infectious disease outbreak?
p.000038: • What are the key ethical issues related to rapid data sharing?
p.000038:
p.000038:
p.000038:
p.000038:
p.000038:
p.000038: The collection and sharing of data are essential parts of ordinary public health practice. During an infectious disease
...

Health / ill

Searching for indicator ill:

(return to top)
p.000043: a volunteer basis.
p.000043:
p.000043: Regardless of whether a particular individual has a pre-existing duty to assume
p.000043: heightened risks during an infectious disease outbreak, once a worker has taken on these
p.000043: 44 risks, society has a reciprocal obligation to
p.000043: provide necessary support. At a minimum, fulfilment of society’s reciprocal obligations to frontline workers requires
p.000043: the following actions:
p.000043:
p.000043: • Minimizing the risk of infection —
p.000043: Individuals should not be expected to take on risky work assignments
p.000043: during an infectious disease outbreak unless they are provided with
p.000043: the training, tools, and resources necessary to minimize the risks to the extent reasonably possible. This includes
p.000043: complete and accurate information known about the nature
p.000043: of the pathogen and infection control measures, updated information on the epidemiological situation at the local
p.000043: level, and the provision of personal protective equipment. Regular screening of frontline workers should be put
p.000043: in place to detect any infection as quickly as possible, in order to initiate immediate care and minimize the risk of
p.000043: transmission to colleagues, patients, families, and community members.
p.000043:
p.000043: • Priority access to health care — Frontline workers who become sick, as well as any immediate family members who
p.000043: become ill through contact with the worker, should be ensured access to the highest level of care reasonably available.
p.000043: In addition, countries should consider giving frontline workers and their families priority access to vaccines
p.000043: and other treatments as they become available.
p.000043:
p.000043: • Appropriate remuneration — Frontline workers should be given fair remuneration for their work. Governments should
p.000043: ensure that public sector workers are paid in
p.000043: a timely manner, and make efforts to ensure that actors in the private and nongovernmental sectors fulfil their own
p.000043: obligations to pay their employees and contractors. Fair remuneration for frontline workers includes the provision of
p.000043: financial support during periods in which workers are unable to carry out their normal responsibilities because of an
p.000043: infection acquired on the job.
p.000043:
p.000043: • Support for reintegrating into the community — Frontline workers may experience stigma and discrimination,
p.000043: particularly those involved in unpopular measures such as infection control or burials not conducted according to
p.000043: the traditional customs. Governments should make efforts to reduce the risk of stigmatization and discrimination and
p.000043: help such workers to reintegrate into the community, including by providing job placement assistance and relocation to
p.000043: other communities if needed.
p.000043:
...

p.000047: the local government, and have ongoing discussions among themselves and with the local government to clarify and
p.000047: coordinate their roles
p.000047: and responsibilities and address any disparities in standards of practice. Efforts should be coordinated with local
p.000047: authorities and care providers to
p.000047: ensure that the foreign agency does not excessively draw resources away from other essential services.
p.000047:
p.000047: • Fairness in assigning foreign workers for deployment — Foreign aid workers should be deployed only if they are
p.000047: capable of providing necessary services not sufficiently available in the local setting. Assignment of foreign
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047: health workers should take into consideration their relevant skills and knowledge, as well as their linguistic and
p.000047: cultural competencies to meet mission objectives and understand and communicate with affected communities. It is
p.000047: inappropriate to deploy unqualified or unnecessary
p.000047: 48 workers solely to satisfy their personal
p.000047: or professional desire to be helpful (so-called “disaster tourism”).
p.000047:
p.000047: • Clarity about conditions of deployment — Prospective foreign aid workers should be given
p.000047: comprehensive information about the project’s expectations and risks so they can make informed decisions about whether
p.000047: or not they will be able to make appropriate contributions. In addition, foreign aid workers should be clearly
p.000047: informed of the conditions of their deployment, including the level of health care they can expect if they become ill,
p.000047: the circumstances under
p.000047: which they will be repatriated, available insurance, and whether benefits will
p.000047: be provided to their families in case of illness or death.
p.000047:
p.000047: • Provision of necessary training and resources — Aid workers must be provided with appropriate
p.000047: training, preparation, and equipment to ensure that they can effectively carry out their mission with the lowest risks
p.000047: practicable. Training should include preparation in psychosocial and communication skills, and in understanding and
p.000047: respecting the local culture and traditions. Managers and organizations have an obligation to provide adequate support
p.000047: and guidance to the staff, both during their activity in the field and following
p.000047: their mission. This should include training and resources for managing challenging ethical issues, such as resource
p.000047: allocation decisions, triage, and inequities.
p.000047:
p.000047: • Ensuring the security and safety of aid workers — Organizations that deploy foreign aid workers have an
p.000047: obligation to take all necessary measures to ensure the workers’ security, particularly in situations of crisis; this
p.000047: obligation includes the provision of measures to reduce risks of exposure to infectious agents, contamination and
p.000047: violence. A clear chain of authority must be in place to provide oversight and ongoing advice. Individuals who object
p.000047: to assigned duties should have an opportunity for review and appeal, according to the norms of the organizations for
p.000047: which they work.
p.000047:
p.000047: Aid workers also have their own ethical obligations to patients, affected communities, their sponsoring
...

Health / of childbearing age/fertile

Searching for indicator childbearing age:

(return to top)
p.000041: Sex (biological and physiological characteristics) and gender (socially constructed roles, behaviours, activities, and
p.000041: attributes)20 can influence the spread, containment, course, and consequences of infectious disease outbreaks. Sex and
p.000041: gender differences have been associated with differences in susceptibility to infection, levels of health care
p.000041: received, and in the course and outcome of illness.21 Addressing sex and gender differences in infectious disease
p.000041: outbreak planning and response efforts requires attention to the following considerations:
p.000041:
p.000041: • Sex- and gender-inclusive surveillance programmes — Public health surveillance should systematically collect
p.000041: disaggregated information on sex, gender, and pregnancy status, both to identify differential risks and
p.000041: modes of transmission, and to monitor any differential impact of an infectious disease outbreak and the interventions
p.000041: used to control it. This information is particularly important for pregnant women and their offspring.
p.000041:
p.000041: • Ensuring the availability of high- quality reproductive health-care services — Whether or not they are currently
p.000041: pregnant, women of childbearing age should have access to the full range of high-quality
p.000041: reproductive health-care services during an infectious disease outbreak. These services should be organized and
p.000041: delivered in a manner that does not stigmatize persons who use them or expose them to a heightened risk of infection
p.000041: with the outbreak pathogen. If there is evidence that an infectious
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: disease creates special risks for pregnant women or their fetus, both men and women should be informed of these risks
p.000041: and have access to safe methods to minimize them, along with reproductive counselling services.
p.000041:
p.000041: • Sex- and gender-inclusive research
p.000041: 42 strategies — Researchers should make efforts to ensure that studies do not disproportionately
p.000041: favour a particular sex or gender, and that women who are or might become pregnant are not inappropriately excluded
p.000041: from research participation. During an outbreak, research on experimental treatments and preventive measures should
p.000041: seek to identify any sex- or gender-related differences in outcomes.
p.000041:
...

Health / patients in emergency situations

Searching for indicator emergencies:

(return to top)
p.000039: outbreaks 52
p.000039: Annex 2. Participants at meetings to formulate Guidance for managing ethical issues in infectious disease outbreaks
p.000055: 55
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055: Foreword
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055: Infectious disease outbreaks are periods of great uncertainty. Events unfold, resources and capacities that are often
p.000055: limited
p.000055: are stretched yet further, and decisions for a public health response must be made quickly, even though the evidence
p.000055: for decision-making may be scant. In such a situation, public health officials, policy-makers, funders, researchers,
p.000055: field epidemiologists, first responders, national
p.000055: ethics boards, health-care workers, and public health practitioners need a moral compass
p.000055: to guide them in their decision-making. Bioethics puts people at the heart of the problem, emphasizes the principles
p.000055: that should guide health systems, and provides the moral rationale for making choices, particularly in a crisis.
p.000055:
p.000055: I therefore welcome the development of the Guidance for managing ethical issues in infectious disease outbreaks, which
p.000055: will be key to embedding ethics within the integrated global alert and response system for epidemics and other public
p.000055: health emergencies. The publication will also
p.000055: support and strengthen the implementation and uptake of policies and programmes in this context.
p.000055:
p.000055: Research is an integral part of the public health response – not only to learn about the current epidemic but also to
p.000055: build an evidence base for future epidemics. Research during
p.000055: an epidemic ranges from epidemiological and socio-behavioral to clinical trials and toxicity studies, all of which are
p.000055: crucial. I am pleased
p.000055: to see that the guidance touches upon this 3
p.000055: important area with advice, not only on research and emergency use of unproven interventions, but also on rapid data
p.000055: sharing see: http://www.who.int/ihr/procedures/ SPG_data_sharing.pdf?ua=1.
p.000055:
p.000055: The importance given to communication during an infectious disease outbreak can make or break public health efforts,
p.000055: and WHO takes this very seriously. This
p.000055: document outlines the ethical principles that should guide communication planning and implementation at every level
p.000055: from frontline workers to policy-makers.
p.000055:
p.000055: The guidance represents the work of an international group of stakeholders and experts, including public health
p.000055: practitioners in charge of response management at
p.000055: the local, national and international level; nongovernmental organization representatives; directors of funding
p.000055: agencies; chairs of ethics committees; heads of research laboratories; representatives
p.000055: of national regulatory agencies; patient representatives; and experts in public health ethics, bioethics, human rights,
...

p.000017: to necessary resources such as clean water or bednets to reduce the risk of contracting a mosquito-borne disease.
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017: • Need for effective alternative communication strategies — Some types of vulnerability can impede
p.000017: an individual’s ability to transmit or receive information. Communication barriers can stem from a wide range of
p.000017: factors including, but not limited to, illiteracy, unfamiliarity with the
p.000017: 18 local or official language(s), vision or
p.000017: hearing impairments, social isolation, or lack of access to Internet and other communication services. These barriers
p.000017: make it difficult for individuals to receive necessary public health messages
p.000017: or to participate fully in community engagement activities. To overcome these barriers, messages should be delivered in
p.000017: multiple formats (e.g. radio, text messages, billboards, cartoons) as well as direct oral communication with key
p.000017: stakeholders. Health authorities should not assume that the public will search for information; instead, they should
p.000017: proactively reach out to the concerned population wherever they are.
p.000017:
p.000017: • Impact of stigmatization and discrimination — Members of socially disadvantaged groups often face considerable
p.000017: stigma and discrimination, which can be exacerbated in public health emergencies characterized by fear and distrust.
p.000017: Those responsible for infectious disease outbreak response should ensure that all individuals are treated fairly and
p.000017: equitably regardless of their social status or perceived “worth” to society. They should also take measures to prevent
p.000017: stigmatization and social violence.
p.000017:
p.000017: • Disproportionate burdens of outbreak response measures — Even when public health measures
p.000017: are designed with the best of intentions, they can inadvertently place a disproportionate burden on particular
p.000017: populations. For example, quarantine orders that require individuals to stay
p.000017: in their homes can have devastating consequences for persons who need to leave their homes to obtain basic
p.000017: necessities such as clean water or food. Similarly, social distancing measures such as school closures can place
p.000017: disproportionate burdens on children who depend on going to school to access regular meals, as well as on working
p.000017: parents who may have no one available to provide child care.
p.000017:
p.000017: • Greater need for resources — Accommodating the needs of individuals whose situation makes them particularly
p.000017: vulnerable sometimes requires the use of additional resources.
p.000017: In some cases, additional resources are relatively minimal, such as when an interpreter is hired to make
...

p.000050: Committee on Economic, Social and Cultural Rights (E/C. 12/2000/4 – 2000; www1.umn.edu/
p.000050: humanrts/gencomm/escgencom14.htm, accessed 23 July 2016).
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050: 10 Parpia AS, Ndeffo-Mbah ML, Wenzel NS, Galvani AP. Effects of response to the 2014–2015 Ebola outbreak on deaths
p.000050: from malaria, HIV/AIDS, and tuberculosis, West Africa. Emerg Infect Dis. 2016;22(3)
p.000050: (http://dx.doi.org/10.3201/eid2203.150977, accessed 23 July 2016).
p.000050:
p.000050: 11 Declaration of Helsinki – Ethical principles for medical research involving human subjects, revised October 2013
p.000050: Ferney-Voltaire: World Medical Association; 2013 (www.wma.net/ en/30publications/10policies/b3/index.html, accessed 23
p.000050: July 2016).
p.000050:
p.000050: 12 International ethical guidelines for biomedical research involving human subjects.
p.000050: Geneva: Council for International Organizations of Medical Sciences; 2002 (www.cioms. 51
p.000050: ch/publications/guidelines/guidelines_nov_2002_blurb.htm, accessed 23 July 2016).
p.000050:
p.000050: 13 Standards and operational guidance for ethics review of health-related research with human participants. Geneva:
p.000050: World Health Organization; 2011 (www.who.int/ethics/ publications/9789241502948/en/, accessed 23 July 2016).
p.000050:
p.000050: 14 Ethics in epidemics, emergencies and disasters: Research, surveillance and patient care.
p.000050: Geneva: World Health Organization; 2015 (who.int/ethics/publications/epidemics- emergencies-research/en/, accessed 23
p.000050: July 2016).
p.000050:
p.000050: 15 Research ethics in international epidemic response. Geneva: World Health Organization; 2009 (WHO/HSE/GIP/ITP/10.1;
p.000050: www.who.int/ethics/gip_research_ethics_.pdf, accessed 23 July 2016).
p.000050:
p.000050: 16 Developing global norms for sharing data and results during public health emergencies. Geneva: World Health
p.000050: Organization; 2015 (www.who.int/medicines/ebola-treatment/ blueprint_phe_data-share-results/en/, accessed 23 July
p.000050: 2016).
p.000050:
p.000050: 17 Overlapping publications. International Committee of Medical Journal Editors (www.
p.000050: icmje.org/recommendations/browse/publishing-and-editorial-issues/overlapping- publications.html, accessed 23 July
p.000050: 2016).
p.000050:
p.000050: 18 Ethical issues related to study design for trials on therapeutics for Ebola Virus Disease.
p.000050: 2014. Report of the WHO Ethics Working Group meeting, 20–21 October 2014. Geneva: World Health Organization; 2014
p.000050: (WHO/HIS/KER/GHE/14.2; http://apps.who.int/iris/ bitstream/10665/137509/1/WHO_HIS_KER_GHE_14.2_eng.pdf, accessed 23
p.000050: July 2016).
p.000050:
p.000050: 19 Dye C, Bartolomeos K, Moorthy V, Kieny MP. Data sharing in public health emergencies: a call to researchers. Bull
p.000050: World Health Organ. 2016;1:94(3):158. doi: 10.2471/ BLT.16.170860
p.000050: (www.who.int/bulletin/volumes/94/3/16-170860.pdf?ua=1).
p.000050:
p.000050: 20 Gender, women and health. In: WHO [website]. Geneva: World Health Organization
p.000050: (http://apps.who.int/gender/whatisgender/en/, accessed 23 July 2016).
p.000050:
p.000050: 21 Addressing sex and gender in epidemic-prone infectious diseases. Geneva: World Health Organization; 2007
p.000050: (www.who.int/csr/resources/publications/SexGenderInfectDis.pdf).
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050: Annex 1. Ethics guidance documents that contributed to the Guidance for managing ethical issues in infectious disease
p.000050: outbreaks
p.000050:
p.000050:
p.000050: WHO guidance documents
p.000050:
p.000050: 52 Addressing ethical issues in pandemic influenza planning: Discussion papers. Geneva: World Health
p.000050: Organization; 2008 (WHO/HSE/EPR/GIP/2008.2, WHO/IER/ETH/2008.1; http://apps.
p.000050: who.int/iris/bitstream/10665/69902/1/WHO_IER_ETH_2008.1_eng.pdf?ua=1).
p.000050:
p.000050: Ethical considerations for use of unregistered interventions for Ebola viral disease. Report of an advisory panel to
p.000050: WHO. Geneva: World Health Organization; 2014 (WHO/HIS/KER/ GHE/14.1;
p.000050: http://apps.who.int/iris/bitstream/10665/130997/1/WHO_HIS_KER_GHE_14.1_ eng.pdf?ua=1).
p.000050:
p.000050: Ethical considerations in developing a public health response to pandemic influenza. Geneva: World Health Organization;
p.000050: 2007 (WHO/CDS/EPR/GIP/2007.2; http://www.who.int/ csr/resources/publications/WHO_CDS_EPR_GIP_2007_2c.pdf?ua=1).
p.000050:
p.000050: Ethical issues related to study design for trials on therapeutics for Ebola virus disease. WHO Ethics Working Group
p.000050: Meeting, 20–21 October 2014. Geneva: World Health Organization; 2014 (WHO/HIS/KER/GHE/14.2;
p.000050: http://apps.who.int/iris/bitstream/10665/137509/1/WHO_ HIS_KER_GHE_14.2_eng.pdf?ua=1).
p.000050:
p.000050: Ethics of using convalescent whole blood and convalescent plasma during the Ebola epidemic: Interim guidance for ethics
p.000050: review committees, researchers, national health authorities and blood transfusion services. Geneva: World Health
p.000050: Organization; 2015 (http://apps.who.int/iris/bitstream/10665/161912/1/WHO_HIS_KER_GHE_15.1_eng. pdf?ua=1&ua=1).
p.000050:
p.000050: Ethics in epidemics, emergencies and disasters: Research, surveillance and patient care: Training manual. Geneva: World
p.000050: Health Organization; 2015 (http://apps.who.int/iris/ bitstream/10665/196326/1/9789241549349_eng.pdf?ua=1).
p.000050:
p.000050: Guidance on ethics of tuberculosis prevention, care and control. Geneva: World Health Organization; 2010
p.000050: (http://apps.who.int/iris/bitstream/10665/44452/1/9789241500531_ eng.pdf?ua=1).
p.000050:
p.000050: Research ethics in international epidemic response: WHO Technical Consultation. Geneva: World Health Organization; 2009
p.000050: (www.who.int/ethics/gip_research_ethics_.pdf).
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050: Standards and operational guidance for ethics review of health-related research with human participants. Geneva: World
p.000050: Health Organization; 2011 (http://apps.who.int/iris/ bitstream/10665/44783/1/9789241502948_eng.pdf?ua=1&ua=1).
p.000050:
p.000050: National guidance/opinion papers
p.000050:
p.000050: Allocation of ventilators in an influenza pandemic: Planning document. New York State Task Force on Life and the Law;
p.000050: 2007 (www.cidrap.umn.edu/sites/default/files/public/
p.000050: php/196/196_guidance.pdf).
p.000053: 53
p.000053:
p.000053: Altevogt BM, Stroud C, Hanson S, Hanfling D, Gostin LO, editors. Guidance for establishing crisis standards of care for
p.000053: use in disaster situations: A letter report. Washington: National Academies Press; 2009
p.000053: (www.nap.edu/read/12749/chapter/1).
p.000053:
...

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p.000006: that had arisen in other global infectious disease outbreaks, including severe acute respiratory syndrome (SARS),
p.000006: pandemic influenza, and multidrug-resistant tuberculosis. However, while WHO has issued ethical guidance
p.000006: on some of these outbreaks,2,3,4,5 prior guidance has only focused on the specific pathogen in isolation. The purpose
p.000006: of this document is to look beyond issues specific to particular epidemic pathogens and instead focus on the
p.000006: cross-cutting ethical issues that apply to infectious disease outbreaks generally. In addition to setting forth general
p.000006: principles, it examines how these principles can be adapted to different epidemiological and social circumstances.
p.000006:
p.000006: While many of the ethical issues that arise in infectious disease outbreaks are the same as those that arise in other
p.000006: areas of public health, the context of 7
p.000006: an outbreak has particular complexities. Decisions during an outbreak need to be made on an urgent basis, often in the
p.000006: context of scientific uncertainty, social and institutional disruption, and an overall climate of fear and distrust.
p.000006: Invariably,
p.000006: the countries most affected by outbreaks have limited resources, underdeveloped legal and regulatory structures, and
p.000006: health systems that lack the resilience to deal with crisis situations. Countries that experience natural disasters and
p.000006: armed conflicts are particularly at risk, as these circumstances simultaneously increase the risk of infectious disease
p.000006: outbreaks while
p.000006: decreasing needed resources and access to health care. Moreover, infectious disease outbreaks can generate or
p.000006: exacerbate social crises that can weaken already fragile health systems. Within such contexts, it
p.000006: is not possible to satisfy all urgent needs simultaneously, forcing decision-makers to weigh and prioritize potentially
p.000006: competing ethical values. Time pressures and resource constraints may force action without
p.000006: the thorough deliberation, inclusiveness and transparency that a robust ethical decision-making process demands.
p.000006:
p.000006: This guidance document on ethical issues that arise specifically in the context of infectious disease outbreaks aims to
p.000006: complement existing guidance on ethics in public health. It should therefore be read in conjunction with more general
p.000006: guidance on issues such as public health surveillance,
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006: research with human participants, and addressing the needs of vulnerable populations.
p.000006:
p.000006: Setting up decision-making systems and procedures in advance is the best way to ensure that ethically appropriate
p.000006: decisions will be made if an outbreak
p.000006: 8 occurs. Countries, health-care institutions,
p.000006: international organizations and others involved in epidemic response efforts are encouraged to develop practical
p.000006: strategies and tools to apply the principles in this guidance document to their specific settings, taking into account
p.000006: local social, cultural, and political contexts. WHO is committed to providing countries with technical assistance in
...

p.000013: obligation to ensure the long-term capacity of the systems necessary to carry out effective epidemic prevention and
p.000013: response efforts.
p.000013:
p.000013: Countries have obligations not only to persons within their own borders but also to the broader international
p.000013: community. As the United Nations Committee on
p.000013:
p.000013: Economic, Social and Cultural Rights has recognized, “given that some diseases are easily transmissible beyond the
p.000013: frontiers of a State, the international community has a collective responsibility to address this problem. The
p.000013: economically developed States Parties have a special responsibility
p.000013: and interest to assist the poorer developing States in this regard.”9
p.000013:
p.000013: These obligations reflect the practical reality that infectious disease outbreaks do not respect national borders, and
p.000013: that an outbreak in one country can put the rest of the world at risk.
p.000013:
p.000013: Countries’ obligations to consider the needs of the international community do not arise solely in times of emergency.
p.000013: Instead, they require ongoing attention to ameliorate the social determinants of poor
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013: health that contribute to infectious disease outbreaks, including poverty, limited access to education, and inadequate
p.000013: systems of water and sanitation.
p.000013:
p.000013: The following are key elements of the obligations of governments and the international community:
p.000014: 14
p.000014: • Ensuring the sufficiency of national public health laws — As discussed later in this document, certain public
p.000014: health interventions that might be necessary during an infectious disease outbreak (e.g. restrictions on freedom of
p.000014: movement) depend on having a clear legal basis for government action, as well as a system in place to provide oversight
p.000014: and review. All countries should review their public health laws to ensure that they give the government sufficient
p.000014: authority to respond effectively to an epidemic while also providing individuals with appropriate human rights
p.000014: protections.
p.000014:
p.000014: • Participating in global surveillance and preparedness efforts —
p.000014: All countries must carry out their responsibilities under the IHR to participate in global surveillance efforts in a
p.000014: truthful and transparent manner. This includes providing prompt notification of events that may constitute a public
p.000014: health emergency of international concern, regardless
p.000014: of any negative consequences that may be associated with notification, such as a possible reduction in trade or
p.000014: tourism. The obligation to provide
p.000014: prompt notification to the international community stems not only from the text of the IHR but also from the ethical
p.000014: principles of solidarity and reciprocity. In addition, countries should develop
p.000014: preparedness plans for infectious disease outbreaks and other potential disasters and provide guidance to relevant
...

p.000015: to include them in community engagement plans.
p.000015:
p.000015: • Openness to diverse perspectives — Communication efforts should be designed to facilitate a genuine
p.000015: two-way dialogue, rather than as merely a means to announce decisions
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015: that have already been made. Decision-makers should be prepared to recognize and debate alternative approaches and
p.000015: revise their decisions based on information they receive. Reaching out to the community early, and allowing for
p.000015: consideration of
p.000015: the interests of all people who will
p.000015: 16 potentially be affected, can play an important role in building trust and empowering communities to
p.000015: be involved in a genuine dialogue.
p.000015:
p.000015: • Transparency — The ethical principle of transparency requires that decision-makers publicly explain the basis for
p.000015: decisions in language that is
p.000015: linguistically and culturally appropriate.
p.000015: When decisions must be made in the face of uncertain information, the uncertainties should be explicitly acknowledged
p.000015: and conveyed to the public.
p.000015:
p.000015: • Accountability — The public should know who is responsible for making
p.000015: and implementing decisions in relation to the outbreak response, and how they can challenge decisions they believe are
p.000015: inappropriate.
p.000015:
p.000015: The media will play an important role in any infectious disease outbreak response effort. It is therefore important to
p.000015: ensure that the media has access to accurate and timely information about the disease and its management. Governments,
p.000015: nongovernmental organizations, and
p.000015: academic institutions should make efforts to support media training in relevant scientific concepts and techniques for
p.000015: communicating risk information without raising unnecessary alarm. Media training is important for public health sector
p.000015: employees who may interact with media covering public health issues.
p.000015: In turn, the media has a responsibility to provide accurate, factual, and balanced reporting. This is an important
p.000015: component of media ethics.
p.000015:
p.000015:
p.000015: Cholera outbreak in Sierra Leone
p.000015: Source: Fid Thompson
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015: 3. Situations of particular vulnerability
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000017: 17
p.000017: Questions addressed:
p.000017:
p.000017: • Why are some individuals and groups considered particularly vulnerable during infectious disease outbreaks?
p.000017: • How can vulnerability affect a person’s ability to access services during infectious disease outbreaks?
p.000017: • How can vulnerability affect a person’s willingness and ability to share and receive information during an
p.000017: infectious disease outbreak?
p.000017: • Why are stigmatization and discrimination particular risks during infectious disease outbreaks?
p.000017: • In what ways might vulnerable persons suffer disproportionate burdens from infectious disease response efforts,
p.000017: or have a greater need for resources?
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017: Some individuals and groups face heightened susceptibility to harm or injustice during infectious disease outbreaks.
p.000017: Policy-makers and epidemic responders should develop plans to address the needs of such individuals and groups in
p.000017: advance of an outbreak and,
p.000017: if an outbreak occurs, make reasonable efforts to ensure that these needs are actually met. Doing this requires ongoing
p.000017: attention to community engagement and the development of active social networks between community representatives and
p.000017: government actors.
p.000017:
p.000017: Efforts to address the ways in which individuals and groups may be vulnerable should take into account the following:
p.000017: • Difficulty accessing services and resources — Many of the
p.000017: characteristics that contribute to social vulnerability can make it difficult
p.000017: for individuals to access necessary services. For example, persons with physical disabilities may have mobility
p.000017: impairments that make travelling even short distances difficult or impossible.
p.000017: Other socially vulnerable persons may lack access to safe and reliable transportation or have caregiving
p.000017: responsibilities that make it difficult for them to leave their homes. In addition, vulnerable persons may lack access
p.000017: to necessary resources such as clean water or bednets to reduce the risk of contracting a mosquito-borne disease.
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017: • Need for effective alternative communication strategies — Some types of vulnerability can impede
p.000017: an individual’s ability to transmit or receive information. Communication barriers can stem from a wide range of
p.000017: factors including, but not limited to, illiteracy, unfamiliarity with the
p.000017: 18 local or official language(s), vision or
p.000017: hearing impairments, social isolation, or lack of access to Internet and other communication services. These barriers
p.000017: make it difficult for individuals to receive necessary public health messages
p.000017: or to participate fully in community engagement activities. To overcome these barriers, messages should be delivered in
p.000017: multiple formats (e.g. radio, text messages, billboards, cartoons) as well as direct oral communication with key
p.000017: stakeholders. Health authorities should not assume that the public will search for information; instead, they should
p.000017: proactively reach out to the concerned population wherever they are.
p.000017:
p.000017: • Impact of stigmatization and discrimination — Members of socially disadvantaged groups often face considerable
p.000017: stigma and discrimination, which can be exacerbated in public health emergencies characterized by fear and distrust.
p.000017: Those responsible for infectious disease outbreak response should ensure that all individuals are treated fairly and
p.000017: equitably regardless of their social status or perceived “worth” to society. They should also take measures to prevent
p.000017: stigmatization and social violence.
p.000017:
p.000017: • Disproportionate burdens of outbreak response measures — Even when public health measures
p.000017: are designed with the best of intentions, they can inadvertently place a disproportionate burden on particular
p.000017: populations. For example, quarantine orders that require individuals to stay
p.000017: in their homes can have devastating consequences for persons who need to leave their homes to obtain basic
p.000017: necessities such as clean water or food. Similarly, social distancing measures such as school closures can place
p.000017: disproportionate burdens on children who depend on going to school to access regular meals, as well as on working
p.000017: parents who may have no one available to provide child care.
p.000017:
p.000017: • Greater need for resources — Accommodating the needs of individuals whose situation makes them particularly
p.000017: vulnerable sometimes requires the use of additional resources.
p.000017: In some cases, additional resources are relatively minimal, such as when an interpreter is hired to make
p.000017: a community engagement forum accessible to members of a linguistic minority group. In other cases, they may be more
p.000017: substantial, such as when mobile health teams are assembled to dispatch vaccines and treatments to hard-to-reach rural
p.000017: areas. It is legitimate to take costs into consideration in determining whether a particular accommodation is
p.000017: warranted; indeed, the goal of maximizing utility demands that such assessments be made.
p.000017: However, despite the importance of conserving limited resources, the ethical principle of equity may sometimes justify
p.000017: providing greater resources to persons who have greater needs.
p.000017:
p.000017: • Heightened risk of violence — Infectious disease outbreaks can
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017: exacerbate social unrest, increase criminality, and induce violent behaviour, especially against vulnerable groups such
...

p.000017: specific populations may be targeted as being the cause of the outbreak or provoking transmission; strategies should be
p.000017: proactively designed to
p.000017: protect members of such groups from a heightened risk of violence.
p.000017:
p.000017:
p.000019: 19
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019: A doctor inspects patients in an MSF supported hospital in Aweil,
p.000019: Northern Bar El Ghazal in South Sudan, 2011
p.000019: Source: Siegfried Modola/IRIN
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019: 4. Allocating scarce resources
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000020: 20
p.000020: Questions addressed:
p.000020:
p.000020: • What type of resource allocation decisions might need to be made during infectious disease outbreaks?
p.000020: • How do the principles of utility and equity apply to decisions about allocating scarce resources during
p.000020: infectious disease outbreaks?
p.000020: • How does the principle of reciprocity apply to decisions about allocating scarce resources during infectious
p.000020: disease outbreaks?
p.000020: • What procedural considerations apply to decisions about resource allocation during infectious disease outbreaks?
p.000020: • What obligations do health-care providers have towards persons who are not able to access life-saving resources
p.000020: during infectious disease outbreaks?
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020: Infectious disease outbreaks can quickly overwhelm the capacities of governments and health-care systems, requiring
p.000020: them to make difficult decisions about the allocation of limited resources. Some of these decisions may arise in the
p.000020: context of allocating medical interventions, such as hospital beds, medications, and medical equipment. Others may
p.000020: relate to broader questions about how public health resources should be utilized. For example, how should limited
p.000020: resources be allocated between activities such as surveillance, health promotion, and community engagement? Should
p.000020: human resources be devoted to contact tracing at the possible expense of patient management? Should
p.000020: limited funds be spent improving water and
p.000020: sanitation facilities or building quarantine facilities?
p.000020:
p.000020: Infectious disease outbreaks also compete with other important public health
p.000020: issues for attention and resources. For example, one of the consequences of the Ebola outbreak was a reduction in
p.000020: access to general health-care services due to a combination of a greater number of patients and the sickness and death
p.000020: of health-care workers. As
p.000020: a result, deaths from tuberculosis, human immunodeficiency virus (HIV), and malaria increased dramatically during this
p.000020: period.10
p.000020:
p.000020: Governments, health-care facilities, and others involved in response efforts should
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020: prepare for such situations by developing guidelines on the allocation of scarce resources in outbreak situations. Such
p.000020: guidelines should be developed through an open and transparent process involving broad stakeholder input and, to the
p.000020: extent
p.000020: possible, should be incorporated into formal written documents that establish clear priorities and procedures. Those
p.000020: involved
p.000020: in developing these guidelines should be guided by the following considerations:
p.000020:
p.000020: • Balancing considerations of utility and equity — Resource allocation decisions should be guided by the ethical
p.000020: principles of utility and equity. The principle of utility requires allocating resources to maximize benefits and
p.000020: minimize burdens, while the principle of equity requires attention to the fair distribution of benefits
p.000020: and burdens. In some cases, an equal distribution of benefits and burdens may be considered fair, but in others, it may
...

p.000020: mechanisms, whether defined in terms 21
p.000020: of the total number of lives saved, the total number of life years saved, or the total number of quality-adjusted life
p.000020: years saved. For this reason,
p.000020: while it might be ethical to prioritize persons who are essential to manage an outbreak, it is not appropriate to
p.000020: prioritize persons based on social value considerations unrelated to carrying out critical services necessary for
p.000020: society.
p.000020:
p.000020: • Paying attention to the needs of vulnerable populations — In applying the ethical principle of equity, special
p.000020: attention should be given to individuals and groups that are the most vulnerable to discrimination, stigmatization, or
p.000020: isolation, as discussed in Guideline 3.
p.000020: Particular consideration must be given to individuals who are confined in institutional settings, where they are highly
p.000020: dependent on others and
p.000020: potentially exposed to much higher risks of infection than persons living in the community.
p.000020:
p.000020: • Fulfilling reciprocity-based obligations to those who contribute to infectious disease outbreak response efforts
p.000020: — The ethical principle of reciprocity implies that society should support persons who face a disproportionate burden
p.000020: or risk in protecting the public good. This principle justifies giving priority access to scarce resources to persons
p.000020: who
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020: assume risks to their own health or life to contribute to outbreak response efforts.
p.000020:
p.000020: • Providing supportive and palliative care to persons unable to access life- saving resources — Even when it is not
p.000020: possible to provide life-saving medical
p.000020: 22 resources to all who could benefit from
p.000020: them, efforts should be made to ensure that no patients are abandoned. One way to do this is to ensure that adequate
p.000020: resources are directed to providing supportive and palliative care.
p.000020:
p.000020: The application of allocation principles should take into account the following considerations:
p.000020:
p.000020: • Consistent application — Allocation principles should be applied in
p.000020: a consistent manner, both within individual institutions and, to the extent possible, across geographic areas.
p.000020: Decision-making tools should be developed to ensure that like cases are treated alike, and that no person receives
p.000020: better or worse treatment due to his or her social status or other factors not explicitly recognized in
p.000020: the allocation plan. Efforts should be made to avoid unintended systemic discrimination in the choice or application of
p.000020: allocation methods.
p.000020:
p.000020: • Resolution of disputes — Mechanisms should be developed to resolve disagreements about the application of
p.000020: allocation principles;
p.000020: these mechanisms should be designed to ensure that anyone who believes that allocation principles have been applied
p.000020: inappropriately has access to impartial and accountable review processes, and has the opportunity to be heard.
p.000020: • Avoiding corruption — Corruption in the health-care sector may be exacerbated during infectious disease
p.000020: outbreaks if large numbers of individuals are competing for access
p.000020: to limited resources. Efforts should be made to ensure that persons involved in the application of allocation systems
p.000020: do not accept or give bribes or engage in other corrupt activities.
p.000020:
p.000020: • Separation of responsibilities — To the extent possible, the interpretation of allocation principles should not
p.000020: be entrusted to clinicians who have pre-existing professional relationships that create an ethical obligation to
p.000020: advocate for the
p.000020: interests of specific patients or groups.
p.000020: Instead, decisions should be made by appropriately qualified clinicians
p.000020: who have no personal or professional reasons to advocate for one patient or group over another.
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020: 5. Public health surveillance
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000023: 23
p.000023: Questions addressed:
p.000023:
p.000023: • What role does surveillance play in infectious disease outbreak response efforts?
p.000023: • Should surveillance activities be subject to ethical review?
p.000023: • What obligations do entities conducting surveillance activities have to protect the confidentiality of
p.000023: information collected?
p.000023: • Are there any circumstances under which individuals should be asked for consent to, or given the opportunity to
p.000023: opt out of, surveillance activities?
p.000023: • What obligations do those conducting surveillance activities have to disclose information they collect to the
p.000023: affected individuals and communities?
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
...

p.000025: individuals in
p.000025: institutions. While isolation in a properly equipped health-care facility is usually recommended for individuals who
p.000025: are already symptomatic, especially for diseases with a high potential for contagiousness, home-based isolation may
p.000025: sometimes be appropriate, provided that adequate medical and
p.000025: logistical support can be organized and family attendants are willing and able to act under the oversight of trained
p.000025: public health staff. This is particularly true if the caseload overwhelms facility capacity.
p.000025:
p.000025: • Costs — In some cases, a less restrictive alternative may involve greater costs. This does not, in itself,
p.000025: justify more restrictive approaches. However, costs and other practical constraints (e.g. logistics, distance,
p.000025: available workforce) may legitimately be taken into account to determine whether a less restrictive alternative is
p.000025: feasible under the circumstances, particularly in settings with severe resource constraints.
p.000025:
p.000025: • Ensuring humane conditions — Any restrictions on freedom of movement, particularly those that are not voluntary,
p.000025: should be backed up with sufficient resources to ensure that those subject to the restrictions do not experience undue
p.000025: burdens. For example, individuals whose mobility is restricted (whether through confinement at home or
p.000025: in institutional settings) should be ensured access to food, drinking water, sanitary facilities, shelter, clothing,
p.000025: and medical care. It is also important to ensure that individuals have adequate physical space, opportunities to engage
p.000025: in activities, and the means
p.000025: to communicate with their loved ones and the outside world. Fulfilling these needs is essential to respect individual
p.000025: dignity and address the significant psychosocial burden of confinement on individuals and their loved ones. Mechanisms
p.000025: should be put in place to minimize the risk of violence (including sexual assault) and local disease
p.000025: transmission, especially when individuals are confined in institutional settings
p.000025: or when communities are under mass quarantine. At a minimum, persons who
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025: are quarantined because they have been exposed to the pathogen responsible for the outbreak should not be put at
p.000025: heightened risk of infection because of the manner in which they are confined. (Decisions on the circumstances and
p.000025: conditions of confinement should consider the heightened needs of vulnerable populations, as discussed
p.000025: in Guideline 3.)
p.000025:
p.000025: • Addressing financial and social consequences — Even short-term restrictions on freedom of movement can have
p.000025: significant — and possibly devastating —financial and social consequences for individuals, their families, and their
p.000025: communities. Countries should provide assistance to households that suffer financial
...

p.000030: case-by-case basis, with attention to both the scientific
p.000030: validity of the data and the acceptability of the methodology to the community from which participants will be drawn.
p.000030: In studies relying on qualitative methods, the potential benefits of using methodologies such as focus groups (in which
p.000030: individual confidentiality cannot be guaranteed) or of interviewing traumatized victims should be balanced against the
p.000030: risks and burdens to the individuals involved.
p.000030:
p.000030: • Rapid data sharing: As WHO has previously recognized, every researcher who engages in generation of information
p.000030: related to a public health emergency or acute public health event with the potential to progress
p.000030: to an emergency has the fundamental moral obligation to share preliminary results once they are adequately quality
p.000030: controlled for release.16 Such information should be shared with
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030: public health officials, the study participants and affected population, and groups involved in wider international
p.000030: response efforts, without waiting for publication in scientific journals. Journals should facilitate
p.000030: this process by allowing researchers to rapidly disseminate information
p.000030: 34 with immediate implications for public
p.000030: health without losing the opportunity for subsequent consideration for publication in a journal.17
p.000030:
p.000030: • Assuring equitable access to the benefits of research — As
p.000030: recognized in existing international ethics guidelines, individuals and communities that participate in research
p.000030: should, where relevant, have access to any benefits that result from their participation. Research sponsors and host
p.000030: countries should agree in advance on mechanisms to ensure that any interventions found to be safe and effective in
p.000030: research will be made available to the local population without undue delay, including, when feasible, on a
p.000030: compassionate use basis before regulatory approval is finalized.
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030: Staff preparing to go into the Isolation Unit at Persahabatan Hospital, East Jakarta.
p.000030: Source: Jonathan Perugia
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030: 9. Emergency use of unproven interventions outside of research
p.000030:
p.000030:
p.000030:
p.000035: 35
p.000035: Questions addressed:
p.000035:
p.000035: • Under what circumstances is it ethically appropriate to offer patients unproven interventions outside clinical
p.000035: trials during infectious disease outbreaks?
p.000035: • How should such interventions be identified?
p.000035: • What type of ethical oversight should be conducted when unproven interventions are offered outside clinical
p.000035: trials during infectious disease outbreaks?
p.000035: • If such interventions are provided, what should individuals be told about them?
p.000035: • What obligations do persons administering unproven interventions outside clinical trials have to communicate with
p.000035: the community?
...

p.000035: this purpose. This committee should base its recommendations on a rigorous review of all data available from
p.000035: laboratory, animal and human studies of the intervention to assess the risk–benefit of MEURI in the context of the
p.000035: risks for patients who do not receive MEURI.
p.000035:
p.000035: MEURI should be guided by the same ethical principles that guide use of
p.000035: unproven compounds in clinical trials, including the following:
p.000035:
p.000035: • Importance of ethical oversight — MEURI is intended to be an exceptional measure for situations in which
p.000035: initiating a clinical trial is not feasible, not as a means to circumvent ethical oversight of the use of unproven
p.000035: interventions. Thus, mechanisms should be established to ensure that MEURI is subject to ethical oversight.
p.000035:
p.000035: • Effective resource allocation — MEURI should not preclude or delay the initiation of clinical research into
p.000035: experimental products. In addition, it should not divert attention or resources from the implementation of effective
p.000035: clinical care and/or public health measures that may be crucial to control an outbreak.
p.000035:
p.000035: • Minimizing risk — Administering unproven interventions necessarily involves risks, some of which will not be
p.000035: fully understood until further testing is conducted. However, any known risks associated with an intervention should be
p.000035: minimized to the extent reasonably possible (e.g. administration under hygienic conditions; using
p.000035: the same safety precautions that would be used during a clinical trial, with close monitoring and access to emergency
p.000035: medication and equipment; and providing necessary supportive treatment). Only investigational products manufactured
p.000035: according to good manufacturing practices should be used for MEURI.
p.000035:
p.000035: • Collection and sharing of meaningful data — Physicians overseeing MEURI have the same moral
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035: obligation to collect all scientifically relevant data on the safety and efficacy of the intervention as researchers
p.000035: overseeing a clinical trial. Knowledge generated through MEURI should be aggregated across patients if possible and
p.000035: shared transparently, completely and rapidly with the MEURI scientific advisory committee, public health authorities,
p.000035: physicians and researchers in the country, and the international medical and scientific community.
p.000035: Information should be described accurately, without overstating benefits or understating uncertainties or risks.
p.000035:
p.000035: • Importance of informed consent — Individuals who are offered MEURI should be made aware that the intervention
p.000035: might not benefit
p.000035: them and might even harm them. The process of obtaining informed consent to MEURI should be carried out in a
p.000035: culturally and linguistically sensitive manner, with an emphasis on the content and understandability of the
p.000035: information conveyed and the voluntariness of the patient’s decision.
...

p.000039: but necessary relationship-building, consultation, and education, as well as the establishment of policies, practices,
p.000039: and institutions capable of commanding public confidence and trust.
p.000040: 40
p.000040: In addition to the general principles discussed elsewhere in this document, specific considerations relevant to the
p.000040: long-term storage of biological specimens collected during infectious disease outbreaks include the following:
p.000040:
p.000040: • Provision of information — Before individuals are asked to provide biospecimens during an infectious disease
p.000040: outbreak, they should be given access to information about the
p.000040: purpose of the collection, whether their samples will be stored and, if so, the ways in which their specimens might be
p.000040: used in the future. When feasible and consistent with public health objectives, individuals should be asked to provide
p.000040: informed consent or be given the opportunity to opt out of the long-term storage of their specimens. Seeking informed
p.000040: consent is particularly important if there is any possibility that the specimens may later be used for research
p.000040: purposes.
p.000040:
p.000040: • Community engagement — Individuals and organizations involved in the long-term storage of biospecimens collected
p.000040: during infectious disease outbreaks should engage representatives of the local community in a dialogue about the
p.000040: process. Community representatives should be involved in the development of policies regarding future use of the
p.000040: samples, including measures to ensure that equitable access is provided to any benefits that result from using the
p.000040: samples in research.
p.000040:
p.000040: • International sharing of biospecimens — Sharing biospecimens internationally may sometimes be necessary to
p.000040: conduct critical research.
p.000040: If it is necessary to transfer specimens internationally, appropriate governance mechanisms and regulatory systems
p.000040: should be established to ensure that representatives of the country where the specimens were collected are involved in
p.000040: decisions about the specimens’ use. The international community should make efforts to strengthen countries’ capacity
p.000040: to maintain biospecimens within their own borders.
p.000040:
p.000040: • Material transfer agreements — Biospecimens should not be transferred outside of the countries from which they
p.000040: are collected without formal material transfer agreements. Such agreements should specify the purpose of the transfer,
p.000040: certify the specimen donor's consent as appropriate, provide for adequate confidentiality protection, cover the
p.000040: physical security of the specimens, require that the country
p.000040: of origin is acknowledged in future research reporting, and guarantee that the benefits of any subsequent use of the
p.000040: specimens will be shared with the communities from which the samples were obtained. Material transfer agreements should
p.000040: be developed with the involvement of persons responsible for the care of patients and the taking of samples,
p.000040: representatives of affected communities and patients, and relevant government officials and ethics committees.
p.000040:
p.000040:
p.000040:
p.000040:
p.000040:
...

p.000041: attributes)20 can influence the spread, containment, course, and consequences of infectious disease outbreaks. Sex and
p.000041: gender differences have been associated with differences in susceptibility to infection, levels of health care
p.000041: received, and in the course and outcome of illness.21 Addressing sex and gender differences in infectious disease
p.000041: outbreak planning and response efforts requires attention to the following considerations:
p.000041:
p.000041: • Sex- and gender-inclusive surveillance programmes — Public health surveillance should systematically collect
p.000041: disaggregated information on sex, gender, and pregnancy status, both to identify differential risks and
p.000041: modes of transmission, and to monitor any differential impact of an infectious disease outbreak and the interventions
p.000041: used to control it. This information is particularly important for pregnant women and their offspring.
p.000041:
p.000041: • Ensuring the availability of high- quality reproductive health-care services — Whether or not they are currently
p.000041: pregnant, women of childbearing age should have access to the full range of high-quality
p.000041: reproductive health-care services during an infectious disease outbreak. These services should be organized and
p.000041: delivered in a manner that does not stigmatize persons who use them or expose them to a heightened risk of infection
p.000041: with the outbreak pathogen. If there is evidence that an infectious
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: disease creates special risks for pregnant women or their fetus, both men and women should be informed of these risks
p.000041: and have access to safe methods to minimize them, along with reproductive counselling services.
p.000041:
p.000041: • Sex- and gender-inclusive research
p.000041: 42 strategies — Researchers should make efforts to ensure that studies do not disproportionately
p.000041: favour a particular sex or gender, and that women who are or might become pregnant are not inappropriately excluded
p.000041: from research participation. During an outbreak, research on experimental treatments and preventive measures should
p.000041: seek to identify any sex- or gender-related differences in outcomes.
p.000041:
p.000041: • Attention to social and cultural practices — Gender-related roles and practices can affect all aspects of
p.000041: infectious disease outbreaks, including
p.000041: individuals’ risk of becoming infected, the consequences of infection, their use of health services and other
p.000041: health-seeking behaviours, and their vulnerability to interpersonal violence.
p.000041: Policy-makers and outbreak responders should identify and respond to these factors, drawing when possible
p.000041: on relevant anthropological and sociological research.
p.000041:
p.000041: • Sex- and gender-sensitive communication strategies —
p.000041: Entities responsible for developing and implementing communication strategies should be sensitive to sex- and gender-
p.000041: based differences in how individuals have access to and respond to health- related information. Separate messages and
p.000041: communication strategies may be needed to provide relevant information to particular subgroups, such as pregnant women
p.000041: or nursing mothers.
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: Influenza in India
p.000041: Source: Tom Pietrasik, WHO
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: 13. Frontline response workers’ rights and obligations
p.000041:
p.000041:
p.000041:
p.000043: 43
p.000043: Questions addressed:
p.000043:
p.000043: • What obligations exist to protect the health of frontline workers who participate in infectious disease outbreak
p.000043: response efforts?
p.000043: • What obligations exist to provide material support to frontline workers who participate in infectious disease
p.000043: outbreak response efforts?
p.000043: • To what extent do these obligations extend to the workers’ family?
p.000043: • What should be taken into account in determining whether individuals have an obligation to serve as frontline
p.000043: workers during infectious disease outbreaks?
p.000043: • What special obligations do workers in the health-care sector have during infectious disease outbreaks?
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: An effective infectious disease outbreak response depends on the contribution of
...

p.000043: workers, many of whom
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: may have precarious employment contracts with no social protection, or work on
p.000043: a volunteer basis.
p.000043:
p.000043: Regardless of whether a particular individual has a pre-existing duty to assume
p.000043: heightened risks during an infectious disease outbreak, once a worker has taken on these
p.000043: 44 risks, society has a reciprocal obligation to
p.000043: provide necessary support. At a minimum, fulfilment of society’s reciprocal obligations to frontline workers requires
p.000043: the following actions:
p.000043:
p.000043: • Minimizing the risk of infection —
p.000043: Individuals should not be expected to take on risky work assignments
p.000043: during an infectious disease outbreak unless they are provided with
p.000043: the training, tools, and resources necessary to minimize the risks to the extent reasonably possible. This includes
p.000043: complete and accurate information known about the nature
p.000043: of the pathogen and infection control measures, updated information on the epidemiological situation at the local
p.000043: level, and the provision of personal protective equipment. Regular screening of frontline workers should be put
p.000043: in place to detect any infection as quickly as possible, in order to initiate immediate care and minimize the risk of
p.000043: transmission to colleagues, patients, families, and community members.
p.000043:
p.000043: • Priority access to health care — Frontline workers who become sick, as well as any immediate family members who
p.000043: become ill through contact with the worker, should be ensured access to the highest level of care reasonably available.
p.000043: In addition, countries should consider giving frontline workers and their families priority access to vaccines
p.000043: and other treatments as they become available.
p.000043:
p.000043: • Appropriate remuneration — Frontline workers should be given fair remuneration for their work. Governments should
p.000043: ensure that public sector workers are paid in
p.000043: a timely manner, and make efforts to ensure that actors in the private and nongovernmental sectors fulfil their own
p.000043: obligations to pay their employees and contractors. Fair remuneration for frontline workers includes the provision of
p.000043: financial support during periods in which workers are unable to carry out their normal responsibilities because of an
p.000043: infection acquired on the job.
p.000043:
p.000043: • Support for reintegrating into the community — Frontline workers may experience stigma and discrimination,
p.000043: particularly those involved in unpopular measures such as infection control or burials not conducted according to
p.000043: the traditional customs. Governments should make efforts to reduce the risk of stigmatization and discrimination and
p.000043: help such workers to reintegrate into the community, including by providing job placement assistance and relocation to
p.000043: other communities if needed.
p.000043:
p.000043: • Assistance to family members — Assistance should be provided to families of frontline workers who need to remain
p.000043: away from home in order
...

p.002014: Dr Johan van Griensven, Department of Clinical Sciences, Institute of Tropical Medicine, Belgium
p.002014: Professor John Whitehead, Emeritus Professor, Department of Mathematics and Statistics, Fylde College, Lancaster
p.002014: University, United Kingdom
p.002014:
p.002014:
p.002014:
p.002014:
p.002014:
p.002014:
p.002014:
p.002014:
p.002014: WHO Secretariat
p.002014: Dr Marie-Paule Kieny, Assistant Director-General, Health Systems and Innovation Dr Marie-Charlotte Bouesseau, Advisor,
p.002014: Department of Service Delivery and Safety Dr Vânia de la Fuente-Núñez,Technical Officer, Global Health Ethics,
p.002014: Department of Knowledge, Ethics and Research
p.002014: Dr Martin Friede, Scientist, Public Health, Innovation and Intellectual Property, Department of Essential Medicines and
p.002014: Health Products
p.002014: Ms Marisol Guraiib, Technical Officer, Global Health Ethics, Department of Knowledge,
p.002014: Ethics and Research
p.000059: 59
p.000059: Ms Corinna Klingler, Intern, Global Health Ethics, Department of Knowledge, Ethics and Research
p.000059: Dr Selena Knight, Intern, Global Health Ethics, Department of Knowledge, Ethics and Research Dr Nicola Magrini,
p.000059: Scientist, Policy, Access and Use, Department of Essential Medicines and Health Products
p.000059: Dr Cathy Roth, Adviser, Office of the Assistant Director-General, Health Systems and Innovation Dr Vasee
p.000059: Sathiyamoorthy, Technical Officer, Initiative for Vaccine Research, Department of Immunization, Vaccines and
p.000059: Biologicals
p.000059: Dr Abha Saxena, Coordinator, Global Health Ethics, Department of Knowledge, Ethics and Research
p.000059: Dr David Wood, Coordinator, Technologies, Standards and Norms, Department of Essential Medicines and Health Products
p.000059:
p.000059: Developing ethics guidelines for public health responses during epidemics, including for the conduct of related
p.000059: research, Dublin, Ireland, 25–26 May 2015
p.000059:
p.000059: Participants
p.000059: Dr Annick Antierens, Manager, Investigational Platform for Experimental Ebola Products, Médecins Sans Frontières,
p.000059: Switzerland
p.000059: Dr Philippe Calain, Senior Researcher, Unit of Research on Humanitarian Stakes and Practices, Médecins Sans Frontières,
p.000059: Switzerland
p.000059: Dr Edward Cox, Director, Office of Antimicrobial Products, Food and Drug Administration, United States of America
p.000059: Professor Heather Draper, Professor of Biomedical Ethics, University of Birmingham, United Kingdom
p.000059: Dr Sarah Edwards, Senior Lecturer in Research Ethics and Governance, University College London, United Kingdom
...

Social / Access to information

Searching for indicator access to information:

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p.000039:
p.000039: may mitigate the harm of similar outbreaks in the future. At the same time, long-term storage of biospecimens involves
p.000039: potential risks to individuals and communities.
p.000039: Risks to individuals primarily relate to the unwanted disclosure of personal information. This can be minimized by
p.000039: protecting the confidentiality of individuals’ identities, but confidentiality may be difficult to protect when only a
p.000039: small number of people are being tested. Moreover, even when individual confidentiality can be adequately protected,
p.000039: some individuals or communities might still be uncomfortable making their biospecimens available for future use,
p.000039: especially if such use is not subject to community control. Particular concerns can arise when specimens are
p.000039:
p.000039:
p.000039:
p.000039:
p.000039:
p.000039:
p.000039:
p.000039:
p.000039:
p.000039: transferred abroad without the originating country’s prior agreement. Addressing these concerns requires time-consuming
p.000039: but necessary relationship-building, consultation, and education, as well as the establishment of policies, practices,
p.000039: and institutions capable of commanding public confidence and trust.
p.000040: 40
p.000040: In addition to the general principles discussed elsewhere in this document, specific considerations relevant to the
p.000040: long-term storage of biological specimens collected during infectious disease outbreaks include the following:
p.000040:
p.000040: • Provision of information — Before individuals are asked to provide biospecimens during an infectious disease
p.000040: outbreak, they should be given access to information about the
p.000040: purpose of the collection, whether their samples will be stored and, if so, the ways in which their specimens might be
p.000040: used in the future. When feasible and consistent with public health objectives, individuals should be asked to provide
p.000040: informed consent or be given the opportunity to opt out of the long-term storage of their specimens. Seeking informed
p.000040: consent is particularly important if there is any possibility that the specimens may later be used for research
p.000040: purposes.
p.000040:
p.000040: • Community engagement — Individuals and organizations involved in the long-term storage of biospecimens collected
p.000040: during infectious disease outbreaks should engage representatives of the local community in a dialogue about the
p.000040: process. Community representatives should be involved in the development of policies regarding future use of the
p.000040: samples, including measures to ensure that equitable access is provided to any benefits that result from using the
p.000040: samples in research.
p.000040:
p.000040: • International sharing of biospecimens — Sharing biospecimens internationally may sometimes be necessary to
p.000040: conduct critical research.
p.000040: If it is necessary to transfer specimens internationally, appropriate governance mechanisms and regulatory systems
p.000040: should be established to ensure that representatives of the country where the specimens were collected are involved in
p.000040: decisions about the specimens’ use. The international community should make efforts to strengthen countries’ capacity
p.000040: to maintain biospecimens within their own borders.
p.000040:
...

Social / Child

Searching for indicator child:

(return to top)
p.000017:
p.000017: • Impact of stigmatization and discrimination — Members of socially disadvantaged groups often face considerable
p.000017: stigma and discrimination, which can be exacerbated in public health emergencies characterized by fear and distrust.
p.000017: Those responsible for infectious disease outbreak response should ensure that all individuals are treated fairly and
p.000017: equitably regardless of their social status or perceived “worth” to society. They should also take measures to prevent
p.000017: stigmatization and social violence.
p.000017:
p.000017: • Disproportionate burdens of outbreak response measures — Even when public health measures
p.000017: are designed with the best of intentions, they can inadvertently place a disproportionate burden on particular
p.000017: populations. For example, quarantine orders that require individuals to stay
p.000017: in their homes can have devastating consequences for persons who need to leave their homes to obtain basic
p.000017: necessities such as clean water or food. Similarly, social distancing measures such as school closures can place
p.000017: disproportionate burdens on children who depend on going to school to access regular meals, as well as on working
p.000017: parents who may have no one available to provide child care.
p.000017:
p.000017: • Greater need for resources — Accommodating the needs of individuals whose situation makes them particularly
p.000017: vulnerable sometimes requires the use of additional resources.
p.000017: In some cases, additional resources are relatively minimal, such as when an interpreter is hired to make
p.000017: a community engagement forum accessible to members of a linguistic minority group. In other cases, they may be more
p.000017: substantial, such as when mobile health teams are assembled to dispatch vaccines and treatments to hard-to-reach rural
p.000017: areas. It is legitimate to take costs into consideration in determining whether a particular accommodation is
p.000017: warranted; indeed, the goal of maximizing utility demands that such assessments be made.
p.000017: However, despite the importance of conserving limited resources, the ethical principle of equity may sometimes justify
p.000017: providing greater resources to persons who have greater needs.
p.000017:
p.000017: • Heightened risk of violence — Infectious disease outbreaks can
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017: exacerbate social unrest, increase criminality, and induce violent behaviour, especially against vulnerable groups such
p.000017: as minority populations
p.000017: or migrants. In addition, public health measures such as home isolation, quarantine, or closure of schools and work
...

Searching for indicator children:

(return to top)
p.000017: multiple formats (e.g. radio, text messages, billboards, cartoons) as well as direct oral communication with key
p.000017: stakeholders. Health authorities should not assume that the public will search for information; instead, they should
p.000017: proactively reach out to the concerned population wherever they are.
p.000017:
p.000017: • Impact of stigmatization and discrimination — Members of socially disadvantaged groups often face considerable
p.000017: stigma and discrimination, which can be exacerbated in public health emergencies characterized by fear and distrust.
p.000017: Those responsible for infectious disease outbreak response should ensure that all individuals are treated fairly and
p.000017: equitably regardless of their social status or perceived “worth” to society. They should also take measures to prevent
p.000017: stigmatization and social violence.
p.000017:
p.000017: • Disproportionate burdens of outbreak response measures — Even when public health measures
p.000017: are designed with the best of intentions, they can inadvertently place a disproportionate burden on particular
p.000017: populations. For example, quarantine orders that require individuals to stay
p.000017: in their homes can have devastating consequences for persons who need to leave their homes to obtain basic
p.000017: necessities such as clean water or food. Similarly, social distancing measures such as school closures can place
p.000017: disproportionate burdens on children who depend on going to school to access regular meals, as well as on working
p.000017: parents who may have no one available to provide child care.
p.000017:
p.000017: • Greater need for resources — Accommodating the needs of individuals whose situation makes them particularly
p.000017: vulnerable sometimes requires the use of additional resources.
p.000017: In some cases, additional resources are relatively minimal, such as when an interpreter is hired to make
p.000017: a community engagement forum accessible to members of a linguistic minority group. In other cases, they may be more
p.000017: substantial, such as when mobile health teams are assembled to dispatch vaccines and treatments to hard-to-reach rural
p.000017: areas. It is legitimate to take costs into consideration in determining whether a particular accommodation is
p.000017: warranted; indeed, the goal of maximizing utility demands that such assessments be made.
p.000017: However, despite the importance of conserving limited resources, the ethical principle of equity may sometimes justify
p.000017: providing greater resources to persons who have greater needs.
p.000017:
p.000017: • Heightened risk of violence — Infectious disease outbreaks can
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017: exacerbate social unrest, increase criminality, and induce violent behaviour, especially against vulnerable groups such
p.000017: as minority populations
p.000017: or migrants. In addition, public health measures such as home isolation, quarantine, or closure of schools and work
p.000017: facilities can induce violence, particularly against women and children. Officials involved in outbreak planning and
p.000017: response efforts should be prepared for the possibility that
p.000017: specific populations may be targeted as being the cause of the outbreak or provoking transmission; strategies should be
p.000017: proactively designed to
p.000017: protect members of such groups from a heightened risk of violence.
p.000017:
p.000017:
p.000019: 19
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019: A doctor inspects patients in an MSF supported hospital in Aweil,
p.000019: Northern Bar El Ghazal in South Sudan, 2011
p.000019: Source: Siegfried Modola/IRIN
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019: 4. Allocating scarce resources
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000020: 20
p.000020: Questions addressed:
p.000020:
p.000020: • What type of resource allocation decisions might need to be made during infectious disease outbreaks?
p.000020: • How do the principles of utility and equity apply to decisions about allocating scarce resources during
p.000020: infectious disease outbreaks?
p.000020: • How does the principle of reciprocity apply to decisions about allocating scarce resources during infectious
p.000020: disease outbreaks?
p.000020: • What procedural considerations apply to decisions about resource allocation during infectious disease outbreaks?
...

p.000030: ordinary medical care, and this should not in itself preclude their enrolment.
p.000030:
p.000030: • Addressing other barriers to informed consent — In addition to the impact of fear and desperation,
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030: other factors can challenge researchers’ ability to obtain informed consent to research; these range from cultural and
p.000030: linguistic differences between foreign researchers and local participants, to the fact that prospective participants in
p.000030: quarantine or isolation may be cut off from their families and other support
p.000030: systems and feel powerless to decline an invitation to participate in research. To the extent possible, consent
p.000030: processes compatible with international research ethics guidelines should be developed
p.000030: in consultation with local communities and implemented by locally recruited personnel. In addition, researchers should
p.000030: be well informed about the medical, psychological and social support systems available locally so that they can guide
p.000030: participants in need towards these services. In some situations, it may be necessary to develop rapid mechanisms for
p.000030: appointing proxy decision-makers, such as during outbreaks of diseases that affect cognitive abilities, or when
p.000030: an outbreak leaves a large number of children as orphans.
p.000030:
p.000030: • Gaining and maintaining trust — Failure to build and maintain community trust during the process of research
p.000030: design and implementation, or when disclosing preliminary results, will not only impede study recruitment and
p.000030: completion but may also undermine
p.000030: the uptake of any interventions proven to be efficacious. Engaging with affected communities before, during, and after
p.000030: a study is essential to build and maintain trust. In environments in which the public’s trust in government is fragile,
p.000030: researchers should remain as independent as possible from official public health activities. If government workers are
p.000030: themselves involved in
p.000030: conducting research, they should inform participants of this fact. Individuals who observe unethical practices carried
p.000030: out in the name of public health or emergency response efforts should promptly report them to ethics committees or
p.000030: other independent bodies.
p.000030: • Selecting an appropriate research 33
p.000030: methodology — Exposing research participants to risk is ethically unacceptable if the study is not designed in a manner
p.000030: capable of providing valid results. It is therefore imperative that all research be designed and conducted in a
p.000030: methodologically rigorous manner. In clinical trials,
p.000030: the appropriateness of features such as randomization, placebo controls, blinding or masking should be determined on a
p.000030: case-by-case basis, with attention to both the scientific
...

Social / Ethnicity

Searching for indicator ethnicity:

(return to top)
p.000025: professional reintegration of individuals for whom confinement is no longer necessary, including measures to reduce
p.000025: stigmatization and discrimination.
p.000025:
p.000025: • Due process protections — Mechanisms should be in place to allow individuals whose liberty has been restricted to
p.000025: challenge the appropriateness of those restrictions, the way they are enforced, and the conditions under which the
p.000025: restrictions are carried out. If it is not feasible to provide full due process protection before the restrictions are
p.000025: implemented in an emergency scenario, mechanisms for review and appeal should be made
p.000025: available without excessive delay. All persons involved in decisions to restrict individuals’ freedom of movement
p.000025: should be accountable for any abuses of authority.
p.000025:
p.000025: • Equitable application — Restrictions on freedom of movement should be
p.000025: applied in the same manner to all 27
p.000025: persons posing a comparable public health risk. Thus, individuals should not be subject to greater or lesser
p.000025: restrictions for reasons unrelated to the
p.000025: risks they may pose to others, including membership in any disfavoured or favoured social group or class (for example,
p.000025: groups defined by gender, ethnicity, or religion). In addition, policy- makers should seek to ensure that restrictions
p.000025: are not applied in a manner that imposes a disproportionate burden on vulnerable segments of society.
p.000025:
p.000025: • Communication and transparency —
p.000025: Policy-makers and public health officials should engage communities in a dialogue about any restrictions on freedom of
p.000025: movement and solicit community members’ views on how restrictions can be carried out with the least possible burden.
p.000025: They should also provide regular updates on the implementation of such measures,
p.000025: both to the public at large and to those whose movement has been restricted. Communication strategies should be
p.000025: designed to avoid the stigmatization
p.000025: of individuals whose liberty has been restricted and to protect their privacy and confidentiality, particularly in the
p.000025: media.
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025: 7. Obligations related to medical interventions for the diagnosis, treatment, and prevention of infectious disease
p.000028: 28
p.000028:
p.000028:
p.000028: Questions addressed:
p.000028:
p.000028: • What quality and safety standards should govern the administration of medical interventions offered during
p.000028: infectious disease outbreaks?
p.000028: • What rights do patients (or their authorized proxy decision-makers) have to receive information about the risks
...

Social / Fetus/Neonate

Searching for indicator fetus:

(return to top)
p.000041:
p.000041: • Sex- and gender-inclusive surveillance programmes — Public health surveillance should systematically collect
p.000041: disaggregated information on sex, gender, and pregnancy status, both to identify differential risks and
p.000041: modes of transmission, and to monitor any differential impact of an infectious disease outbreak and the interventions
p.000041: used to control it. This information is particularly important for pregnant women and their offspring.
p.000041:
p.000041: • Ensuring the availability of high- quality reproductive health-care services — Whether or not they are currently
p.000041: pregnant, women of childbearing age should have access to the full range of high-quality
p.000041: reproductive health-care services during an infectious disease outbreak. These services should be organized and
p.000041: delivered in a manner that does not stigmatize persons who use them or expose them to a heightened risk of infection
p.000041: with the outbreak pathogen. If there is evidence that an infectious
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: disease creates special risks for pregnant women or their fetus, both men and women should be informed of these risks
p.000041: and have access to safe methods to minimize them, along with reproductive counselling services.
p.000041:
p.000041: • Sex- and gender-inclusive research
p.000041: 42 strategies — Researchers should make efforts to ensure that studies do not disproportionately
p.000041: favour a particular sex or gender, and that women who are or might become pregnant are not inappropriately excluded
p.000041: from research participation. During an outbreak, research on experimental treatments and preventive measures should
p.000041: seek to identify any sex- or gender-related differences in outcomes.
p.000041:
p.000041: • Attention to social and cultural practices — Gender-related roles and practices can affect all aspects of
p.000041: infectious disease outbreaks, including
p.000041: individuals’ risk of becoming infected, the consequences of infection, their use of health services and other
p.000041: health-seeking behaviours, and their vulnerability to interpersonal violence.
p.000041: Policy-makers and outbreak responders should identify and respond to these factors, drawing when possible
p.000041: on relevant anthropological and sociological research.
p.000041:
...

Social / Incarcerated

Searching for indicator liberty:

(return to top)
p.000001: Guidance For Managing Ethical Issues
p.000001: In Infectious Disease
p.000001: Outbreaks
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
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p.000001:
p.000001:
p.000001: privacy
p.000001: principle
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001: confidentiality
p.000001: procedural justice
p.000001: solidarity
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001: equity
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001: value
p.000001: bioethics
p.000001: solidarity
p.000001:
p.000001:
p.000001:
p.000001:
p.000001: confidentiality
p.000001: solidarity justice
p.000001: value
p.000001: non-maleficence
p.000001:
p.000001: values
p.000001:
p.000001: value
p.000001: dignityproportionality
p.000001: equity
p.000001:
p.000001: libvaluee
p.000001: rty
p.000001: liberty
p.000001: procedural justice
p.000001: principle
p.000001: solidarity
p.000001:
p.000001:
p.000001:
p.000001: beneficence
p.000001: valueprinciplesvalue
p.000001:
p.000001:
p.000001: informed consent
p.000001: dignity
p.000001: liberty
p.000001: human rights
p.000001: bioliberty ethics
p.000001: liberty solidarity distributive justice
p.000001:
p.000001: confidentiality
p.000001: procedural justice
p.000001: reciprocity human rights
p.000001:
p.000001: public health ethics
p.000001: principle
p.000001: public good
p.000001: equity
p.000001: informed consent
p.000001:
p.000001: beneficence
p.000001: principle
p.000001:
p.000001: value
p.000001:
p.000001: solidarity
p.000001: justice
p.000001: social justice confidentiality
p.000001:
p.000001: value
p.000001: public health ethics
p.000001: procedural justice
p.000001:
p.000001: equity
p.000001:
p.000001: principle
p.000001: public good
p.000001: value dignity
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001: Guidance for Managing Ethical Issues
p.000001: in Infectious Disease Outbreaks
p.000001:
p.000001:
p.000001:
p.000001: WHO Library Cataloguing-in-Publication Data
p.000001:
p.000001: Guidance for managing ethical issues in infectious disease outbreaks.
p.000001:
p.000001: 1.Disease Outbreaks. 2.Communicable Diseases. 3.Ethics. I.World Health Organization. ISBN 978 92 4 154983 7
p.000001: (NLM classification: WA 105)
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001: © World Health Organization 2016
p.000001:
...

p.000006: of an activity against any risks of harm) and
p.000006: efficiency (achieving the greatest benefits at the lowest possible cost).
p.000006:
p.000006: Respect for persons — The term “respect for persons” refers to treating individuals in ways that are fitting to and
p.000006: informed by a recognition of our common humanity, dignity and inherent rights. A central
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006: aspect of respect for persons is respect for autonomy, which requires letting individuals make their own choices based
p.000006: on their values and preferences. Informed consent, a process in which a competent individual authorizes a course of
p.000006: action based on sufficient relevant information, without coercion or undue inducement, is one
p.000006: way to operationalize this concept. Where individuals lack decision-making capacity, it may be necessary for others to
p.000006: be charged with protecting their interests. Respect for persons also includes paying attention to values such as
p.000006: privacy and confidentiality, as well as social, religious and cultural beliefs and important relationships, including
p.000006: family bonds. Finally, respect for persons requires transparency and truth-telling in the context of carrying out
p.000006: public health and research activities.
p.000006:
p.000006: LibertyLiberty includes a broad range of social, religious and political freedoms, such as freedom of movement,
p.000006: freedom of peaceful assembly, and freedom of speech. Many aspects of liberty are protected as fundamental human rights.
p.000006:
p.000006: Reciprocity — Reciprocity consists of making a “fitting and proportional return” for contributions that people have
p.000006: made.6 Policies that encourage reciprocity can
p.000006: be an important means of promoting the principle of justice, as they can correct unfair disparities in the distribution
p.000006: of the benefits and burdens of epidemic response efforts.
p.000006:
p.000006: Solidarity — Solidarity is a social relation in which a group, community, nation
p.000006: or, potentially, global community stands together.7 The principle of solidarity justifies collective action in the
p.000006: face of common threats. It also supports efforts to overcome inequalities that undermine the welfare
p.000006: of minorities and groups that suffer from discrimination.
p.000006:
p.000006:
p.000006: Practical applications
p.000006:
p.000006: The application of ethical principles should be informed by evidence as far as it is
p.000006: available. For example, in determining 9
p.000006: whether a particular action contributes to utility, decision-makers should be guided by any available scientific
p.000006: evidence about the action’s expected benefits and harms.
p.000006: The more intrusive the proposed action, the greater the need for robust evidence that what is being proposed is likely
p.000006: to achieve its desired aim. When specific evidence is not available, decisions should be based
p.000006: on reasoned, substantive arguments and informed by evidence from analogous situations, to the extent possible.
p.000006:
p.000006: In balancing competing principles during infectious disease outbreaks, countries must respect their obligations under
...

p.000025: transmission, especially when individuals are confined in institutional settings
p.000025: or when communities are under mass quarantine. At a minimum, persons who
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025: are quarantined because they have been exposed to the pathogen responsible for the outbreak should not be put at
p.000025: heightened risk of infection because of the manner in which they are confined. (Decisions on the circumstances and
p.000025: conditions of confinement should consider the heightened needs of vulnerable populations, as discussed
p.000025: in Guideline 3.)
p.000025:
p.000025: • Addressing financial and social consequences — Even short-term restrictions on freedom of movement can have
p.000025: significant — and possibly devastating —financial and social consequences for individuals, their families, and their
p.000025: communities. Countries should provide assistance to households that suffer financial
p.000025: losses as a result of inability to conduct business, loss of a job, damage to crops, or other consequences of
p.000025: restrictions on freedom of movement. In some cases, this support may need to continue
p.000025: for a period following the end of confinement. In addition, efforts should be made to support the social and
p.000025: professional reintegration of individuals for whom confinement is no longer necessary, including measures to reduce
p.000025: stigmatization and discrimination.
p.000025:
p.000025: • Due process protections — Mechanisms should be in place to allow individuals whose liberty has been restricted to
p.000025: challenge the appropriateness of those restrictions, the way they are enforced, and the conditions under which the
p.000025: restrictions are carried out. If it is not feasible to provide full due process protection before the restrictions are
p.000025: implemented in an emergency scenario, mechanisms for review and appeal should be made
p.000025: available without excessive delay. All persons involved in decisions to restrict individuals’ freedom of movement
p.000025: should be accountable for any abuses of authority.
p.000025:
p.000025: • Equitable application — Restrictions on freedom of movement should be
p.000025: applied in the same manner to all 27
p.000025: persons posing a comparable public health risk. Thus, individuals should not be subject to greater or lesser
p.000025: restrictions for reasons unrelated to the
p.000025: risks they may pose to others, including membership in any disfavoured or favoured social group or class (for example,
p.000025: groups defined by gender, ethnicity, or religion). In addition, policy- makers should seek to ensure that restrictions
p.000025: are not applied in a manner that imposes a disproportionate burden on vulnerable segments of society.
p.000025:
p.000025: • Communication and transparency —
p.000025: Policy-makers and public health officials should engage communities in a dialogue about any restrictions on freedom of
p.000025: movement and solicit community members’ views on how restrictions can be carried out with the least possible burden.
p.000025: They should also provide regular updates on the implementation of such measures,
p.000025: both to the public at large and to those whose movement has been restricted. Communication strategies should be
p.000025: designed to avoid the stigmatization
p.000025: of individuals whose liberty has been restricted and to protect their privacy and confidentiality, particularly in the
p.000025: media.
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025: 7. Obligations related to medical interventions for the diagnosis, treatment, and prevention of infectious disease
p.000028: 28
p.000028:
p.000028:
p.000028: Questions addressed:
p.000028:
p.000028: • What quality and safety standards should govern the administration of medical interventions offered during
p.000028: infectious disease outbreaks?
p.000028: • What rights do patients (or their authorized proxy decision-makers) have to receive information about the risks
p.000028: and benefits of, and alternatives to, medical interventions during infectious disease outbreaks?
p.000028: • Under what circumstances, if any, might it be appropriate to override an individual’s refusal of diagnostic,
p.000028: therapeutic, or preventive measures during an infectious disease outbreak?
p.000028: • What procedural safeguards should be provided before overriding an individual’s refusal of diagnostic,
p.000028: therapeutic, or preventive measures during an infectious disease outbreak?
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028: Any medical intervention for the diagnosis, treatment, or prevention of infectious disease should be provided in accord
p.000028: with professional medical standards, under conditions designed to ensure the highest attainable level of patient
p.000028: safety. Countries, with the support of international experts, should establish the minimum standards
p.000028: to be applied in the care and treatment of patients affected by an outbreak.
...

Searching for indicator restricted:

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p.000023: allowing individuals to opt out of particular surveillance activities, taking into account the nature and degree of
p.000023: individual risks involved and the extent to which allowing opt-outs
p.000023: would undermine the activity’s public health goals.
p.000023:
p.000023: • Disclosing information to individuals and communities — Regardless of whether individuals are given the choice to
p.000023: opt out of surveillance activities, the process of surveillance should be conducted on a transparent basis. At a
p.000023: minimum, individuals and communities should be aware of the type of information
p.000023: that will be gathered about them, the purposes for which this information will be used, and any circumstances under
p.000023: which the information collected may be shared with third parties. In addition, information about the outcome of the
p.000023: surveillance activity should be made available as soon as reasonably possible.
p.000023: Careful attention should be given to the manner in which this information is communicated, in order to minimize
p.000023: the risk that subjects of surveillance may face stigmatization or discrimination.
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023: 6. Restrictions on freedom of movement
p.000023:
p.000023:
p.000023:
p.000025: 25
p.000025: Questions addressed:
p.000025:
p.000025: • Under what circumstances is it legitimate to restrict an individual’s freedom of movement during an infectious
p.000025: disease outbreak?
p.000025: • What living conditions should be assured for individuals whose freedom of movement has been restricted?
p.000025: • What other obligations are owed to individuals whose freedom of movement has been restricted?
p.000025: • What procedural protections must be established to ensure that restrictions on freedom of movement are carried
p.000025: out appropriately?
p.000025: • What are the obligations of policy-makers and public health officials to inform the public about restrictions on
p.000025: freedom of movement?
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025: Restrictions on freedom of movement include isolation, quarantine, travel advisories or restrictions, and community-
p.000025: based measures to reduce contact between people (e.g. closing schools or prohibiting large gatherings). These measures
p.000025: can often play an important role in controlling infectious disease outbreaks, and in these circumstances, their use is
p.000025: justified by the ethical value of protecting community well- being. However, the effectiveness of these measures should
p.000025: not be assumed; in fact, under some epidemiological circumstances, they may contribute little or nothing to outbreak
p.000025: control efforts, and may even
p.000025: be counterproductive if they engender a backlash that leads to resistance to
p.000025: other control measures. Moreover, all such measures impose a significant burden on individuals and communities,
p.000025: including direct limitations of fundamental human rights, particularly the rights to freedom of movement and peaceful
p.000025: assembly.
p.000025:
p.000025: In light of these considerations, no restrictions on freedom of movement should be implemented without careful
p.000025: attention to the following considerations:
p.000025:
p.000025: • Justifiable basis for imposing restrictions — Decisions to impose restrictions on freedom of movement should be
p.000025: grounded on the best available evidence
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
...

p.000025: enforced by law or military authorities. Similarly, home-based quarantine should be considered before confining
p.000025: individuals in
p.000025: institutions. While isolation in a properly equipped health-care facility is usually recommended for individuals who
p.000025: are already symptomatic, especially for diseases with a high potential for contagiousness, home-based isolation may
p.000025: sometimes be appropriate, provided that adequate medical and
p.000025: logistical support can be organized and family attendants are willing and able to act under the oversight of trained
p.000025: public health staff. This is particularly true if the caseload overwhelms facility capacity.
p.000025:
p.000025: • Costs — In some cases, a less restrictive alternative may involve greater costs. This does not, in itself,
p.000025: justify more restrictive approaches. However, costs and other practical constraints (e.g. logistics, distance,
p.000025: available workforce) may legitimately be taken into account to determine whether a less restrictive alternative is
p.000025: feasible under the circumstances, particularly in settings with severe resource constraints.
p.000025:
p.000025: • Ensuring humane conditions — Any restrictions on freedom of movement, particularly those that are not voluntary,
p.000025: should be backed up with sufficient resources to ensure that those subject to the restrictions do not experience undue
p.000025: burdens. For example, individuals whose mobility is restricted (whether through confinement at home or
p.000025: in institutional settings) should be ensured access to food, drinking water, sanitary facilities, shelter, clothing,
p.000025: and medical care. It is also important to ensure that individuals have adequate physical space, opportunities to engage
p.000025: in activities, and the means
p.000025: to communicate with their loved ones and the outside world. Fulfilling these needs is essential to respect individual
p.000025: dignity and address the significant psychosocial burden of confinement on individuals and their loved ones. Mechanisms
p.000025: should be put in place to minimize the risk of violence (including sexual assault) and local disease
p.000025: transmission, especially when individuals are confined in institutional settings
p.000025: or when communities are under mass quarantine. At a minimum, persons who
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025: are quarantined because they have been exposed to the pathogen responsible for the outbreak should not be put at
p.000025: heightened risk of infection because of the manner in which they are confined. (Decisions on the circumstances and
p.000025: conditions of confinement should consider the heightened needs of vulnerable populations, as discussed
p.000025: in Guideline 3.)
p.000025:
p.000025: • Addressing financial and social consequences — Even short-term restrictions on freedom of movement can have
p.000025: significant — and possibly devastating —financial and social consequences for individuals, their families, and their
p.000025: communities. Countries should provide assistance to households that suffer financial
p.000025: losses as a result of inability to conduct business, loss of a job, damage to crops, or other consequences of
p.000025: restrictions on freedom of movement. In some cases, this support may need to continue
p.000025: for a period following the end of confinement. In addition, efforts should be made to support the social and
p.000025: professional reintegration of individuals for whom confinement is no longer necessary, including measures to reduce
p.000025: stigmatization and discrimination.
p.000025:
p.000025: • Due process protections — Mechanisms should be in place to allow individuals whose liberty has been restricted to
p.000025: challenge the appropriateness of those restrictions, the way they are enforced, and the conditions under which the
p.000025: restrictions are carried out. If it is not feasible to provide full due process protection before the restrictions are
p.000025: implemented in an emergency scenario, mechanisms for review and appeal should be made
p.000025: available without excessive delay. All persons involved in decisions to restrict individuals’ freedom of movement
p.000025: should be accountable for any abuses of authority.
p.000025:
p.000025: • Equitable application — Restrictions on freedom of movement should be
p.000025: applied in the same manner to all 27
p.000025: persons posing a comparable public health risk. Thus, individuals should not be subject to greater or lesser
p.000025: restrictions for reasons unrelated to the
p.000025: risks they may pose to others, including membership in any disfavoured or favoured social group or class (for example,
p.000025: groups defined by gender, ethnicity, or religion). In addition, policy- makers should seek to ensure that restrictions
p.000025: are not applied in a manner that imposes a disproportionate burden on vulnerable segments of society.
p.000025:
p.000025: • Communication and transparency —
p.000025: Policy-makers and public health officials should engage communities in a dialogue about any restrictions on freedom of
p.000025: movement and solicit community members’ views on how restrictions can be carried out with the least possible burden.
p.000025: They should also provide regular updates on the implementation of such measures,
p.000025: both to the public at large and to those whose movement has been restricted. Communication strategies should be
p.000025: designed to avoid the stigmatization
p.000025: of individuals whose liberty has been restricted and to protect their privacy and confidentiality, particularly in the
p.000025: media.
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025: 7. Obligations related to medical interventions for the diagnosis, treatment, and prevention of infectious disease
p.000028: 28
p.000028:
p.000028:
p.000028: Questions addressed:
p.000028:
p.000028: • What quality and safety standards should govern the administration of medical interventions offered during
p.000028: infectious disease outbreaks?
p.000028: • What rights do patients (or their authorized proxy decision-makers) have to receive information about the risks
p.000028: and benefits of, and alternatives to, medical interventions during infectious disease outbreaks?
p.000028: • Under what circumstances, if any, might it be appropriate to override an individual’s refusal of diagnostic,
p.000028: therapeutic, or preventive measures during an infectious disease outbreak?
p.000028: • What procedural safeguards should be provided before overriding an individual’s refusal of diagnostic,
p.000028: therapeutic, or preventive measures during an infectious disease outbreak?
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028: Any medical intervention for the diagnosis, treatment, or prevention of infectious disease should be provided in accord
p.000028: with professional medical standards, under conditions designed to ensure the highest attainable level of patient
p.000028: safety. Countries, with the support of international experts, should establish the minimum standards
p.000028: to be applied in the care and treatment of patients affected by an outbreak.
...

Social / Linguistic Proficiency

Searching for indicator language:

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p.000015: representatives. Adequate communication platforms and tools should be put in place to facilitate
p.000015:
p.000015: public communication with health authorities.
p.000015:
p.000015: • Situations of particular vulnerability — As discussed further in Guideline 3, special attention should be given
p.000015: to ensuring that persons who face heightened susceptibility to harm or injustice during infectious disease outbreaks
p.000015: are able to contribute to decisions about infectious disease outbreak planning and response. Public health officials
p.000015: should recognize that such persons might be distrustful of government and other institutions, and make special efforts
p.000015: to include them in community engagement plans.
p.000015:
p.000015: • Openness to diverse perspectives — Communication efforts should be designed to facilitate a genuine
p.000015: two-way dialogue, rather than as merely a means to announce decisions
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015: that have already been made. Decision-makers should be prepared to recognize and debate alternative approaches and
p.000015: revise their decisions based on information they receive. Reaching out to the community early, and allowing for
p.000015: consideration of
p.000015: the interests of all people who will
p.000015: 16 potentially be affected, can play an important role in building trust and empowering communities to
p.000015: be involved in a genuine dialogue.
p.000015:
p.000015: • Transparency — The ethical principle of transparency requires that decision-makers publicly explain the basis for
p.000015: decisions in language that is
p.000015: linguistically and culturally appropriate.
p.000015: When decisions must be made in the face of uncertain information, the uncertainties should be explicitly acknowledged
p.000015: and conveyed to the public.
p.000015:
p.000015: • Accountability — The public should know who is responsible for making
p.000015: and implementing decisions in relation to the outbreak response, and how they can challenge decisions they believe are
p.000015: inappropriate.
p.000015:
p.000015: The media will play an important role in any infectious disease outbreak response effort. It is therefore important to
p.000015: ensure that the media has access to accurate and timely information about the disease and its management. Governments,
p.000015: nongovernmental organizations, and
p.000015: academic institutions should make efforts to support media training in relevant scientific concepts and techniques for
p.000015: communicating risk information without raising unnecessary alarm. Media training is important for public health sector
p.000015: employees who may interact with media covering public health issues.
p.000015: In turn, the media has a responsibility to provide accurate, factual, and balanced reporting. This is an important
p.000015: component of media ethics.
p.000015:
p.000015:
p.000015: Cholera outbreak in Sierra Leone
p.000015: Source: Fid Thompson
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015: 3. Situations of particular vulnerability
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
...

p.000017: government actors.
p.000017:
p.000017: Efforts to address the ways in which individuals and groups may be vulnerable should take into account the following:
p.000017: • Difficulty accessing services and resources — Many of the
p.000017: characteristics that contribute to social vulnerability can make it difficult
p.000017: for individuals to access necessary services. For example, persons with physical disabilities may have mobility
p.000017: impairments that make travelling even short distances difficult or impossible.
p.000017: Other socially vulnerable persons may lack access to safe and reliable transportation or have caregiving
p.000017: responsibilities that make it difficult for them to leave their homes. In addition, vulnerable persons may lack access
p.000017: to necessary resources such as clean water or bednets to reduce the risk of contracting a mosquito-borne disease.
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017: • Need for effective alternative communication strategies — Some types of vulnerability can impede
p.000017: an individual’s ability to transmit or receive information. Communication barriers can stem from a wide range of
p.000017: factors including, but not limited to, illiteracy, unfamiliarity with the
p.000017: 18 local or official language(s), vision or
p.000017: hearing impairments, social isolation, or lack of access to Internet and other communication services. These barriers
p.000017: make it difficult for individuals to receive necessary public health messages
p.000017: or to participate fully in community engagement activities. To overcome these barriers, messages should be delivered in
p.000017: multiple formats (e.g. radio, text messages, billboards, cartoons) as well as direct oral communication with key
p.000017: stakeholders. Health authorities should not assume that the public will search for information; instead, they should
p.000017: proactively reach out to the concerned population wherever they are.
p.000017:
p.000017: • Impact of stigmatization and discrimination — Members of socially disadvantaged groups often face considerable
p.000017: stigma and discrimination, which can be exacerbated in public health emergencies characterized by fear and distrust.
p.000017: Those responsible for infectious disease outbreak response should ensure that all individuals are treated fairly and
p.000017: equitably regardless of their social status or perceived “worth” to society. They should also take measures to prevent
p.000017: stigmatization and social violence.
p.000017:
p.000017: • Disproportionate burdens of outbreak response measures — Even when public health measures
p.000017: are designed with the best of intentions, they can inadvertently place a disproportionate burden on particular
...

Searching for indicator linguistic:

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p.000017: equitably regardless of their social status or perceived “worth” to society. They should also take measures to prevent
p.000017: stigmatization and social violence.
p.000017:
p.000017: • Disproportionate burdens of outbreak response measures — Even when public health measures
p.000017: are designed with the best of intentions, they can inadvertently place a disproportionate burden on particular
p.000017: populations. For example, quarantine orders that require individuals to stay
p.000017: in their homes can have devastating consequences for persons who need to leave their homes to obtain basic
p.000017: necessities such as clean water or food. Similarly, social distancing measures such as school closures can place
p.000017: disproportionate burdens on children who depend on going to school to access regular meals, as well as on working
p.000017: parents who may have no one available to provide child care.
p.000017:
p.000017: • Greater need for resources — Accommodating the needs of individuals whose situation makes them particularly
p.000017: vulnerable sometimes requires the use of additional resources.
p.000017: In some cases, additional resources are relatively minimal, such as when an interpreter is hired to make
p.000017: a community engagement forum accessible to members of a linguistic minority group. In other cases, they may be more
p.000017: substantial, such as when mobile health teams are assembled to dispatch vaccines and treatments to hard-to-reach rural
p.000017: areas. It is legitimate to take costs into consideration in determining whether a particular accommodation is
p.000017: warranted; indeed, the goal of maximizing utility demands that such assessments be made.
p.000017: However, despite the importance of conserving limited resources, the ethical principle of equity may sometimes justify
p.000017: providing greater resources to persons who have greater needs.
p.000017:
p.000017: • Heightened risk of violence — Infectious disease outbreaks can
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017: exacerbate social unrest, increase criminality, and induce violent behaviour, especially against vulnerable groups such
p.000017: as minority populations
p.000017: or migrants. In addition, public health measures such as home isolation, quarantine, or closure of schools and work
p.000017: facilities can induce violence, particularly against women and children. Officials involved in outbreak planning and
p.000017: response efforts should be prepared for the possibility that
p.000017: specific populations may be targeted as being the cause of the outbreak or provoking transmission; strategies should be
...

p.000030: should ensure that clinical trials are not initiated unless there is a reasonable scientific basis to believe that the
p.000030: experimental intervention is likely
p.000030: to be safe and efficacious, and that the risks have been minimized to the extent reasonably possible. In addition,
p.000030: researchers and ethics committees should recognize that, during an outbreak, prospective participants may be especially
p.000030: prone to the therapeutic misconception — that is, the mistaken view that the intervention is primarily designed to
p.000030: directly benefit the individual participants, as opposed to developing generalizable knowledge for the potential
p.000030: benefit of persons
p.000030: in the future. Indeed, researchers themselves, as well as humanitarian aid workers, may sometimes fail
p.000030: to distinguish between engaging in research and providing ordinary
p.000030: clinical care. Efforts should be made to dispel the therapeutic misconception to the extent reasonably possible.
p.000030: Despite such efforts, some prospective participants may still not fully appreciate the difference between research and
p.000030: ordinary medical care, and this should not in itself preclude their enrolment.
p.000030:
p.000030: • Addressing other barriers to informed consent — In addition to the impact of fear and desperation,
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030: other factors can challenge researchers’ ability to obtain informed consent to research; these range from cultural and
p.000030: linguistic differences between foreign researchers and local participants, to the fact that prospective participants in
p.000030: quarantine or isolation may be cut off from their families and other support
p.000030: systems and feel powerless to decline an invitation to participate in research. To the extent possible, consent
p.000030: processes compatible with international research ethics guidelines should be developed
p.000030: in consultation with local communities and implemented by locally recruited personnel. In addition, researchers should
p.000030: be well informed about the medical, psychological and social support systems available locally so that they can guide
p.000030: participants in need towards these services. In some situations, it may be necessary to develop rapid mechanisms for
p.000030: appointing proxy decision-makers, such as during outbreaks of diseases that affect cognitive abilities, or when
p.000030: an outbreak leaves a large number of children as orphans.
p.000030:
p.000030: • Gaining and maintaining trust — Failure to build and maintain community trust during the process of research
p.000030: design and implementation, or when disclosing preliminary results, will not only impede study recruitment and
p.000030: completion but may also undermine
p.000030: the uptake of any interventions proven to be efficacious. Engaging with affected communities before, during, and after
p.000030: a study is essential to build and maintain trust. In environments in which the public’s trust in government is fragile,
p.000030: researchers should remain as independent as possible from official public health activities. If government workers are
p.000030: themselves involved in
...

p.000047: • What obligations do foreign aid workers have before, during, and after deployment?
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047: Foreign governments and humanitarian aid organizations that deploy workers in infectious disease outbreaks have ethical
p.000047: obligations to both the workers themselves and the affected communities. These obligations include the following:
p.000047:
p.000047: • Coordination with local officials — Foreign governments and external humanitarian aid organizations should deploy
p.000047: workers following discussion and agreement with local officials about their roles and responsibilities or, if
p.000047: this is not possible, with international organizations like WHO. Organizations working in a particular area should
p.000047: register their presence as a foreign Emergency Medical Team (EMT) with
p.000047: the local government, and have ongoing discussions among themselves and with the local government to clarify and
p.000047: coordinate their roles
p.000047: and responsibilities and address any disparities in standards of practice. Efforts should be coordinated with local
p.000047: authorities and care providers to
p.000047: ensure that the foreign agency does not excessively draw resources away from other essential services.
p.000047:
p.000047: • Fairness in assigning foreign workers for deployment — Foreign aid workers should be deployed only if they are
p.000047: capable of providing necessary services not sufficiently available in the local setting. Assignment of foreign
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047: health workers should take into consideration their relevant skills and knowledge, as well as their linguistic and
p.000047: cultural competencies to meet mission objectives and understand and communicate with affected communities. It is
p.000047: inappropriate to deploy unqualified or unnecessary
p.000047: 48 workers solely to satisfy their personal
p.000047: or professional desire to be helpful (so-called “disaster tourism”).
p.000047:
p.000047: • Clarity about conditions of deployment — Prospective foreign aid workers should be given
p.000047: comprehensive information about the project’s expectations and risks so they can make informed decisions about whether
p.000047: or not they will be able to make appropriate contributions. In addition, foreign aid workers should be clearly
p.000047: informed of the conditions of their deployment, including the level of health care they can expect if they become ill,
p.000047: the circumstances under
p.000047: which they will be repatriated, available insurance, and whether benefits will
p.000047: be provided to their families in case of illness or death.
p.000047:
p.000047: • Provision of necessary training and resources — Aid workers must be provided with appropriate
p.000047: training, preparation, and equipment to ensure that they can effectively carry out their mission with the lowest risks
p.000047: practicable. Training should include preparation in psychosocial and communication skills, and in understanding and
p.000047: respecting the local culture and traditions. Managers and organizations have an obligation to provide adequate support
p.000047: and guidance to the staff, both during their activity in the field and following
p.000047: their mission. This should include training and resources for managing challenging ethical issues, such as resource
...

Social / Marital Status

Searching for indicator single:

(return to top)
p.000020: guidelines should be developed through an open and transparent process involving broad stakeholder input and, to the
p.000020: extent
p.000020: possible, should be incorporated into formal written documents that establish clear priorities and procedures. Those
p.000020: involved
p.000020: in developing these guidelines should be guided by the following considerations:
p.000020:
p.000020: • Balancing considerations of utility and equity — Resource allocation decisions should be guided by the ethical
p.000020: principles of utility and equity. The principle of utility requires allocating resources to maximize benefits and
p.000020: minimize burdens, while the principle of equity requires attention to the fair distribution of benefits
p.000020: and burdens. In some cases, an equal distribution of benefits and burdens may be considered fair, but in others, it may
p.000020: be fairer to give preference to groups that are worse off, such as the poor, the sick, or the vulnerable. It is not
p.000020: always be possible to achieve fully both utility and equity. For example, establishing treatment centres in large urban
p.000020: settings promotes the value of utility because it makes it possible to treat a large number of people with relatively
p.000020: few resources. However, such
p.000020: an approach may be in tension with the principle of equity if it means that fewer resources will be directed to
p.000020: isolated communities in remote rural areas.
p.000020: There is no single correct way to resolve potential tensions between utility
p.000020: and equity; what is important is that decisions are made through an inclusive and transparent process that takes into
p.000020: account local circumstances.
p.000020: • Defining utility on the basis of health-related considerations —
p.000020: In order to apply the ethical principle of utility, it is first necessary to identify the type of outcomes that will be
p.000020: counted as improvements to welfare. In general, the focus should be on the health-related benefits of allocation
p.000020: mechanisms, whether defined in terms 21
p.000020: of the total number of lives saved, the total number of life years saved, or the total number of quality-adjusted life
p.000020: years saved. For this reason,
p.000020: while it might be ethical to prioritize persons who are essential to manage an outbreak, it is not appropriate to
p.000020: prioritize persons based on social value considerations unrelated to carrying out critical services necessary for
p.000020: society.
p.000020:
p.000020: • Paying attention to the needs of vulnerable populations — In applying the ethical principle of equity, special
p.000020: attention should be given to individuals and groups that are the most vulnerable to discrimination, stigmatization, or
p.000020: isolation, as discussed in Guideline 3.
p.000020: Particular consideration must be given to individuals who are confined in institutional settings, where they are highly
p.000020: dependent on others and
p.000020: potentially exposed to much higher risks of infection than persons living in the community.
p.000020:
...

Social / Mothers

Searching for indicator mothers:

(return to top)
p.000041:
p.000041: • Attention to social and cultural practices — Gender-related roles and practices can affect all aspects of
p.000041: infectious disease outbreaks, including
p.000041: individuals’ risk of becoming infected, the consequences of infection, their use of health services and other
p.000041: health-seeking behaviours, and their vulnerability to interpersonal violence.
p.000041: Policy-makers and outbreak responders should identify and respond to these factors, drawing when possible
p.000041: on relevant anthropological and sociological research.
p.000041:
p.000041: • Sex- and gender-sensitive communication strategies —
p.000041: Entities responsible for developing and implementing communication strategies should be sensitive to sex- and gender-
p.000041: based differences in how individuals have access to and respond to health- related information. Separate messages and
p.000041: communication strategies may be needed to provide relevant information to particular subgroups, such as pregnant women
p.000041: or nursing mothers.
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: Influenza in India
p.000041: Source: Tom Pietrasik, WHO
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: 13. Frontline response workers’ rights and obligations
p.000041:
p.000041:
p.000041:
p.000043: 43
p.000043: Questions addressed:
p.000043:
p.000043: • What obligations exist to protect the health of frontline workers who participate in infectious disease outbreak
p.000043: response efforts?
p.000043: • What obligations exist to provide material support to frontline workers who participate in infectious disease
p.000043: outbreak response efforts?
p.000043: • To what extent do these obligations extend to the workers’ family?
p.000043: • What should be taken into account in determining whether individuals have an obligation to serve as frontline
p.000043: workers during infectious disease outbreaks?
p.000043: • What special obligations do workers in the health-care sector have during infectious disease outbreaks?
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: An effective infectious disease outbreak response depends on the contribution of
p.000043: a diverse range of frontline workers, some of whom may be working on a volunteer basis. These workers often assume
p.000043: considerable personal risk to carry out their jobs. Within the health-care sector, frontline workers range from
p.000043: health-care professionals
...

Social / Occupation

Searching for indicator job:

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p.000025: and medical care. It is also important to ensure that individuals have adequate physical space, opportunities to engage
p.000025: in activities, and the means
p.000025: to communicate with their loved ones and the outside world. Fulfilling these needs is essential to respect individual
p.000025: dignity and address the significant psychosocial burden of confinement on individuals and their loved ones. Mechanisms
p.000025: should be put in place to minimize the risk of violence (including sexual assault) and local disease
p.000025: transmission, especially when individuals are confined in institutional settings
p.000025: or when communities are under mass quarantine. At a minimum, persons who
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025: are quarantined because they have been exposed to the pathogen responsible for the outbreak should not be put at
p.000025: heightened risk of infection because of the manner in which they are confined. (Decisions on the circumstances and
p.000025: conditions of confinement should consider the heightened needs of vulnerable populations, as discussed
p.000025: in Guideline 3.)
p.000025:
p.000025: • Addressing financial and social consequences — Even short-term restrictions on freedom of movement can have
p.000025: significant — and possibly devastating —financial and social consequences for individuals, their families, and their
p.000025: communities. Countries should provide assistance to households that suffer financial
p.000025: losses as a result of inability to conduct business, loss of a job, damage to crops, or other consequences of
p.000025: restrictions on freedom of movement. In some cases, this support may need to continue
p.000025: for a period following the end of confinement. In addition, efforts should be made to support the social and
p.000025: professional reintegration of individuals for whom confinement is no longer necessary, including measures to reduce
p.000025: stigmatization and discrimination.
p.000025:
p.000025: • Due process protections — Mechanisms should be in place to allow individuals whose liberty has been restricted to
p.000025: challenge the appropriateness of those restrictions, the way they are enforced, and the conditions under which the
p.000025: restrictions are carried out. If it is not feasible to provide full due process protection before the restrictions are
p.000025: implemented in an emergency scenario, mechanisms for review and appeal should be made
p.000025: available without excessive delay. All persons involved in decisions to restrict individuals’ freedom of movement
p.000025: should be accountable for any abuses of authority.
p.000025:
p.000025: • Equitable application — Restrictions on freedom of movement should be
p.000025: applied in the same manner to all 27
p.000025: persons posing a comparable public health risk. Thus, individuals should not be subject to greater or lesser
p.000025: restrictions for reasons unrelated to the
...

p.000043: level, and the provision of personal protective equipment. Regular screening of frontline workers should be put
p.000043: in place to detect any infection as quickly as possible, in order to initiate immediate care and minimize the risk of
p.000043: transmission to colleagues, patients, families, and community members.
p.000043:
p.000043: • Priority access to health care — Frontline workers who become sick, as well as any immediate family members who
p.000043: become ill through contact with the worker, should be ensured access to the highest level of care reasonably available.
p.000043: In addition, countries should consider giving frontline workers and their families priority access to vaccines
p.000043: and other treatments as they become available.
p.000043:
p.000043: • Appropriate remuneration — Frontline workers should be given fair remuneration for their work. Governments should
p.000043: ensure that public sector workers are paid in
p.000043: a timely manner, and make efforts to ensure that actors in the private and nongovernmental sectors fulfil their own
p.000043: obligations to pay their employees and contractors. Fair remuneration for frontline workers includes the provision of
p.000043: financial support during periods in which workers are unable to carry out their normal responsibilities because of an
p.000043: infection acquired on the job.
p.000043:
p.000043: • Support for reintegrating into the community — Frontline workers may experience stigma and discrimination,
p.000043: particularly those involved in unpopular measures such as infection control or burials not conducted according to
p.000043: the traditional customs. Governments should make efforts to reduce the risk of stigmatization and discrimination and
p.000043: help such workers to reintegrate into the community, including by providing job placement assistance and relocation to
p.000043: other communities if needed.
p.000043:
p.000043: • Assistance to family members — Assistance should be provided to families of frontline workers who need to remain
p.000043: away from home in order
p.000043: to carry out their responsibilities or to recuperate from illness. Death benefits should be provided to family members
p.000043: of frontline workers who die in the line of duty, including those who were volunteers or “casual workers.”
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: As noted above, some workers may have a duty to work during an infectious
p.000043: disease outbreak. However, even for these individuals, the duty to assume risk is not unlimited. In determining the
p.000043: scope of workers’ duties to assume personal risks, the following factors should be taken into account:
p.000043:
p.000043: • Reciprocal obligations — Any professional or employment-based obligation to assume personal risk is contingent on
p.000043: society’s fulfilment of its reciprocal obligations to workers, as outlined above. If the reciprocal obligations are not
p.000043: met, frontline
p.000043: workers cannot legitimately be expected to assume a significant risk of harm to themselves and their families.
p.000043:
p.000043: • Risks and benefits — Frontline workers should not be expected to expose themselves to risks that are
p.000043: disproportionate to the public health
p.000043: benefits their efforts are likely to achieve.
p.000043:
p.000043: • Equity and transparency — Entities responsible for assigning frontline workers to specific tasks should ensure
p.000043: that risks are distributed among individuals and occupational categories in an equitable manner, and that the process
p.000043: of assigning workers is as transparent as possible.
p.000043:
p.000043: • Consequences for non- participation — Frontline workers should be informed of the risks they are being asked to
p.000043: assume. Insofar as possible, expectations should be made clear in written employment agreements. Workers who are
p.000043: unwilling to accept reasonable risks and work assignments may be subject to professional repercussions
p.000043: (for example, loss of their job), but additional punishments, such as fines or imprisonment, are generally unwarranted.
p.000043: Persons responsible for assessing the consequences for non- participation should recognize that
p.000043: workers may sometimes need to balance other obligations, such as duty to family,
p.000043: against job-related responsibilities. 45
p.000043:
p.000043: Additional obligations of those working in the health‑care sector:
p.000043:
p.000043: In addition to the issues addressed above, persons working in the health-care sector have obligations to the community
p.000043: during an infectious disease outbreak, including the following:
p.000043:
p.000043: • Participate in public health surveillance and reporting efforts — Persons working in the health sector have an
p.000043: obligation to participate in organized measures to respond to infectious disease outbreaks, including public health
p.000043: surveillance and reporting. Health-care providers should protect the confidentiality of patient information to the
p.000043: maximum extent compatible with legitimate public health interests.
p.000043:
p.000043: • Provide accurate information to the public — During an infectious disease outbreak, public health officials have
p.000043: the primary responsibility to communicate information about the outbreak pathogen, including how
p.000043: it is transmitted, how infection can be prevented, and what treatments or preventive measures may be effective. Those
p.000043: responsible for designing communication strategies should anticipate and respond to misinformation, exaggeration, and
p.000043: mistrust, and should seek (without
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: withholding key information) to minimize the risk that information about risk factors will lead to stigmatization and
...

Social / Police Officer

Searching for indicator officer:

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p.000054: Kingdom
p.000054: Ms Jeanine Thomas, Patient Safety Champion, United States of America
p.000054: Professor Aisssatou Touré, Head, Immunology Department, Institut Pasteurde Dakar,,Senegal Professor Ross Upshur, Chair
p.000054: in Primary Care Research; Professor, Department of Family and Community Medicine and Dalla Lana School of Public
p.000054: Health, University of Toronto; Canada
p.000054:
p.000054: Resource persons
p.000054: Dr Daniel Bausch, Head, Virology and Emerging Infections Department, US Naval Medical Research Unit No. 6, Peru
p.000054: Professor Luciana Borio, Assistant Commissioner for Counterterrorism Policy; Director, Office of Counterterrorism and
p.000054: Emerging Threats, Food and Drug Administration, United States of America
p.000054: Dr Frederick Hayden, Professor of Clinical Virology and Professor of Medicine, University of Virginia School of
p.000054: Medicine, United States of America
p.000054: Dr Stephan Monroe, Deputy Director, National Centre for Emerging and Zoonotic Infectious Diseases, Centers for Disease
p.000054: Control and Prevention, United States of America
p.000054:
p.000054:
p.000054:
p.000054:
p.000054:
p.000054:
p.000054:
p.000054:
p.000054: WHO Secretariat
p.000054:
p.000054: WHO headquarters, Geneva, Switzerland
p.000054: Dr Margaret Chan, Director-General
p.000054: Dr Marie-Paule Kieny, Assistant Director-General, Health Systems and Innovation Dr Marie-Charlotte Bouesseau, Ethics
p.000054: Advisor, Service Delivery and Safety
p.000054: Dr Pierre Formenty, Scientist, Control of Epidemic Diseases, Department of Pandemic and Epidemic Diseases
p.000054: 56 Dr Margaret Harris, Communication Officer, Department of Pandemic and Epidemic
p.000054: Diseases
p.000054: Mr Gregory Hartl, Coordinator, Department of Communications Dr Rüdiger Krech, Director, Health Systems and Innovation
p.000054: Dr Andreas Reis, Technical Officer, Global Health Ethics, Department of Knowledge, Ethics and Research
p.000054: Dr Cathy Roth, Adviser, Office of the Assistant Director-General, Health Systems and Innovation
p.000054: Dr Vasee Sathyamoorthy, Technical Officer, Initiative for Vaccine Research, Department of Immunization, Vaccines and
p.000054: Biologicals
p.000054: Dr Abha Saxena, Coordinator, Global Health Ethics, Department of Knowledge, Ethics and Research
p.000054: Dr David Wood, Coordinator, Technologies Standards and Norms, Department of Essential Medicines and Health Products
p.000054:
p.000054: Regional offices
p.000054: Dr Marion Motari, Partnership and Resource Mobilization, Regional Office for Africa, Brazzaville, Congo
p.000054: Dr Martin Ota, Medical Officer, Health Information and Knowledge Management, Regional Office for Africa, Brazzaville,
p.000054: Congo
p.000054: Dr Carla Saenz, Bioethics Advisor, Regional Office for the Americas, Washington DC, United States of America
p.000054:
p.000054: Consultation on potential Ebola therapies and vaccines: Pre‑meeting of the Ethics Working Group, World Health
p.000054: Organization, Geneva, 3 September 2014
p.000054:
p.000054: Participants
p.000054: Professor Clement Adebamowo, Chair, National Research Ethics Committee, Nigeria Dr Philippe Calain, Senior Researcher,
p.000054: Unit of Research on Humanitarian Stakes and Practices, Médecins Sans Frontières, Switzerland
p.000054: Dr Marion Danis, Head, Ethics and Health Policy and Chief, Bioethics Consultation Service, National Institutes of
p.000054: Health, United States of America
p.000054: Professor Jeremy Farrar, Director, Wellcome Trust, United Kingdom
p.000054: Professor Jennifer Gibson, Sun Life Financial Chair in Bioethics; Director, Joint Centre for Bioethics; and Associate
p.000054: Professor, Institute of Health Policy, Management and Evaluation, University of Toronto, Canada
p.000054:
p.000054:
p.000054:
p.000054:
p.000054:
p.000054:
p.000054:
p.000054:
p.000054: Ms Robinah Kaitiritimba, Patient Representative (community representative, Makerere University Institutional Review
p.000054: Boards; Uganda National Health Consumers’ Organisation), Uganda
p.000054: Dr Bocar Kouyate, Special Advisor to the Minister of Health (former Chair of National Ethics Committee), Burkina Faso
p.000054: Professor Cheikh Niang, Université Cheikh Anta Diop, Senegal
p.000054: Professor Michael Selgelid,Director, Centre for Human Bioethics, Monash University, Australia Professor Oyewale Tomori
p.000054: (Chair), President, Nigeria National Academy of Sciences, Nigeria
p.000054: Dr Aissatou Touré (Co-Chair), Head, Immunology Department, Institut Pasteur de Dakar and 57
p.000054: Member, National Ethics Committee, Senegal
p.000054:
p.000054: WHO Secretariat
p.000054:
p.000054: WHO headquarters, Geneva, Switzerland
p.000054: Dr Andreas Reis, Technical Officer, Global Health Ethics, Department of Knowledge, Ethics and Research
p.000054: Dr Abha Saxena, Coordinator, Global Health Ethics, Department of Knowledge, Ethics and Research
p.000054:
p.000054: WHO Regional Office
p.000054: Dr Carla Saenz, Bioethics Advisor, Regional Office for the Americas, Washington DC, United States of America
p.000054:
p.000054: Ethical issues related to study design for trials on therapeutics, World Health Organization, Geneva, 20–21 October
p.002014: 2014
p.002014:
p.002014: Ethics Working Group
p.002014: Professor Arthur Caplan, Drs William F and Virginia Connolly Mitty; Director, Division of Medical Ethics, New York
p.002014: University Langone Medical Center’s Department of Population Health, United States of America
p.002014: Dr Clare Chandler, Senior Lecturer, Medical Anthropology, Department of Global Health and Development, London School of
p.002014: Hygiene and Tropical Medicine, United Kingdom
p.002014: Dr Alpha Ahmadou Diallo, Administrator, National Ethics Committee, Ministry of Health and Public Hygiene, Guinea
p.002014: Dr Amar Jesani, Independent Researcher and Teacher, Bioethics and Public Health; Editor, Indian Journal of Medical
p.002014: Ethics; Visiting Professor, Centre for Ethics, Yenepoya University, India Dr Dan O’Connor, Head, Medical Humanities,
p.002014: Wellcome Trust, United Kingdom
...

p.002014: Dr Elizabeth Higgs, Global Health Science Advisor, Office of the Director, Division of Clinical Research, National
p.002014: Institute of Allergy and Infectious Diseases, National Institutes of Health, United States of America
p.002014: Dr Nadia Khelef, Senior Advisor, Global Affairs, Institut Pasteur, France
p.002014: Professor Trudie Lang, Lead Professor, Global Health Network, Nuffield Department of Medicine, University of Oxford,
p.002014: United Kingdom
p.002014: Dr Matthew Lim, Senior Advisor, Global Health Security, Department of Health and Human Services, United States of
p.002014: America
p.002014: Professor Ira Longini, Professor of Biostatistics, Department of Biostatistics, College of Public Health and College of
p.002014: Medicine, University of Florida, United States of America
p.002014: Colonel Scott Miller, Director, Infectious Disease Clinical Research Program, Department of Preventive Medicine,
p.002014: Uniformed Services University, United States of America
p.002014: Ms Adeline Osakwe, Head, National Pharmacovigilance Centre, National Agency for Food and Drug Administration and
p.002014: Control, Nigeria
p.002014: Ms Virginie Pirard, Member, Belgian Advisory Committee on Bioethics; Ethics Advisor, Institut Pasteur, France
p.002014: Dr Micaela Serafini, Medical Director, Médecins Sans Frontières, Switzerland
p.002014: Mr Jemee Tegli, Institutional Review Board Administrator, University of Liberia–Pacific Institute for Research and
p.002014: Evaluation Institutional Review Board, Liberia
p.002014: Dr Gervais Tougas, Representative, International Federation of Pharmaceutical Manufacturers & Associations, Chief
p.002014: Medical Officer, Novartis, Switzerland
p.002014: Dr Johan van Griensven, Department of Clinical Sciences, Institute of Tropical Medicine, Belgium
p.002014: Professor John Whitehead, Emeritus Professor, Department of Mathematics and Statistics, Fylde College, Lancaster
p.002014: University, United Kingdom
p.002014:
p.002014:
p.002014:
p.002014:
p.002014:
p.002014:
p.002014:
p.002014:
p.002014: WHO Secretariat
p.002014: Dr Marie-Paule Kieny, Assistant Director-General, Health Systems and Innovation Dr Marie-Charlotte Bouesseau, Advisor,
p.002014: Department of Service Delivery and Safety Dr Vânia de la Fuente-Núñez,Technical Officer, Global Health Ethics,
p.002014: Department of Knowledge, Ethics and Research
p.002014: Dr Martin Friede, Scientist, Public Health, Innovation and Intellectual Property, Department of Essential Medicines and
p.002014: Health Products
p.002014: Ms Marisol Guraiib, Technical Officer, Global Health Ethics, Department of Knowledge,
p.002014: Ethics and Research
p.000059: 59
p.000059: Ms Corinna Klingler, Intern, Global Health Ethics, Department of Knowledge, Ethics and Research
p.000059: Dr Selena Knight, Intern, Global Health Ethics, Department of Knowledge, Ethics and Research Dr Nicola Magrini,
p.000059: Scientist, Policy, Access and Use, Department of Essential Medicines and Health Products
p.000059: Dr Cathy Roth, Adviser, Office of the Assistant Director-General, Health Systems and Innovation Dr Vasee
p.000059: Sathiyamoorthy, Technical Officer, Initiative for Vaccine Research, Department of Immunization, Vaccines and
p.000059: Biologicals
p.000059: Dr Abha Saxena, Coordinator, Global Health Ethics, Department of Knowledge, Ethics and Research
p.000059: Dr David Wood, Coordinator, Technologies, Standards and Norms, Department of Essential Medicines and Health Products
p.000059:
p.000059: Developing ethics guidelines for public health responses during epidemics, including for the conduct of related
p.000059: research, Dublin, Ireland, 25–26 May 2015
p.000059:
p.000059: Participants
p.000059: Dr Annick Antierens, Manager, Investigational Platform for Experimental Ebola Products, Médecins Sans Frontières,
p.000059: Switzerland
p.000059: Dr Philippe Calain, Senior Researcher, Unit of Research on Humanitarian Stakes and Practices, Médecins Sans Frontières,
p.000059: Switzerland
p.000059: Dr Edward Cox, Director, Office of Antimicrobial Products, Food and Drug Administration, United States of America
p.000059: Professor Heather Draper, Professor of Biomedical Ethics, University of Birmingham, United Kingdom
p.000059: Dr Sarah Edwards, Senior Lecturer in Research Ethics and Governance, University College London, United Kingdom
p.000059: Professor Jónína Einarsdóttir, Medical Anthropology, School of Social Sciences, University of Iceland, Iceland
p.000059: Professor Jeremy Farrar, Director, Wellcome Trust, United Kingdom
p.000059: Dr Margaret Fitzgerald, Public Health Specialist, Irish Health Service Executive, Ireland Dr Gabriel Fitzpatrick,
...

p.000059: Administration, United States of America
p.000059: Professor Alistair Nichol, Consultant Anaesthetist, School of Medicine and Medical Sciences, and EU projects,
p.000059: University College Dublin, Ireland
p.000059: Professor Lisa Schwartz, Arnold Johnson Chair in Health Care Ethics, Ethics in Health Care, McMaster University, Canada
p.000059: Professor Michael Selgelid, Director, Centre for Human Bioethics, Monash University, Australia Dr Kadri Simm, Associate
p.000059: Professor of Practical Philosophy, University of Tartu, Estonia
p.000059: Dr Aissatou Touré, Head, Immunology Department, Institut Pasteur de Dakar and Member, National Ethics Committee,
p.000059: Senegal
p.000059: Professor Ross Upshur, Canada Research Chair in Primary Care Research; Professor, Department of Family and Community
p.000059: Medicine and Dalla Lana School of Public Health, University of Toronto, Canada
p.000059: Dr Maria Van Kerkhove, Centre for Global Health, Institut Pasteur, France
p.000059: Dr Aminu Yakubu, Department of Health Planning and Research, Federal Ministry of Health, Nigeria
p.000059:
p.000059: Resource person
p.000059: Professor Carl Coleman (Rapporteur), Professor of Law and Academic Director, Division of Online Learning, Seton Hall
p.000059: University, New Jersey, United States of America
p.000059:
p.000059: WHO headquarters Secretariat, Geneva, Switzerland
p.000059: Dr Vânia de la Fuente-Núñez, Technical Officer, Global Health Ethics, Department of Knowledge, Ethics and Research
p.000059: Dr Andreas Reis, Technical Officer, Global Health Ethics, Department of Knowledge, Ethics and Research
p.000059: Dr Abha Saxena, Coordinator, Global Health Ethics, Department of Knowledge, Ethics and Research
p.000059:
p.000059:
p.000059:
p.000059:
p.000059:
p.000059:
p.000059:
p.000059:
p.000059: Meeting to develop WHO Guidance on ethics and epidemics. Prato, Italy, 22–24 November 2015
p.000059:
p.000059: Participants
p.000059: Dr Franklyn Prieto Alvarado, Universidad Nacional de Colombia, Colombia Dr Annick Antierens, Médecins Sans Frontières,
p.000059: Switzerland
p.000059: Professor Oumou Younoussa Bah-Sow, Ignace Deen National Hospital, Guinea Dr Ruchi Baxi, The Ethox Centre, United
p.000059: Kingdom
p.000059: Dr Ron Bayer, Mailman School of Public Health, United States of America
p.000061: 61
p.000061: Dr Oscar Cabrera, Executive Director, O’Neill Institute for National and Global Health Law, Georgetown University Law
p.000061: Center, United States of America
p.000061: Dr Philippe Calain, Senior Researcher, Research on Humanitarian Stakes and Practices, Médecins Sans Frontières,
p.000061: Switzerland
p.000061: Dr Voo Teck Chuan, National Academy of Health Sciences, India
p.000061: Professor Alice Desclaux, Institut de Recherche pour le Développement, Unité TRANSVIHMI, Centre Régional de Recherche
p.000061: et de Formation sur le VIH et les Maladies Associées, Hôpital de Fann, Sénégal
p.000061: Dr Benedict Dossen, National Research Ethics Board, University of Liberia–Pacific Institute for Research and
p.000061: Evaluation, Africa Center Institutional Review Board, Liberia
...

p.000061: Transplantation, Pakistan
p.000061: Dr Dónal O’Mathúna, Dublin City University, Ireland
p.000061: Professor Mahmudur Rahman, Director, Institute of Epidemiology, Disease Control and Research; National Influenza
p.000061: Center, Ministry of Health and Family Welfare, Bangladesh Professor Lisa Schwartz, Arnold Johnson Chair in Health Care
p.000061: Ethics, McMaster Ethics in Healthcare, McMaster University, Canada
p.000061: Professor Michael Selgelid, Director, Centre for Human Bioethics, Monash University, Australia Dr Aissatou Touré, Head,
p.000061: Immunology Unit, Institut Pasteur de Dakar, Senegal
p.000061: Dr Maria Van Kerkhove, Centre for Global Health, Institut Pasteur, France
p.000061:
p.000061:
p.000061:
p.000061:
p.000061:
p.000061:
p.000061:
p.000061:
p.000061: Observer
p.000061: Dr Katherine Littler, Senior Policy Adviser, Policy Department, Wellcome Trust, United Kingdom
p.000061:
p.000061: Resource consultants
p.000061: Professor Carl Coleman, Professor of Law and Academic Director, Division of Online Learning, Seton Hall University, New
p.000061: Jersey, United States of America
p.000061: Dr Michele Loi (Rapporteur), Post-doctoral research fellow, ETH Zürich, Switzerland
p.000061: Dr Diego Silva, Assistant Professor, Faculty of Health Sciences, Simon Fraser University, Canada
p.000062: 62
p.000062: WHO headquarters Secretariat, Geneva, Switzerland
p.000062: Dr Pierre Formenty, Scientist, Control of Epidemic Diseases, Department of Pandemic and Epidemic Diseases
p.000062: Dr Vânia de la Fuente-Núñez,Technical Officer, Global Health Ethics, Department of Knowledge, Ethics and Research
p.000062: Dr Andreas Reis, Technical Officer Global Health Ethics, Department of Knowledge, Ethics and Research
p.000062: Dr Abha Saxena, Coordinator, Global Health Ethics, Department of Knowledge, Ethics and Research
p.000062:
p.000062:
p.000062:
p.000062:
p.000062:
p.000062:
p.000062:
p.000062:
p.000062:
p.000062: Infectious disease outbreaks are frequently characterized by scientific uncertainty, social and
p.000062: institutional disruption, and an overall climate of fear and distrust. Invariably, the countries most affected by
p.000062: outbreaks have limited resources, under-developed legal and regulatory structures, and health systems that
p.000062: lack the resilience to deal with crisis situations. Policy-makers and public health professionals may be
p.000062: forced to weigh and prioritize potentially competing ethical values in the face of severe time and resource constraints
p.000062: . This document seeks to assist policy-makers, health care providers, researchers, and others prepare for outbreak
p.000062: situations by anticipating and preparing for the critical ethical issues likely to arise. In addition to
p.000062: setting forth ethical principles applicable to infectious disease outbreaks generally, it shows how these principles
p.000062: can be adapted to different epidemiological and social circumstances.
p.000062:
p.000062:
p.000062:
p.000062:
p.000062:
p.000062:
p.000062:
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p.000062:
...

Social / Property Ownership

Searching for indicator home:

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p.000017:
p.000017: • Greater need for resources — Accommodating the needs of individuals whose situation makes them particularly
p.000017: vulnerable sometimes requires the use of additional resources.
p.000017: In some cases, additional resources are relatively minimal, such as when an interpreter is hired to make
p.000017: a community engagement forum accessible to members of a linguistic minority group. In other cases, they may be more
p.000017: substantial, such as when mobile health teams are assembled to dispatch vaccines and treatments to hard-to-reach rural
p.000017: areas. It is legitimate to take costs into consideration in determining whether a particular accommodation is
p.000017: warranted; indeed, the goal of maximizing utility demands that such assessments be made.
p.000017: However, despite the importance of conserving limited resources, the ethical principle of equity may sometimes justify
p.000017: providing greater resources to persons who have greater needs.
p.000017:
p.000017: • Heightened risk of violence — Infectious disease outbreaks can
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017: exacerbate social unrest, increase criminality, and induce violent behaviour, especially against vulnerable groups such
p.000017: as minority populations
p.000017: or migrants. In addition, public health measures such as home isolation, quarantine, or closure of schools and work
p.000017: facilities can induce violence, particularly against women and children. Officials involved in outbreak planning and
p.000017: response efforts should be prepared for the possibility that
p.000017: specific populations may be targeted as being the cause of the outbreak or provoking transmission; strategies should be
p.000017: proactively designed to
p.000017: protect members of such groups from a heightened risk of violence.
p.000017:
p.000017:
p.000019: 19
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p.000019:
p.000019:
p.000019: A doctor inspects patients in an MSF supported hospital in Aweil,
p.000019: Northern Bar El Ghazal in South Sudan, 2011
p.000019: Source: Siegfried Modola/IRIN
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019: 4. Allocating scarce resources
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000020: 20
p.000020: Questions addressed:
p.000020:
p.000020: • What type of resource allocation decisions might need to be made during infectious disease outbreaks?
p.000020: • How do the principles of utility and equity apply to decisions about allocating scarce resources during
p.000020: infectious disease outbreaks?
...

p.000025: assembly.
p.000025:
p.000025: In light of these considerations, no restrictions on freedom of movement should be implemented without careful
p.000025: attention to the following considerations:
p.000025:
p.000025: • Justifiable basis for imposing restrictions — Decisions to impose restrictions on freedom of movement should be
p.000025: grounded on the best available evidence
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025: about the outbreak pathogen, as determined in consultation with national and international public health officials. No
p.000025: such interventions should be implemented unless there is a reasonable basis to expect they will significantly reduce
p.000025: disease transmission. The rationale for relying
p.000025: 26 on these measures should be made
p.000025: explicit, and the appropriateness of any restrictions should be continuously re-evaluated in light of emerging
p.000025: scientific information about the outbreak. If the original rationale for
p.000025: imposing a restriction no longer applies, the restriction should be lifted without delay.
p.000025:
p.000025: • Least restrictive means — Any restrictions on freedom of movement should be designed and implemented in a manner
p.000025: that imposes the fewest constraints reasonably possible. Greater restrictions should be imposed only when there are
p.000025: strong grounds to believe that less restrictive measures are unlikely to achieve important
p.000025: public health goals. For example, requests for voluntary cooperation are generally preferable to public health mandates
p.000025: enforced by law or military authorities. Similarly, home-based quarantine should be considered before confining
p.000025: individuals in
p.000025: institutions. While isolation in a properly equipped health-care facility is usually recommended for individuals who
p.000025: are already symptomatic, especially for diseases with a high potential for contagiousness, home-based isolation may
p.000025: sometimes be appropriate, provided that adequate medical and
p.000025: logistical support can be organized and family attendants are willing and able to act under the oversight of trained
p.000025: public health staff. This is particularly true if the caseload overwhelms facility capacity.
p.000025:
p.000025: • Costs — In some cases, a less restrictive alternative may involve greater costs. This does not, in itself,
p.000025: justify more restrictive approaches. However, costs and other practical constraints (e.g. logistics, distance,
p.000025: available workforce) may legitimately be taken into account to determine whether a less restrictive alternative is
p.000025: feasible under the circumstances, particularly in settings with severe resource constraints.
p.000025:
p.000025: • Ensuring humane conditions — Any restrictions on freedom of movement, particularly those that are not voluntary,
p.000025: should be backed up with sufficient resources to ensure that those subject to the restrictions do not experience undue
p.000025: burdens. For example, individuals whose mobility is restricted (whether through confinement at home or
p.000025: in institutional settings) should be ensured access to food, drinking water, sanitary facilities, shelter, clothing,
p.000025: and medical care. It is also important to ensure that individuals have adequate physical space, opportunities to engage
p.000025: in activities, and the means
p.000025: to communicate with their loved ones and the outside world. Fulfilling these needs is essential to respect individual
p.000025: dignity and address the significant psychosocial burden of confinement on individuals and their loved ones. Mechanisms
p.000025: should be put in place to minimize the risk of violence (including sexual assault) and local disease
p.000025: transmission, especially when individuals are confined in institutional settings
p.000025: or when communities are under mass quarantine. At a minimum, persons who
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025: are quarantined because they have been exposed to the pathogen responsible for the outbreak should not be put at
p.000025: heightened risk of infection because of the manner in which they are confined. (Decisions on the circumstances and
p.000025: conditions of confinement should consider the heightened needs of vulnerable populations, as discussed
p.000025: in Guideline 3.)
p.000025:
p.000025: • Addressing financial and social consequences — Even short-term restrictions on freedom of movement can have
p.000025: significant — and possibly devastating —financial and social consequences for individuals, their families, and their
...

p.000025: media.
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025: 7. Obligations related to medical interventions for the diagnosis, treatment, and prevention of infectious disease
p.000028: 28
p.000028:
p.000028:
p.000028: Questions addressed:
p.000028:
p.000028: • What quality and safety standards should govern the administration of medical interventions offered during
p.000028: infectious disease outbreaks?
p.000028: • What rights do patients (or their authorized proxy decision-makers) have to receive information about the risks
p.000028: and benefits of, and alternatives to, medical interventions during infectious disease outbreaks?
p.000028: • Under what circumstances, if any, might it be appropriate to override an individual’s refusal of diagnostic,
p.000028: therapeutic, or preventive measures during an infectious disease outbreak?
p.000028: • What procedural safeguards should be provided before overriding an individual’s refusal of diagnostic,
p.000028: therapeutic, or preventive measures during an infectious disease outbreak?
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028: Any medical intervention for the diagnosis, treatment, or prevention of infectious disease should be provided in accord
p.000028: with professional medical standards, under conditions designed to ensure the highest attainable level of patient
p.000028: safety. Countries, with the support of international experts, should establish the minimum standards
p.000028: to be applied in the care and treatment of patients affected by an outbreak.
p.000028: These standards should apply not only to health-care institutions but also to home-based care, community activities
p.000028: (including health education sessions), and environmental decontamination efforts or the management of dead bodies.
p.000028:
p.000028: Individuals offered medical interventions for the diagnosis, treatment, or prevention of an infectious pathogen should
p.000028: be informed about the risks, benefits, and alternatives, just as they would be for other significant medical
p.000028: interventions. The presumption should be that the final decision about which medical interventions to accept, if any,
p.000028: belongs to the patient. For patients who lack the legal capacity to make health- care decisions for themselves,
p.000028: decisions should generally be made by appropriately authorized proxy decision-makers, with efforts made to solicit the
p.000028: patient’s assent whenever possible.
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028: Health-care providers should recognize that, in some situations, the refusal of diagnostic, therapeutic, or preventive
p.000028: measures might be a choice that is rational from the perspective of a mentally competent individual. If an individual
p.000028: is unwilling to accept an intervention, providers should engage the patient in an open and respectful dialogue, paying
p.000028: careful attention to the patient’s concerns, perceptions, and situational needs.
p.000028:
p.000028: In exceptional situations, there may be legitimate reasons to override an individual’s refusal of a diagnostic,
p.000028: therapeutic, or preventive measure that has proven to
p.000028: be safe and effective and is part of the accepted medical standard of care. Decisions on whether to override a refusal
...

p.000043: and other treatments as they become available.
p.000043:
p.000043: • Appropriate remuneration — Frontline workers should be given fair remuneration for their work. Governments should
p.000043: ensure that public sector workers are paid in
p.000043: a timely manner, and make efforts to ensure that actors in the private and nongovernmental sectors fulfil their own
p.000043: obligations to pay their employees and contractors. Fair remuneration for frontline workers includes the provision of
p.000043: financial support during periods in which workers are unable to carry out their normal responsibilities because of an
p.000043: infection acquired on the job.
p.000043:
p.000043: • Support for reintegrating into the community — Frontline workers may experience stigma and discrimination,
p.000043: particularly those involved in unpopular measures such as infection control or burials not conducted according to
p.000043: the traditional customs. Governments should make efforts to reduce the risk of stigmatization and discrimination and
p.000043: help such workers to reintegrate into the community, including by providing job placement assistance and relocation to
p.000043: other communities if needed.
p.000043:
p.000043: • Assistance to family members — Assistance should be provided to families of frontline workers who need to remain
p.000043: away from home in order
p.000043: to carry out their responsibilities or to recuperate from illness. Death benefits should be provided to family members
p.000043: of frontline workers who die in the line of duty, including those who were volunteers or “casual workers.”
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: As noted above, some workers may have a duty to work during an infectious
p.000043: disease outbreak. However, even for these individuals, the duty to assume risk is not unlimited. In determining the
p.000043: scope of workers’ duties to assume personal risks, the following factors should be taken into account:
p.000043:
p.000043: • Reciprocal obligations — Any professional or employment-based obligation to assume personal risk is contingent on
p.000043: society’s fulfilment of its reciprocal obligations to workers, as outlined above. If the reciprocal obligations are not
p.000043: met, frontline
p.000043: workers cannot legitimately be expected to assume a significant risk of harm to themselves and their families.
p.000043:
p.000043: • Risks and benefits — Frontline workers should not be expected to expose themselves to risks that are
p.000043: disproportionate to the public health
p.000043: benefits their efforts are likely to achieve.
p.000043:
p.000043: • Equity and transparency — Entities responsible for assigning frontline workers to specific tasks should ensure
...

Searching for indicator property:

(return to top)
p.002014: Uniformed Services University, United States of America
p.002014: Ms Adeline Osakwe, Head, National Pharmacovigilance Centre, National Agency for Food and Drug Administration and
p.002014: Control, Nigeria
p.002014: Ms Virginie Pirard, Member, Belgian Advisory Committee on Bioethics; Ethics Advisor, Institut Pasteur, France
p.002014: Dr Micaela Serafini, Medical Director, Médecins Sans Frontières, Switzerland
p.002014: Mr Jemee Tegli, Institutional Review Board Administrator, University of Liberia–Pacific Institute for Research and
p.002014: Evaluation Institutional Review Board, Liberia
p.002014: Dr Gervais Tougas, Representative, International Federation of Pharmaceutical Manufacturers & Associations, Chief
p.002014: Medical Officer, Novartis, Switzerland
p.002014: Dr Johan van Griensven, Department of Clinical Sciences, Institute of Tropical Medicine, Belgium
p.002014: Professor John Whitehead, Emeritus Professor, Department of Mathematics and Statistics, Fylde College, Lancaster
p.002014: University, United Kingdom
p.002014:
p.002014:
p.002014:
p.002014:
p.002014:
p.002014:
p.002014:
p.002014:
p.002014: WHO Secretariat
p.002014: Dr Marie-Paule Kieny, Assistant Director-General, Health Systems and Innovation Dr Marie-Charlotte Bouesseau, Advisor,
p.002014: Department of Service Delivery and Safety Dr Vânia de la Fuente-Núñez,Technical Officer, Global Health Ethics,
p.002014: Department of Knowledge, Ethics and Research
p.002014: Dr Martin Friede, Scientist, Public Health, Innovation and Intellectual Property, Department of Essential Medicines and
p.002014: Health Products
p.002014: Ms Marisol Guraiib, Technical Officer, Global Health Ethics, Department of Knowledge,
p.002014: Ethics and Research
p.000059: 59
p.000059: Ms Corinna Klingler, Intern, Global Health Ethics, Department of Knowledge, Ethics and Research
p.000059: Dr Selena Knight, Intern, Global Health Ethics, Department of Knowledge, Ethics and Research Dr Nicola Magrini,
p.000059: Scientist, Policy, Access and Use, Department of Essential Medicines and Health Products
p.000059: Dr Cathy Roth, Adviser, Office of the Assistant Director-General, Health Systems and Innovation Dr Vasee
p.000059: Sathiyamoorthy, Technical Officer, Initiative for Vaccine Research, Department of Immunization, Vaccines and
p.000059: Biologicals
p.000059: Dr Abha Saxena, Coordinator, Global Health Ethics, Department of Knowledge, Ethics and Research
p.000059: Dr David Wood, Coordinator, Technologies, Standards and Norms, Department of Essential Medicines and Health Products
p.000059:
p.000059: Developing ethics guidelines for public health responses during epidemics, including for the conduct of related
p.000059: research, Dublin, Ireland, 25–26 May 2015
p.000059:
...

Social / Racial Minority

Searching for indicator minority:

(return to top)
p.000017: equitably regardless of their social status or perceived “worth” to society. They should also take measures to prevent
p.000017: stigmatization and social violence.
p.000017:
p.000017: • Disproportionate burdens of outbreak response measures — Even when public health measures
p.000017: are designed with the best of intentions, they can inadvertently place a disproportionate burden on particular
p.000017: populations. For example, quarantine orders that require individuals to stay
p.000017: in their homes can have devastating consequences for persons who need to leave their homes to obtain basic
p.000017: necessities such as clean water or food. Similarly, social distancing measures such as school closures can place
p.000017: disproportionate burdens on children who depend on going to school to access regular meals, as well as on working
p.000017: parents who may have no one available to provide child care.
p.000017:
p.000017: • Greater need for resources — Accommodating the needs of individuals whose situation makes them particularly
p.000017: vulnerable sometimes requires the use of additional resources.
p.000017: In some cases, additional resources are relatively minimal, such as when an interpreter is hired to make
p.000017: a community engagement forum accessible to members of a linguistic minority group. In other cases, they may be more
p.000017: substantial, such as when mobile health teams are assembled to dispatch vaccines and treatments to hard-to-reach rural
p.000017: areas. It is legitimate to take costs into consideration in determining whether a particular accommodation is
p.000017: warranted; indeed, the goal of maximizing utility demands that such assessments be made.
p.000017: However, despite the importance of conserving limited resources, the ethical principle of equity may sometimes justify
p.000017: providing greater resources to persons who have greater needs.
p.000017:
p.000017: • Heightened risk of violence — Infectious disease outbreaks can
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017: exacerbate social unrest, increase criminality, and induce violent behaviour, especially against vulnerable groups such
p.000017: as minority populations
p.000017: or migrants. In addition, public health measures such as home isolation, quarantine, or closure of schools and work
p.000017: facilities can induce violence, particularly against women and children. Officials involved in outbreak planning and
p.000017: response efforts should be prepared for the possibility that
p.000017: specific populations may be targeted as being the cause of the outbreak or provoking transmission; strategies should be
p.000017: proactively designed to
p.000017: protect members of such groups from a heightened risk of violence.
p.000017:
p.000017:
p.000019: 19
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019: A doctor inspects patients in an MSF supported hospital in Aweil,
p.000019: Northern Bar El Ghazal in South Sudan, 2011
p.000019: Source: Siegfried Modola/IRIN
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019: 4. Allocating scarce resources
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000020: 20
p.000020: Questions addressed:
p.000020:
p.000020: • What type of resource allocation decisions might need to be made during infectious disease outbreaks?
...

Social / Religion

Searching for indicator religion:

(return to top)
p.000025: professional reintegration of individuals for whom confinement is no longer necessary, including measures to reduce
p.000025: stigmatization and discrimination.
p.000025:
p.000025: • Due process protections — Mechanisms should be in place to allow individuals whose liberty has been restricted to
p.000025: challenge the appropriateness of those restrictions, the way they are enforced, and the conditions under which the
p.000025: restrictions are carried out. If it is not feasible to provide full due process protection before the restrictions are
p.000025: implemented in an emergency scenario, mechanisms for review and appeal should be made
p.000025: available without excessive delay. All persons involved in decisions to restrict individuals’ freedom of movement
p.000025: should be accountable for any abuses of authority.
p.000025:
p.000025: • Equitable application — Restrictions on freedom of movement should be
p.000025: applied in the same manner to all 27
p.000025: persons posing a comparable public health risk. Thus, individuals should not be subject to greater or lesser
p.000025: restrictions for reasons unrelated to the
p.000025: risks they may pose to others, including membership in any disfavoured or favoured social group or class (for example,
p.000025: groups defined by gender, ethnicity, or religion). In addition, policy- makers should seek to ensure that restrictions
p.000025: are not applied in a manner that imposes a disproportionate burden on vulnerable segments of society.
p.000025:
p.000025: • Communication and transparency —
p.000025: Policy-makers and public health officials should engage communities in a dialogue about any restrictions on freedom of
p.000025: movement and solicit community members’ views on how restrictions can be carried out with the least possible burden.
p.000025: They should also provide regular updates on the implementation of such measures,
p.000025: both to the public at large and to those whose movement has been restricted. Communication strategies should be
p.000025: designed to avoid the stigmatization
p.000025: of individuals whose liberty has been restricted and to protect their privacy and confidentiality, particularly in the
p.000025: media.
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025: 7. Obligations related to medical interventions for the diagnosis, treatment, and prevention of infectious disease
p.000028: 28
p.000028:
p.000028:
p.000028: Questions addressed:
p.000028:
p.000028: • What quality and safety standards should govern the administration of medical interventions offered during
p.000028: infectious disease outbreaks?
p.000028: • What rights do patients (or their authorized proxy decision-makers) have to receive information about the risks
p.000028: and benefits of, and alternatives to, medical interventions during infectious disease outbreaks?
...

Searching for indicator religious:

(return to top)
p.000006: obligation to meet the basic needs of individuals and communities, particularly humanitarian needs such as nourishment,
p.000006: shelter, good health, and security.
p.000006:
p.000006: Utility — The principle of utility states that actions are right insofar as they promote the well-being of individuals
p.000006: or communities. Efforts to maximize utility require consideration of proportionality (balancing the potential benefits
p.000006: of an activity against any risks of harm) and
p.000006: efficiency (achieving the greatest benefits at the lowest possible cost).
p.000006:
p.000006: Respect for persons — The term “respect for persons” refers to treating individuals in ways that are fitting to and
p.000006: informed by a recognition of our common humanity, dignity and inherent rights. A central
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006: aspect of respect for persons is respect for autonomy, which requires letting individuals make their own choices based
p.000006: on their values and preferences. Informed consent, a process in which a competent individual authorizes a course of
p.000006: action based on sufficient relevant information, without coercion or undue inducement, is one
p.000006: way to operationalize this concept. Where individuals lack decision-making capacity, it may be necessary for others to
p.000006: be charged with protecting their interests. Respect for persons also includes paying attention to values such as
p.000006: privacy and confidentiality, as well as social, religious and cultural beliefs and important relationships, including
p.000006: family bonds. Finally, respect for persons requires transparency and truth-telling in the context of carrying out
p.000006: public health and research activities.
p.000006:
p.000006: LibertyLiberty includes a broad range of social, religious and political freedoms, such as freedom of movement,
p.000006: freedom of peaceful assembly, and freedom of speech. Many aspects of liberty are protected as fundamental human rights.
p.000006:
p.000006: Reciprocity — Reciprocity consists of making a “fitting and proportional return” for contributions that people have
p.000006: made.6 Policies that encourage reciprocity can
p.000006: be an important means of promoting the principle of justice, as they can correct unfair disparities in the distribution
p.000006: of the benefits and burdens of epidemic response efforts.
p.000006:
p.000006: Solidarity — Solidarity is a social relation in which a group, community, nation
p.000006: or, potentially, global community stands together.7 The principle of solidarity justifies collective action in the
p.000006: face of common threats. It also supports efforts to overcome inequalities that undermine the welfare
p.000006: of minorities and groups that suffer from discrimination.
p.000006:
p.000006:
p.000006: Practical applications
p.000006:
p.000006: The application of ethical principles should be informed by evidence as far as it is
p.000006: available. For example, in determining 9
p.000006: whether a particular action contributes to utility, decision-makers should be guided by any available scientific
p.000006: evidence about the action’s expected benefits and harms.
p.000006: The more intrusive the proposed action, the greater the need for robust evidence that what is being proposed is likely
p.000006: to achieve its desired aim. When specific evidence is not available, decisions should be based
...

Social / Soldier

Searching for indicator military:

(return to top)
p.000025: including direct limitations of fundamental human rights, particularly the rights to freedom of movement and peaceful
p.000025: assembly.
p.000025:
p.000025: In light of these considerations, no restrictions on freedom of movement should be implemented without careful
p.000025: attention to the following considerations:
p.000025:
p.000025: • Justifiable basis for imposing restrictions — Decisions to impose restrictions on freedom of movement should be
p.000025: grounded on the best available evidence
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025: about the outbreak pathogen, as determined in consultation with national and international public health officials. No
p.000025: such interventions should be implemented unless there is a reasonable basis to expect they will significantly reduce
p.000025: disease transmission. The rationale for relying
p.000025: 26 on these measures should be made
p.000025: explicit, and the appropriateness of any restrictions should be continuously re-evaluated in light of emerging
p.000025: scientific information about the outbreak. If the original rationale for
p.000025: imposing a restriction no longer applies, the restriction should be lifted without delay.
p.000025:
p.000025: • Least restrictive means — Any restrictions on freedom of movement should be designed and implemented in a manner
p.000025: that imposes the fewest constraints reasonably possible. Greater restrictions should be imposed only when there are
p.000025: strong grounds to believe that less restrictive measures are unlikely to achieve important
p.000025: public health goals. For example, requests for voluntary cooperation are generally preferable to public health mandates
p.000025: enforced by law or military authorities. Similarly, home-based quarantine should be considered before confining
p.000025: individuals in
p.000025: institutions. While isolation in a properly equipped health-care facility is usually recommended for individuals who
p.000025: are already symptomatic, especially for diseases with a high potential for contagiousness, home-based isolation may
p.000025: sometimes be appropriate, provided that adequate medical and
p.000025: logistical support can be organized and family attendants are willing and able to act under the oversight of trained
p.000025: public health staff. This is particularly true if the caseload overwhelms facility capacity.
p.000025:
p.000025: • Costs — In some cases, a less restrictive alternative may involve greater costs. This does not, in itself,
p.000025: justify more restrictive approaches. However, costs and other practical constraints (e.g. logistics, distance,
p.000025: available workforce) may legitimately be taken into account to determine whether a less restrictive alternative is
p.000025: feasible under the circumstances, particularly in settings with severe resource constraints.
p.000025:
p.000025: • Ensuring humane conditions — Any restrictions on freedom of movement, particularly those that are not voluntary,
p.000025: should be backed up with sufficient resources to ensure that those subject to the restrictions do not experience undue
p.000025: burdens. For example, individuals whose mobility is restricted (whether through confinement at home or
...

p.000059: Switzerland
p.000059: Dr Philippe Calain, Senior Researcher, Unit of Research on Humanitarian Stakes and Practices, Médecins Sans Frontières,
p.000059: Switzerland
p.000059: Dr Edward Cox, Director, Office of Antimicrobial Products, Food and Drug Administration, United States of America
p.000059: Professor Heather Draper, Professor of Biomedical Ethics, University of Birmingham, United Kingdom
p.000059: Dr Sarah Edwards, Senior Lecturer in Research Ethics and Governance, University College London, United Kingdom
p.000059: Professor Jónína Einarsdóttir, Medical Anthropology, School of Social Sciences, University of Iceland, Iceland
p.000059: Professor Jeremy Farrar, Director, Wellcome Trust, United Kingdom
p.000059: Dr Margaret Fitzgerald, Public Health Specialist, Irish Health Service Executive, Ireland Dr Gabriel Fitzpatrick,
p.000059: Médecins Sans Frontières, Ireland
p.000059: Ms Lorraine Gallagher, Development Specialist, Irish Aid, Department of Foreign Affairs, Ireland Professor Jennifer
p.000059: Gibson, Sun Life Financial Chair in Bioethics; Director, Joint Centre for Bioethics; Associate Professor, Institute of
p.000059: Health Policy, Management and Evaluation, University of Toronto, Canada
p.000059:
p.000059:
p.000059:
p.000059:
p.000059:
p.000059:
p.000059:
p.000059:
p.000059: Professor Frederick G Hayden, Professor of Medicine and Pathology, University of Virginia School of Medicine, Unites
p.000059: States of America
p.000059: Dr Rita Helfand, Centers for Disease Control and Prevention, United States of America Dr Simon Jenkins, Research
p.000059: Fellow, University of Birmingham Project on the ethical challenges experienced by British military healthcare
p.000059: professionals in the Ebola region, United Kingdom
p.000059: Dr Pretesh Kiran, Assistant Professor, Community Health; Convener, Disaster Management Unit, St Johns National Academy
p.000059: of Health Sciences, India
p.000059: 60 Dr Markus Kirchner, Department for Infectious Disease Epidemiology, Robert Koch Institute,
p.000059: Germany
p.000059: Dr Katherine Littler, Senior Policy Adviser, Wellcome Trust, United Kingdom
p.000059: Professor Samuel McConkey, Head, International Health and Tropical Medicine, Royal College of Surgeons, Ireland
p.000059: Dr Farhat Moazam, Founding Chairperson, Center of Biomedical Ethics and Culture, Sindh Institute of Urology and
p.000059: Transplantation, Pakistan
p.000059: Dr Robert Nelson, Deputy Director and Senior Pediatric Ethicist, Office of Pediatric Therapeutics, Food and Drug
p.000059: Administration, United States of America
p.000059: Professor Alistair Nichol, Consultant Anaesthetist, School of Medicine and Medical Sciences, and EU projects,
p.000059: University College Dublin, Ireland
p.000059: Professor Lisa Schwartz, Arnold Johnson Chair in Health Care Ethics, Ethics in Health Care, McMaster University, Canada
p.000059: Professor Michael Selgelid, Director, Centre for Human Bioethics, Monash University, Australia Dr Kadri Simm, Associate
p.000059: Professor of Practical Philosophy, University of Tartu, Estonia
p.000059: Dr Aissatou Touré, Head, Immunology Department, Institut Pasteur de Dakar and Member, National Ethics Committee,
p.000059: Senegal
...

Social / Threat of Stigma

Searching for indicator stigma:

(return to top)
p.000017: to necessary resources such as clean water or bednets to reduce the risk of contracting a mosquito-borne disease.
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017: • Need for effective alternative communication strategies — Some types of vulnerability can impede
p.000017: an individual’s ability to transmit or receive information. Communication barriers can stem from a wide range of
p.000017: factors including, but not limited to, illiteracy, unfamiliarity with the
p.000017: 18 local or official language(s), vision or
p.000017: hearing impairments, social isolation, or lack of access to Internet and other communication services. These barriers
p.000017: make it difficult for individuals to receive necessary public health messages
p.000017: or to participate fully in community engagement activities. To overcome these barriers, messages should be delivered in
p.000017: multiple formats (e.g. radio, text messages, billboards, cartoons) as well as direct oral communication with key
p.000017: stakeholders. Health authorities should not assume that the public will search for information; instead, they should
p.000017: proactively reach out to the concerned population wherever they are.
p.000017:
p.000017: • Impact of stigmatization and discrimination — Members of socially disadvantaged groups often face considerable
p.000017: stigma and discrimination, which can be exacerbated in public health emergencies characterized by fear and distrust.
p.000017: Those responsible for infectious disease outbreak response should ensure that all individuals are treated fairly and
p.000017: equitably regardless of their social status or perceived “worth” to society. They should also take measures to prevent
p.000017: stigmatization and social violence.
p.000017:
p.000017: • Disproportionate burdens of outbreak response measures — Even when public health measures
p.000017: are designed with the best of intentions, they can inadvertently place a disproportionate burden on particular
p.000017: populations. For example, quarantine orders that require individuals to stay
p.000017: in their homes can have devastating consequences for persons who need to leave their homes to obtain basic
p.000017: necessities such as clean water or food. Similarly, social distancing measures such as school closures can place
p.000017: disproportionate burdens on children who depend on going to school to access regular meals, as well as on working
p.000017: parents who may have no one available to provide child care.
p.000017:
p.000017: • Greater need for resources — Accommodating the needs of individuals whose situation makes them particularly
p.000017: vulnerable sometimes requires the use of additional resources.
...

p.000043: in place to detect any infection as quickly as possible, in order to initiate immediate care and minimize the risk of
p.000043: transmission to colleagues, patients, families, and community members.
p.000043:
p.000043: • Priority access to health care — Frontline workers who become sick, as well as any immediate family members who
p.000043: become ill through contact with the worker, should be ensured access to the highest level of care reasonably available.
p.000043: In addition, countries should consider giving frontline workers and their families priority access to vaccines
p.000043: and other treatments as they become available.
p.000043:
p.000043: • Appropriate remuneration — Frontline workers should be given fair remuneration for their work. Governments should
p.000043: ensure that public sector workers are paid in
p.000043: a timely manner, and make efforts to ensure that actors in the private and nongovernmental sectors fulfil their own
p.000043: obligations to pay their employees and contractors. Fair remuneration for frontline workers includes the provision of
p.000043: financial support during periods in which workers are unable to carry out their normal responsibilities because of an
p.000043: infection acquired on the job.
p.000043:
p.000043: • Support for reintegrating into the community — Frontline workers may experience stigma and discrimination,
p.000043: particularly those involved in unpopular measures such as infection control or burials not conducted according to
p.000043: the traditional customs. Governments should make efforts to reduce the risk of stigmatization and discrimination and
p.000043: help such workers to reintegrate into the community, including by providing job placement assistance and relocation to
p.000043: other communities if needed.
p.000043:
p.000043: • Assistance to family members — Assistance should be provided to families of frontline workers who need to remain
p.000043: away from home in order
p.000043: to carry out their responsibilities or to recuperate from illness. Death benefits should be provided to family members
p.000043: of frontline workers who die in the line of duty, including those who were volunteers or “casual workers.”
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: As noted above, some workers may have a duty to work during an infectious
p.000043: disease outbreak. However, even for these individuals, the duty to assume risk is not unlimited. In determining the
p.000043: scope of workers’ duties to assume personal risks, the following factors should be taken into account:
p.000043:
...

Searching for indicator threat:

(return to top)
p.000006: international human rights agreements. The Siracusa Principles on the Limitation and Derogation Provisions in the
p.000006: International Covenant on Civil and Political Rights
p.000006: (the “Siracusa Principles”)8 are a widely accepted framework for evaluating
p.000006: the appropriateness of limiting certain fundamental human rights in emergency situations. The Siracusa Principles
p.000006: provide that any restrictions on human rights must be carried out in accordance with the law and in pursuit of a
p.000006: legitimate objective of general interest. In addition, such restrictions must be strictly necessary and there must
p.000006: be no other, less intrusive means available to reach the same objective. Finally, any restrictions must be based on
p.000006: scientific evidence and not imposed in an arbitrary, unreasonable, or discriminatory manner.
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006: For both pragmatic and ethical reasons, maintaining the population’s trust in epidemic response efforts is of
p.000006: fundamental importance. This is possible only if
p.000006: policy-makers and response workers act in a trustworthy manner by applying
p.000006: procedural principles fairly and consistently, being open to review based on new
p.000006: 10 relevant information, and acting with the
p.000006: genuine input of affected communities.
p.000006: In addition, a synchronized approach is indispensable to the success of any
p.000006: response effort. All members of the global community need to act in solidarity, since all countries share a common
p.000006: vulnerability to the threat of infectious disease.
p.000006:
p.000006:
p.000006: How the Guidance was developed
p.000006: Many individuals have helped shape this guidance document, directly or indirectly, starting with the Ethics Panel that
p.000006: was convened by the Director-General on
p.000006: 11 August 2014, and the ad-hoc ethics working groups that met in Geneva, Switzerland between August and October 2014 to
p.000006: provide guidance on the use of untested interventions during the Ebola outbreak in West Africa. Subsequently,
p.000006: in May 2015, a group of experts and stakeholders met in Dublin, Ireland to review existing ethical statements on
p.000006: infectious disease outbreaks and
p.000006: develop a methodology to create a more comprehensive document. To assist this process, an analysis and synthesis of all
p.000006: existing guidance documents relevant
p.000006: to ethical considerations in infectious disease outbreaks was prepared (Annex 1). Reflecting on lessons learnt from
p.000006: previous outbreaks, particularly the recent experiences with Ebola, participants emphasized the need for
p.000006: guidance that could be tailored to different epidemiological, social, and economic contexts. They also discussed the
p.000006: importance of focusing on broader questions of global health governance, community engagement, knowledge generation,
p.000006: and priority setting. Finally,
p.000006: participants emphasized the urgent need to develop concrete operational tools to help individuals involved in epidemic
p.000006: response efforts to incorporate ethical guidance into practical decision-making. The group met again in November 2015
p.000006: in Prato, Italy
p.000006: to review an initial draft of the guidance and to hear from additional experts and stakeholders, including survivors of
...

Searching for indicator stigmatization:

(return to top)
p.000015: nongovernmental organizations, and
p.000015: academic institutions should make efforts to support media training in relevant scientific concepts and techniques for
p.000015: communicating risk information without raising unnecessary alarm. Media training is important for public health sector
p.000015: employees who may interact with media covering public health issues.
p.000015: In turn, the media has a responsibility to provide accurate, factual, and balanced reporting. This is an important
p.000015: component of media ethics.
p.000015:
p.000015:
p.000015: Cholera outbreak in Sierra Leone
p.000015: Source: Fid Thompson
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015: 3. Situations of particular vulnerability
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000017: 17
p.000017: Questions addressed:
p.000017:
p.000017: • Why are some individuals and groups considered particularly vulnerable during infectious disease outbreaks?
p.000017: • How can vulnerability affect a person’s ability to access services during infectious disease outbreaks?
p.000017: • How can vulnerability affect a person’s willingness and ability to share and receive information during an
p.000017: infectious disease outbreak?
p.000017: • Why are stigmatization and discrimination particular risks during infectious disease outbreaks?
p.000017: • In what ways might vulnerable persons suffer disproportionate burdens from infectious disease response efforts,
p.000017: or have a greater need for resources?
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017: Some individuals and groups face heightened susceptibility to harm or injustice during infectious disease outbreaks.
p.000017: Policy-makers and epidemic responders should develop plans to address the needs of such individuals and groups in
p.000017: advance of an outbreak and,
p.000017: if an outbreak occurs, make reasonable efforts to ensure that these needs are actually met. Doing this requires ongoing
p.000017: attention to community engagement and the development of active social networks between community representatives and
p.000017: government actors.
p.000017:
p.000017: Efforts to address the ways in which individuals and groups may be vulnerable should take into account the following:
p.000017: • Difficulty accessing services and resources — Many of the
p.000017: characteristics that contribute to social vulnerability can make it difficult
p.000017: for individuals to access necessary services. For example, persons with physical disabilities may have mobility
p.000017: impairments that make travelling even short distances difficult or impossible.
p.000017: Other socially vulnerable persons may lack access to safe and reliable transportation or have caregiving
p.000017: responsibilities that make it difficult for them to leave their homes. In addition, vulnerable persons may lack access
p.000017: to necessary resources such as clean water or bednets to reduce the risk of contracting a mosquito-borne disease.
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017: • Need for effective alternative communication strategies — Some types of vulnerability can impede
p.000017: an individual’s ability to transmit or receive information. Communication barriers can stem from a wide range of
p.000017: factors including, but not limited to, illiteracy, unfamiliarity with the
p.000017: 18 local or official language(s), vision or
p.000017: hearing impairments, social isolation, or lack of access to Internet and other communication services. These barriers
p.000017: make it difficult for individuals to receive necessary public health messages
p.000017: or to participate fully in community engagement activities. To overcome these barriers, messages should be delivered in
p.000017: multiple formats (e.g. radio, text messages, billboards, cartoons) as well as direct oral communication with key
p.000017: stakeholders. Health authorities should not assume that the public will search for information; instead, they should
p.000017: proactively reach out to the concerned population wherever they are.
p.000017:
p.000017: • Impact of stigmatization and discrimination — Members of socially disadvantaged groups often face considerable
p.000017: stigma and discrimination, which can be exacerbated in public health emergencies characterized by fear and distrust.
p.000017: Those responsible for infectious disease outbreak response should ensure that all individuals are treated fairly and
p.000017: equitably regardless of their social status or perceived “worth” to society. They should also take measures to prevent
p.000017: stigmatization and social violence.
p.000017:
p.000017: • Disproportionate burdens of outbreak response measures — Even when public health measures
p.000017: are designed with the best of intentions, they can inadvertently place a disproportionate burden on particular
p.000017: populations. For example, quarantine orders that require individuals to stay
p.000017: in their homes can have devastating consequences for persons who need to leave their homes to obtain basic
p.000017: necessities such as clean water or food. Similarly, social distancing measures such as school closures can place
p.000017: disproportionate burdens on children who depend on going to school to access regular meals, as well as on working
p.000017: parents who may have no one available to provide child care.
p.000017:
p.000017: • Greater need for resources — Accommodating the needs of individuals whose situation makes them particularly
p.000017: vulnerable sometimes requires the use of additional resources.
p.000017: In some cases, additional resources are relatively minimal, such as when an interpreter is hired to make
p.000017: a community engagement forum accessible to members of a linguistic minority group. In other cases, they may be more
p.000017: substantial, such as when mobile health teams are assembled to dispatch vaccines and treatments to hard-to-reach rural
p.000017: areas. It is legitimate to take costs into consideration in determining whether a particular accommodation is
...

p.000020: few resources. However, such
p.000020: an approach may be in tension with the principle of equity if it means that fewer resources will be directed to
p.000020: isolated communities in remote rural areas.
p.000020: There is no single correct way to resolve potential tensions between utility
p.000020: and equity; what is important is that decisions are made through an inclusive and transparent process that takes into
p.000020: account local circumstances.
p.000020: • Defining utility on the basis of health-related considerations —
p.000020: In order to apply the ethical principle of utility, it is first necessary to identify the type of outcomes that will be
p.000020: counted as improvements to welfare. In general, the focus should be on the health-related benefits of allocation
p.000020: mechanisms, whether defined in terms 21
p.000020: of the total number of lives saved, the total number of life years saved, or the total number of quality-adjusted life
p.000020: years saved. For this reason,
p.000020: while it might be ethical to prioritize persons who are essential to manage an outbreak, it is not appropriate to
p.000020: prioritize persons based on social value considerations unrelated to carrying out critical services necessary for
p.000020: society.
p.000020:
p.000020: • Paying attention to the needs of vulnerable populations — In applying the ethical principle of equity, special
p.000020: attention should be given to individuals and groups that are the most vulnerable to discrimination, stigmatization, or
p.000020: isolation, as discussed in Guideline 3.
p.000020: Particular consideration must be given to individuals who are confined in institutional settings, where they are highly
p.000020: dependent on others and
p.000020: potentially exposed to much higher risks of infection than persons living in the community.
p.000020:
p.000020: • Fulfilling reciprocity-based obligations to those who contribute to infectious disease outbreak response efforts
p.000020: — The ethical principle of reciprocity implies that society should support persons who face a disproportionate burden
p.000020: or risk in protecting the public good. This principle justifies giving priority access to scarce resources to persons
p.000020: who
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020: assume risks to their own health or life to contribute to outbreak response efforts.
p.000020:
p.000020: • Providing supportive and palliative care to persons unable to access life- saving resources — Even when it is not
p.000020: possible to provide life-saving medical
p.000020: 22 resources to all who could benefit from
p.000020: them, efforts should be made to ensure that no patients are abandoned. One way to do this is to ensure that adequate
p.000020: resources are directed to providing supportive and palliative care.
p.000020:
p.000020: The application of allocation principles should take into account the following considerations:
p.000020:
p.000020: • Consistent application — Allocation principles should be applied in
...

p.000023: mandatory basis, without
p.000023: the possibility of individual refusal. Collecting surveillance information on a mandatory basis is ethically
p.000023: appropriate on the grounds of public
p.000023: interest if an accountable governmental authority has determined that universal participation is necessary to achieve
p.000023: compelling public health objectives.
p.000023: However, it should not be assumed that surveillance activities must always be carried out on a mandatory basis.
p.000023: Entities responsible for designing and approving surveillance programmes should consider the appropriateness of
p.000023: allowing individuals to opt out of particular surveillance activities, taking into account the nature and degree of
p.000023: individual risks involved and the extent to which allowing opt-outs
p.000023: would undermine the activity’s public health goals.
p.000023:
p.000023: • Disclosing information to individuals and communities — Regardless of whether individuals are given the choice to
p.000023: opt out of surveillance activities, the process of surveillance should be conducted on a transparent basis. At a
p.000023: minimum, individuals and communities should be aware of the type of information
p.000023: that will be gathered about them, the purposes for which this information will be used, and any circumstances under
p.000023: which the information collected may be shared with third parties. In addition, information about the outcome of the
p.000023: surveillance activity should be made available as soon as reasonably possible.
p.000023: Careful attention should be given to the manner in which this information is communicated, in order to minimize
p.000023: the risk that subjects of surveillance may face stigmatization or discrimination.
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023: 6. Restrictions on freedom of movement
p.000023:
p.000023:
p.000023:
p.000025: 25
p.000025: Questions addressed:
p.000025:
p.000025: • Under what circumstances is it legitimate to restrict an individual’s freedom of movement during an infectious
p.000025: disease outbreak?
p.000025: • What living conditions should be assured for individuals whose freedom of movement has been restricted?
p.000025: • What other obligations are owed to individuals whose freedom of movement has been restricted?
p.000025: • What procedural protections must be established to ensure that restrictions on freedom of movement are carried
p.000025: out appropriately?
p.000025: • What are the obligations of policy-makers and public health officials to inform the public about restrictions on
p.000025: freedom of movement?
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025: Restrictions on freedom of movement include isolation, quarantine, travel advisories or restrictions, and community-
p.000025: based measures to reduce contact between people (e.g. closing schools or prohibiting large gatherings). These measures
p.000025: can often play an important role in controlling infectious disease outbreaks, and in these circumstances, their use is
p.000025: justified by the ethical value of protecting community well- being. However, the effectiveness of these measures should
p.000025: not be assumed; in fact, under some epidemiological circumstances, they may contribute little or nothing to outbreak
p.000025: control efforts, and may even
p.000025: be counterproductive if they engender a backlash that leads to resistance to
...

p.000025: should be put in place to minimize the risk of violence (including sexual assault) and local disease
p.000025: transmission, especially when individuals are confined in institutional settings
p.000025: or when communities are under mass quarantine. At a minimum, persons who
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025: are quarantined because they have been exposed to the pathogen responsible for the outbreak should not be put at
p.000025: heightened risk of infection because of the manner in which they are confined. (Decisions on the circumstances and
p.000025: conditions of confinement should consider the heightened needs of vulnerable populations, as discussed
p.000025: in Guideline 3.)
p.000025:
p.000025: • Addressing financial and social consequences — Even short-term restrictions on freedom of movement can have
p.000025: significant — and possibly devastating —financial and social consequences for individuals, their families, and their
p.000025: communities. Countries should provide assistance to households that suffer financial
p.000025: losses as a result of inability to conduct business, loss of a job, damage to crops, or other consequences of
p.000025: restrictions on freedom of movement. In some cases, this support may need to continue
p.000025: for a period following the end of confinement. In addition, efforts should be made to support the social and
p.000025: professional reintegration of individuals for whom confinement is no longer necessary, including measures to reduce
p.000025: stigmatization and discrimination.
p.000025:
p.000025: • Due process protections — Mechanisms should be in place to allow individuals whose liberty has been restricted to
p.000025: challenge the appropriateness of those restrictions, the way they are enforced, and the conditions under which the
p.000025: restrictions are carried out. If it is not feasible to provide full due process protection before the restrictions are
p.000025: implemented in an emergency scenario, mechanisms for review and appeal should be made
p.000025: available without excessive delay. All persons involved in decisions to restrict individuals’ freedom of movement
p.000025: should be accountable for any abuses of authority.
p.000025:
p.000025: • Equitable application — Restrictions on freedom of movement should be
p.000025: applied in the same manner to all 27
p.000025: persons posing a comparable public health risk. Thus, individuals should not be subject to greater or lesser
p.000025: restrictions for reasons unrelated to the
p.000025: risks they may pose to others, including membership in any disfavoured or favoured social group or class (for example,
p.000025: groups defined by gender, ethnicity, or religion). In addition, policy- makers should seek to ensure that restrictions
p.000025: are not applied in a manner that imposes a disproportionate burden on vulnerable segments of society.
p.000025:
p.000025: • Communication and transparency —
p.000025: Policy-makers and public health officials should engage communities in a dialogue about any restrictions on freedom of
p.000025: movement and solicit community members’ views on how restrictions can be carried out with the least possible burden.
p.000025: They should also provide regular updates on the implementation of such measures,
p.000025: both to the public at large and to those whose movement has been restricted. Communication strategies should be
p.000025: designed to avoid the stigmatization
p.000025: of individuals whose liberty has been restricted and to protect their privacy and confidentiality, particularly in the
p.000025: media.
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025: 7. Obligations related to medical interventions for the diagnosis, treatment, and prevention of infectious disease
p.000028: 28
p.000028:
p.000028:
p.000028: Questions addressed:
p.000028:
p.000028: • What quality and safety standards should govern the administration of medical interventions offered during
p.000028: infectious disease outbreaks?
p.000028: • What rights do patients (or their authorized proxy decision-makers) have to receive information about the risks
p.000028: and benefits of, and alternatives to, medical interventions during infectious disease outbreaks?
p.000028: • Under what circumstances, if any, might it be appropriate to override an individual’s refusal of diagnostic,
p.000028: therapeutic, or preventive measures during an infectious disease outbreak?
p.000028: • What procedural safeguards should be provided before overriding an individual’s refusal of diagnostic,
p.000028: therapeutic, or preventive measures during an infectious disease outbreak?
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028: Any medical intervention for the diagnosis, treatment, or prevention of infectious disease should be provided in accord
p.000028: with professional medical standards, under conditions designed to ensure the highest attainable level of patient
p.000028: safety. Countries, with the support of international experts, should establish the minimum standards
...

p.000043: become ill through contact with the worker, should be ensured access to the highest level of care reasonably available.
p.000043: In addition, countries should consider giving frontline workers and their families priority access to vaccines
p.000043: and other treatments as they become available.
p.000043:
p.000043: • Appropriate remuneration — Frontline workers should be given fair remuneration for their work. Governments should
p.000043: ensure that public sector workers are paid in
p.000043: a timely manner, and make efforts to ensure that actors in the private and nongovernmental sectors fulfil their own
p.000043: obligations to pay their employees and contractors. Fair remuneration for frontline workers includes the provision of
p.000043: financial support during periods in which workers are unable to carry out their normal responsibilities because of an
p.000043: infection acquired on the job.
p.000043:
p.000043: • Support for reintegrating into the community — Frontline workers may experience stigma and discrimination,
p.000043: particularly those involved in unpopular measures such as infection control or burials not conducted according to
p.000043: the traditional customs. Governments should make efforts to reduce the risk of stigmatization and discrimination and
p.000043: help such workers to reintegrate into the community, including by providing job placement assistance and relocation to
p.000043: other communities if needed.
p.000043:
p.000043: • Assistance to family members — Assistance should be provided to families of frontline workers who need to remain
p.000043: away from home in order
p.000043: to carry out their responsibilities or to recuperate from illness. Death benefits should be provided to family members
p.000043: of frontline workers who die in the line of duty, including those who were volunteers or “casual workers.”
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: As noted above, some workers may have a duty to work during an infectious
p.000043: disease outbreak. However, even for these individuals, the duty to assume risk is not unlimited. In determining the
p.000043: scope of workers’ duties to assume personal risks, the following factors should be taken into account:
p.000043:
p.000043: • Reciprocal obligations — Any professional or employment-based obligation to assume personal risk is contingent on
p.000043: society’s fulfilment of its reciprocal obligations to workers, as outlined above. If the reciprocal obligations are not
p.000043: met, frontline
...

p.000043: against job-related responsibilities. 45
p.000043:
p.000043: Additional obligations of those working in the health‑care sector:
p.000043:
p.000043: In addition to the issues addressed above, persons working in the health-care sector have obligations to the community
p.000043: during an infectious disease outbreak, including the following:
p.000043:
p.000043: • Participate in public health surveillance and reporting efforts — Persons working in the health sector have an
p.000043: obligation to participate in organized measures to respond to infectious disease outbreaks, including public health
p.000043: surveillance and reporting. Health-care providers should protect the confidentiality of patient information to the
p.000043: maximum extent compatible with legitimate public health interests.
p.000043:
p.000043: • Provide accurate information to the public — During an infectious disease outbreak, public health officials have
p.000043: the primary responsibility to communicate information about the outbreak pathogen, including how
p.000043: it is transmitted, how infection can be prevented, and what treatments or preventive measures may be effective. Those
p.000043: responsible for designing communication strategies should anticipate and respond to misinformation, exaggeration, and
p.000043: mistrust, and should seek (without
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: withholding key information) to minimize the risk that information about risk factors will lead to stigmatization and
p.000043: discrimination. If persons working in the health sector are asked medical questions about the outbreak by patients or
p.000043: the general public, they should not spread
p.000043: 46 unsubstantiated rumours or suspicion
p.000043: and ensure that information they provide comes from reliable sources.
p.000043:
p.000043: • Avoiding exploitation — In the context of a rapidly spreading life- threatening illness with no proven
p.000043: treatment, desperate individuals may be willing to try any intervention offered, regardless of the expected risks or
p.000043: benefits. Health-care workers have a duty not to exploit individuals’ vulnerability by offering treatments or
p.000043: preventive measures for which
p.000043: there is no reasonable basis to believe that the potential benefits outweigh the uncertainties and risks. This duty
p.000043: does not preclude the appropriate use of unproven interventions on an
p.000043: experimental basis, consistent with the guidelines set forth in Guideline 9.
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: Earthquake Haiti 2010
p.000043: Source: Victor Ariscain, PAHO/WHO
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: 14. Ethical issues in deploying foreign humanitarian aid workers
p.000043:
p.000043:
p.000043:
p.000047: 47
p.000047: Questions addressed:
p.000047:
...

Social / Threat of Violence

Searching for indicator violence:

(return to top)
p.000017: factors including, but not limited to, illiteracy, unfamiliarity with the
p.000017: 18 local or official language(s), vision or
p.000017: hearing impairments, social isolation, or lack of access to Internet and other communication services. These barriers
p.000017: make it difficult for individuals to receive necessary public health messages
p.000017: or to participate fully in community engagement activities. To overcome these barriers, messages should be delivered in
p.000017: multiple formats (e.g. radio, text messages, billboards, cartoons) as well as direct oral communication with key
p.000017: stakeholders. Health authorities should not assume that the public will search for information; instead, they should
p.000017: proactively reach out to the concerned population wherever they are.
p.000017:
p.000017: • Impact of stigmatization and discrimination — Members of socially disadvantaged groups often face considerable
p.000017: stigma and discrimination, which can be exacerbated in public health emergencies characterized by fear and distrust.
p.000017: Those responsible for infectious disease outbreak response should ensure that all individuals are treated fairly and
p.000017: equitably regardless of their social status or perceived “worth” to society. They should also take measures to prevent
p.000017: stigmatization and social violence.
p.000017:
p.000017: • Disproportionate burdens of outbreak response measures — Even when public health measures
p.000017: are designed with the best of intentions, they can inadvertently place a disproportionate burden on particular
p.000017: populations. For example, quarantine orders that require individuals to stay
p.000017: in their homes can have devastating consequences for persons who need to leave their homes to obtain basic
p.000017: necessities such as clean water or food. Similarly, social distancing measures such as school closures can place
p.000017: disproportionate burdens on children who depend on going to school to access regular meals, as well as on working
p.000017: parents who may have no one available to provide child care.
p.000017:
p.000017: • Greater need for resources — Accommodating the needs of individuals whose situation makes them particularly
p.000017: vulnerable sometimes requires the use of additional resources.
p.000017: In some cases, additional resources are relatively minimal, such as when an interpreter is hired to make
p.000017: a community engagement forum accessible to members of a linguistic minority group. In other cases, they may be more
p.000017: substantial, such as when mobile health teams are assembled to dispatch vaccines and treatments to hard-to-reach rural
p.000017: areas. It is legitimate to take costs into consideration in determining whether a particular accommodation is
p.000017: warranted; indeed, the goal of maximizing utility demands that such assessments be made.
p.000017: However, despite the importance of conserving limited resources, the ethical principle of equity may sometimes justify
p.000017: providing greater resources to persons who have greater needs.
p.000017:
p.000017: • Heightened risk of violence — Infectious disease outbreaks can
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017: exacerbate social unrest, increase criminality, and induce violent behaviour, especially against vulnerable groups such
p.000017: as minority populations
p.000017: or migrants. In addition, public health measures such as home isolation, quarantine, or closure of schools and work
p.000017: facilities can induce violence, particularly against women and children. Officials involved in outbreak planning and
p.000017: response efforts should be prepared for the possibility that
p.000017: specific populations may be targeted as being the cause of the outbreak or provoking transmission; strategies should be
p.000017: proactively designed to
p.000017: protect members of such groups from a heightened risk of violence.
p.000017:
p.000017:
p.000019: 19
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
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p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019: A doctor inspects patients in an MSF supported hospital in Aweil,
p.000019: Northern Bar El Ghazal in South Sudan, 2011
p.000019: Source: Siegfried Modola/IRIN
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019: 4. Allocating scarce resources
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000020: 20
p.000020: Questions addressed:
p.000020:
p.000020: • What type of resource allocation decisions might need to be made during infectious disease outbreaks?
p.000020: • How do the principles of utility and equity apply to decisions about allocating scarce resources during
p.000020: infectious disease outbreaks?
p.000020: • How does the principle of reciprocity apply to decisions about allocating scarce resources during infectious
p.000020: disease outbreaks?
p.000020: • What procedural considerations apply to decisions about resource allocation during infectious disease outbreaks?
p.000020: • What obligations do health-care providers have towards persons who are not able to access life-saving resources
p.000020: during infectious disease outbreaks?
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020: Infectious disease outbreaks can quickly overwhelm the capacities of governments and health-care systems, requiring
p.000020: them to make difficult decisions about the allocation of limited resources. Some of these decisions may arise in the
...

p.000025: public health staff. This is particularly true if the caseload overwhelms facility capacity.
p.000025:
p.000025: • Costs — In some cases, a less restrictive alternative may involve greater costs. This does not, in itself,
p.000025: justify more restrictive approaches. However, costs and other practical constraints (e.g. logistics, distance,
p.000025: available workforce) may legitimately be taken into account to determine whether a less restrictive alternative is
p.000025: feasible under the circumstances, particularly in settings with severe resource constraints.
p.000025:
p.000025: • Ensuring humane conditions — Any restrictions on freedom of movement, particularly those that are not voluntary,
p.000025: should be backed up with sufficient resources to ensure that those subject to the restrictions do not experience undue
p.000025: burdens. For example, individuals whose mobility is restricted (whether through confinement at home or
p.000025: in institutional settings) should be ensured access to food, drinking water, sanitary facilities, shelter, clothing,
p.000025: and medical care. It is also important to ensure that individuals have adequate physical space, opportunities to engage
p.000025: in activities, and the means
p.000025: to communicate with their loved ones and the outside world. Fulfilling these needs is essential to respect individual
p.000025: dignity and address the significant psychosocial burden of confinement on individuals and their loved ones. Mechanisms
p.000025: should be put in place to minimize the risk of violence (including sexual assault) and local disease
p.000025: transmission, especially when individuals are confined in institutional settings
p.000025: or when communities are under mass quarantine. At a minimum, persons who
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025: are quarantined because they have been exposed to the pathogen responsible for the outbreak should not be put at
p.000025: heightened risk of infection because of the manner in which they are confined. (Decisions on the circumstances and
p.000025: conditions of confinement should consider the heightened needs of vulnerable populations, as discussed
p.000025: in Guideline 3.)
p.000025:
p.000025: • Addressing financial and social consequences — Even short-term restrictions on freedom of movement can have
p.000025: significant — and possibly devastating —financial and social consequences for individuals, their families, and their
p.000025: communities. Countries should provide assistance to households that suffer financial
p.000025: losses as a result of inability to conduct business, loss of a job, damage to crops, or other consequences of
p.000025: restrictions on freedom of movement. In some cases, this support may need to continue
p.000025: for a period following the end of confinement. In addition, efforts should be made to support the social and
p.000025: professional reintegration of individuals for whom confinement is no longer necessary, including measures to reduce
p.000025: stigmatization and discrimination.
p.000025:
...

p.000041: and have access to safe methods to minimize them, along with reproductive counselling services.
p.000041:
p.000041: • Sex- and gender-inclusive research
p.000041: 42 strategies — Researchers should make efforts to ensure that studies do not disproportionately
p.000041: favour a particular sex or gender, and that women who are or might become pregnant are not inappropriately excluded
p.000041: from research participation. During an outbreak, research on experimental treatments and preventive measures should
p.000041: seek to identify any sex- or gender-related differences in outcomes.
p.000041:
p.000041: • Attention to social and cultural practices — Gender-related roles and practices can affect all aspects of
p.000041: infectious disease outbreaks, including
p.000041: individuals’ risk of becoming infected, the consequences of infection, their use of health services and other
p.000041: health-seeking behaviours, and their vulnerability to interpersonal violence.
p.000041: Policy-makers and outbreak responders should identify and respond to these factors, drawing when possible
p.000041: on relevant anthropological and sociological research.
p.000041:
p.000041: • Sex- and gender-sensitive communication strategies —
p.000041: Entities responsible for developing and implementing communication strategies should be sensitive to sex- and gender-
p.000041: based differences in how individuals have access to and respond to health- related information. Separate messages and
p.000041: communication strategies may be needed to provide relevant information to particular subgroups, such as pregnant women
p.000041: or nursing mothers.
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: Influenza in India
p.000041: Source: Tom Pietrasik, WHO
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: 13. Frontline response workers’ rights and obligations
p.000041:
p.000041:
p.000041:
p.000043: 43
p.000043: Questions addressed:
p.000043:
p.000043: • What obligations exist to protect the health of frontline workers who participate in infectious disease outbreak
p.000043: response efforts?
...

p.000047: comprehensive information about the project’s expectations and risks so they can make informed decisions about whether
p.000047: or not they will be able to make appropriate contributions. In addition, foreign aid workers should be clearly
p.000047: informed of the conditions of their deployment, including the level of health care they can expect if they become ill,
p.000047: the circumstances under
p.000047: which they will be repatriated, available insurance, and whether benefits will
p.000047: be provided to their families in case of illness or death.
p.000047:
p.000047: • Provision of necessary training and resources — Aid workers must be provided with appropriate
p.000047: training, preparation, and equipment to ensure that they can effectively carry out their mission with the lowest risks
p.000047: practicable. Training should include preparation in psychosocial and communication skills, and in understanding and
p.000047: respecting the local culture and traditions. Managers and organizations have an obligation to provide adequate support
p.000047: and guidance to the staff, both during their activity in the field and following
p.000047: their mission. This should include training and resources for managing challenging ethical issues, such as resource
p.000047: allocation decisions, triage, and inequities.
p.000047:
p.000047: • Ensuring the security and safety of aid workers — Organizations that deploy foreign aid workers have an
p.000047: obligation to take all necessary measures to ensure the workers’ security, particularly in situations of crisis; this
p.000047: obligation includes the provision of measures to reduce risks of exposure to infectious agents, contamination and
p.000047: violence. A clear chain of authority must be in place to provide oversight and ongoing advice. Individuals who object
p.000047: to assigned duties should have an opportunity for review and appeal, according to the norms of the organizations for
p.000047: which they work.
p.000047:
p.000047: Aid workers also have their own ethical obligations to patients, affected communities, their sponsoring
p.000047: organizations, and themselves. In addition to the obligations described in other sections of this document, obligations
p.000047: of foreign aid workers include the following:
p.000047:
p.000047: • Adequate preparation — Aid workers should take part in any training that is offered. If they believe that the
p.000047: training they have been given is inadequate, they should bring their concerns to
p.000047: the attention of their organization managers. Foreign aid workers deployed during crises and where resources are scarce
p.000047: should carefully consider whether they are prepared to deal with ethical issues that may lead to moral and
p.000047: psychological distress.
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047: • Adherence to assigned roles and responsibilities — Aid workers should understand the roles and responsibilities
p.000047: they have been asked to assume and should not, except in the most extreme circumstances, undertake tasks they have not
p.000047: been authorized to perform. In addition, they should provide clear and timely information to both their sponsoring
p.000047: organizations and local officials and should understand that,
p.000047: if they go beyond the tasks they have been authorized to perform, they will be accountable not only within their
p.000047: own organizations but also under applicable local standards and laws.
p.000047:
...

Social / Trade Union Membership

Searching for indicator union:

(return to top)
p.000055: people affected by the outbreaks, their cultures and their societies.
p.000055:
p.000055: The guidance document specifically benefited from reviews of the following WHO staff: Juliet Bedford, Carla Saenz
p.000055: Bresciani, Ian Clarke, Rudi J J M Coninx, Pierre Formenty, Gaya Manori Gamhewage, Theo Grace, Paul Gully, Brooke Ronald
p.000055: Johnson JR, Annette Kuesel, Anaïs
p.000055: Legand, Ahmed Mohamed Amin Mandil, Bernadette Murgue, Tim Nguyen, Asiya Ismail Odugleh-Kolev, Martin Matthew Okechukwu
p.000055: Ota, Bruce Jay Plotkin, Annie Portela, Marie-Pierre Preziosi, Manju Rani, Nigel Campbell Rollins, Cathy Roth,
p.000055: Manisha Shridhar, Rajesh Sreedharan, David Wood, and Yousef Elbes.
p.000055:
p.000055: A special thanks to Vânia de la Fuente Núñez, who was responsible for managing the Ethics Working Group; and Michele
p.000055: Loi who coordinated the whole process.
p.000055: Former interns of the Global Health Ethics team Patrick Hummel (University of
p.000055: St Andrews, United Kingdom) and Corinna Klingler (University of Munich, Germany) deserve a special mention for
p.000055: undertaking a scoping review in relation to pregnancy
p.000055: and infectious diseases, which informed the development of guidance in this area.
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055: The guidance document would not have been possible without the generous support of the Wellcome Trust. The kind support
p.000055: of the following partners is also very gratefully acknowledged: 3U Global Health Partnership; Canadian Institutes of
p.000055: Health Research; Dublin City University; European Union Cooperation in Science and Technology; Monash University;
p.000055: University of Miami Miller School of Medicine Institute for Bioethics and Health Policy.
p.000055:
p.000006: 6
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006: Introduction
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006: This guidance grew out of concern at the World Health Organization (WHO) about ethical issues raised by the Ebola
p.000006: outbreak in West Africa in 2014–2016. The WHO Global Health Ethics Unit’s response to Ebola began in August 2014,
p.000006: immediately after it was declared a “public health emergency of international concern” pursuant to the International
p.000006: Health Regulations (2005) (IHR).1 That declaration led to the formation of an Ethics Panel, and later an Ethics
p.000006: Working Group, which was charged with developing ethics guidance on issues and concerns as they arose in
p.000006: the course of the epidemic. It became increasingly apparent that the ethical issues raised by Ebola mirrored concerns
p.000006: that had arisen in other global infectious disease outbreaks, including severe acute respiratory syndrome (SARS),
p.000006: pandemic influenza, and multidrug-resistant tuberculosis. However, while WHO has issued ethical guidance
p.000006: on some of these outbreaks,2,3,4,5 prior guidance has only focused on the specific pathogen in isolation. The purpose
p.000006: of this document is to look beyond issues specific to particular epidemic pathogens and instead focus on the
...

Social / Women

Searching for indicator women:

(return to top)
p.000017: In some cases, additional resources are relatively minimal, such as when an interpreter is hired to make
p.000017: a community engagement forum accessible to members of a linguistic minority group. In other cases, they may be more
p.000017: substantial, such as when mobile health teams are assembled to dispatch vaccines and treatments to hard-to-reach rural
p.000017: areas. It is legitimate to take costs into consideration in determining whether a particular accommodation is
p.000017: warranted; indeed, the goal of maximizing utility demands that such assessments be made.
p.000017: However, despite the importance of conserving limited resources, the ethical principle of equity may sometimes justify
p.000017: providing greater resources to persons who have greater needs.
p.000017:
p.000017: • Heightened risk of violence — Infectious disease outbreaks can
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017: exacerbate social unrest, increase criminality, and induce violent behaviour, especially against vulnerable groups such
p.000017: as minority populations
p.000017: or migrants. In addition, public health measures such as home isolation, quarantine, or closure of schools and work
p.000017: facilities can induce violence, particularly against women and children. Officials involved in outbreak planning and
p.000017: response efforts should be prepared for the possibility that
p.000017: specific populations may be targeted as being the cause of the outbreak or provoking transmission; strategies should be
p.000017: proactively designed to
p.000017: protect members of such groups from a heightened risk of violence.
p.000017:
p.000017:
p.000019: 19
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019: A doctor inspects patients in an MSF supported hospital in Aweil,
p.000019: Northern Bar El Ghazal in South Sudan, 2011
p.000019: Source: Siegfried Modola/IRIN
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000019: 4. Allocating scarce resources
p.000019:
p.000019:
p.000019:
p.000019:
p.000019:
p.000020: 20
p.000020: Questions addressed:
p.000020:
p.000020: • What type of resource allocation decisions might need to be made during infectious disease outbreaks?
p.000020: • How do the principles of utility and equity apply to decisions about allocating scarce resources during
p.000020: infectious disease outbreaks?
p.000020: • How does the principle of reciprocity apply to decisions about allocating scarce resources during infectious
p.000020: disease outbreaks?
...

p.000041: • How should appropriate reproductive health-care services be safely provided during an infectious disease
p.000041: outbreak?
p.000041: • How are sex and gender relevant to communication strategies during outbreaks?
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: Sex (biological and physiological characteristics) and gender (socially constructed roles, behaviours, activities, and
p.000041: attributes)20 can influence the spread, containment, course, and consequences of infectious disease outbreaks. Sex and
p.000041: gender differences have been associated with differences in susceptibility to infection, levels of health care
p.000041: received, and in the course and outcome of illness.21 Addressing sex and gender differences in infectious disease
p.000041: outbreak planning and response efforts requires attention to the following considerations:
p.000041:
p.000041: • Sex- and gender-inclusive surveillance programmes — Public health surveillance should systematically collect
p.000041: disaggregated information on sex, gender, and pregnancy status, both to identify differential risks and
p.000041: modes of transmission, and to monitor any differential impact of an infectious disease outbreak and the interventions
p.000041: used to control it. This information is particularly important for pregnant women and their offspring.
p.000041:
p.000041: • Ensuring the availability of high- quality reproductive health-care services — Whether or not they are currently
p.000041: pregnant, women of childbearing age should have access to the full range of high-quality
p.000041: reproductive health-care services during an infectious disease outbreak. These services should be organized and
p.000041: delivered in a manner that does not stigmatize persons who use them or expose them to a heightened risk of infection
p.000041: with the outbreak pathogen. If there is evidence that an infectious
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: disease creates special risks for pregnant women or their fetus, both men and women should be informed of these risks
p.000041: and have access to safe methods to minimize them, along with reproductive counselling services.
p.000041:
p.000041: • Sex- and gender-inclusive research
p.000041: 42 strategies — Researchers should make efforts to ensure that studies do not disproportionately
p.000041: favour a particular sex or gender, and that women who are or might become pregnant are not inappropriately excluded
p.000041: from research participation. During an outbreak, research on experimental treatments and preventive measures should
p.000041: seek to identify any sex- or gender-related differences in outcomes.
p.000041:
p.000041: • Attention to social and cultural practices — Gender-related roles and practices can affect all aspects of
p.000041: infectious disease outbreaks, including
p.000041: individuals’ risk of becoming infected, the consequences of infection, their use of health services and other
p.000041: health-seeking behaviours, and their vulnerability to interpersonal violence.
p.000041: Policy-makers and outbreak responders should identify and respond to these factors, drawing when possible
p.000041: on relevant anthropological and sociological research.
p.000041:
p.000041: • Sex- and gender-sensitive communication strategies —
p.000041: Entities responsible for developing and implementing communication strategies should be sensitive to sex- and gender-
p.000041: based differences in how individuals have access to and respond to health- related information. Separate messages and
p.000041: communication strategies may be needed to provide relevant information to particular subgroups, such as pregnant women
p.000041: or nursing mothers.
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: Influenza in India
p.000041: Source: Tom Pietrasik, WHO
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: 13. Frontline response workers’ rights and obligations
p.000041:
p.000041:
p.000041:
p.000043: 43
p.000043: Questions addressed:
p.000043:
p.000043: • What obligations exist to protect the health of frontline workers who participate in infectious disease outbreak
p.000043: response efforts?
p.000043: • What obligations exist to provide material support to frontline workers who participate in infectious disease
p.000043: outbreak response efforts?
p.000043: • To what extent do these obligations extend to the workers’ family?
p.000043: • What should be taken into account in determining whether individuals have an obligation to serve as frontline
p.000043: workers during infectious disease outbreaks?
p.000043: • What special obligations do workers in the health-care sector have during infectious disease outbreaks?
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: An effective infectious disease outbreak response depends on the contribution of
p.000043: a diverse range of frontline workers, some of whom may be working on a volunteer basis. These workers often assume
p.000043: considerable personal risk to carry out their jobs. Within the health-care sector, frontline workers range from
...

p.000050: July 2016).
p.000050:
p.000050: 15 Research ethics in international epidemic response. Geneva: World Health Organization; 2009 (WHO/HSE/GIP/ITP/10.1;
p.000050: www.who.int/ethics/gip_research_ethics_.pdf, accessed 23 July 2016).
p.000050:
p.000050: 16 Developing global norms for sharing data and results during public health emergencies. Geneva: World Health
p.000050: Organization; 2015 (www.who.int/medicines/ebola-treatment/ blueprint_phe_data-share-results/en/, accessed 23 July
p.000050: 2016).
p.000050:
p.000050: 17 Overlapping publications. International Committee of Medical Journal Editors (www.
p.000050: icmje.org/recommendations/browse/publishing-and-editorial-issues/overlapping- publications.html, accessed 23 July
p.000050: 2016).
p.000050:
p.000050: 18 Ethical issues related to study design for trials on therapeutics for Ebola Virus Disease.
p.000050: 2014. Report of the WHO Ethics Working Group meeting, 20–21 October 2014. Geneva: World Health Organization; 2014
p.000050: (WHO/HIS/KER/GHE/14.2; http://apps.who.int/iris/ bitstream/10665/137509/1/WHO_HIS_KER_GHE_14.2_eng.pdf, accessed 23
p.000050: July 2016).
p.000050:
p.000050: 19 Dye C, Bartolomeos K, Moorthy V, Kieny MP. Data sharing in public health emergencies: a call to researchers. Bull
p.000050: World Health Organ. 2016;1:94(3):158. doi: 10.2471/ BLT.16.170860
p.000050: (www.who.int/bulletin/volumes/94/3/16-170860.pdf?ua=1).
p.000050:
p.000050: 20 Gender, women and health. In: WHO [website]. Geneva: World Health Organization
p.000050: (http://apps.who.int/gender/whatisgender/en/, accessed 23 July 2016).
p.000050:
p.000050: 21 Addressing sex and gender in epidemic-prone infectious diseases. Geneva: World Health Organization; 2007
p.000050: (www.who.int/csr/resources/publications/SexGenderInfectDis.pdf).
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050: Annex 1. Ethics guidance documents that contributed to the Guidance for managing ethical issues in infectious disease
p.000050: outbreaks
p.000050:
p.000050:
p.000050: WHO guidance documents
p.000050:
p.000050: 52 Addressing ethical issues in pandemic influenza planning: Discussion papers. Geneva: World Health
p.000050: Organization; 2008 (WHO/HSE/EPR/GIP/2008.2, WHO/IER/ETH/2008.1; http://apps.
p.000050: who.int/iris/bitstream/10665/69902/1/WHO_IER_ETH_2008.1_eng.pdf?ua=1).
p.000050:
p.000050: Ethical considerations for use of unregistered interventions for Ebola viral disease. Report of an advisory panel to
p.000050: WHO. Geneva: World Health Organization; 2014 (WHO/HIS/KER/ GHE/14.1;
p.000050: http://apps.who.int/iris/bitstream/10665/130997/1/WHO_HIS_KER_GHE_14.1_ eng.pdf?ua=1).
p.000050:
p.000050: Ethical considerations in developing a public health response to pandemic influenza. Geneva: World Health Organization;
p.000050: 2007 (WHO/CDS/EPR/GIP/2007.2; http://www.who.int/ csr/resources/publications/WHO_CDS_EPR_GIP_2007_2c.pdf?ua=1).
p.000050:
p.000050: Ethical issues related to study design for trials on therapeutics for Ebola virus disease. WHO Ethics Working Group
...

Social / education

Searching for indicator education:

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p.000013: obligation to ensure the long-term capacity of the systems necessary to carry out effective epidemic prevention and
p.000013: response efforts.
p.000013:
p.000013: Countries have obligations not only to persons within their own borders but also to the broader international
p.000013: community. As the United Nations Committee on
p.000013:
p.000013: Economic, Social and Cultural Rights has recognized, “given that some diseases are easily transmissible beyond the
p.000013: frontiers of a State, the international community has a collective responsibility to address this problem. The
p.000013: economically developed States Parties have a special responsibility
p.000013: and interest to assist the poorer developing States in this regard.”9
p.000013:
p.000013: These obligations reflect the practical reality that infectious disease outbreaks do not respect national borders, and
p.000013: that an outbreak in one country can put the rest of the world at risk.
p.000013:
p.000013: Countries’ obligations to consider the needs of the international community do not arise solely in times of emergency.
p.000013: Instead, they require ongoing attention to ameliorate the social determinants of poor
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013: health that contribute to infectious disease outbreaks, including poverty, limited access to education, and inadequate
p.000013: systems of water and sanitation.
p.000013:
p.000013: The following are key elements of the obligations of governments and the international community:
p.000014: 14
p.000014: • Ensuring the sufficiency of national public health laws — As discussed later in this document, certain public
p.000014: health interventions that might be necessary during an infectious disease outbreak (e.g. restrictions on freedom of
p.000014: movement) depend on having a clear legal basis for government action, as well as a system in place to provide oversight
p.000014: and review. All countries should review their public health laws to ensure that they give the government sufficient
p.000014: authority to respond effectively to an epidemic while also providing individuals with appropriate human rights
p.000014: protections.
p.000014:
p.000014: • Participating in global surveillance and preparedness efforts —
p.000014: All countries must carry out their responsibilities under the IHR to participate in global surveillance efforts in a
p.000014: truthful and transparent manner. This includes providing prompt notification of events that may constitute a public
p.000014: health emergency of international concern, regardless
p.000014: of any negative consequences that may be associated with notification, such as a possible reduction in trade or
p.000014: tourism. The obligation to provide
p.000014: prompt notification to the international community stems not only from the text of the IHR but also from the ethical
p.000014: principles of solidarity and reciprocity. In addition, countries should develop
p.000014: preparedness plans for infectious disease outbreaks and other potential disasters and provide guidance to relevant
p.000014: health-care facilities to implement the plans.
p.000014:
...

p.000025: media.
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025: 7. Obligations related to medical interventions for the diagnosis, treatment, and prevention of infectious disease
p.000028: 28
p.000028:
p.000028:
p.000028: Questions addressed:
p.000028:
p.000028: • What quality and safety standards should govern the administration of medical interventions offered during
p.000028: infectious disease outbreaks?
p.000028: • What rights do patients (or their authorized proxy decision-makers) have to receive information about the risks
p.000028: and benefits of, and alternatives to, medical interventions during infectious disease outbreaks?
p.000028: • Under what circumstances, if any, might it be appropriate to override an individual’s refusal of diagnostic,
p.000028: therapeutic, or preventive measures during an infectious disease outbreak?
p.000028: • What procedural safeguards should be provided before overriding an individual’s refusal of diagnostic,
p.000028: therapeutic, or preventive measures during an infectious disease outbreak?
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028: Any medical intervention for the diagnosis, treatment, or prevention of infectious disease should be provided in accord
p.000028: with professional medical standards, under conditions designed to ensure the highest attainable level of patient
p.000028: safety. Countries, with the support of international experts, should establish the minimum standards
p.000028: to be applied in the care and treatment of patients affected by an outbreak.
p.000028: These standards should apply not only to health-care institutions but also to home-based care, community activities
p.000028: (including health education sessions), and environmental decontamination efforts or the management of dead bodies.
p.000028:
p.000028: Individuals offered medical interventions for the diagnosis, treatment, or prevention of an infectious pathogen should
p.000028: be informed about the risks, benefits, and alternatives, just as they would be for other significant medical
p.000028: interventions. The presumption should be that the final decision about which medical interventions to accept, if any,
p.000028: belongs to the patient. For patients who lack the legal capacity to make health- care decisions for themselves,
p.000028: decisions should generally be made by appropriately authorized proxy decision-makers, with efforts made to solicit the
p.000028: patient’s assent whenever possible.
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028: Health-care providers should recognize that, in some situations, the refusal of diagnostic, therapeutic, or preventive
p.000028: measures might be a choice that is rational from the perspective of a mentally competent individual. If an individual
p.000028: is unwilling to accept an intervention, providers should engage the patient in an open and respectful dialogue, paying
p.000028: careful attention to the patient’s concerns, perceptions, and situational needs.
p.000028:
p.000028: In exceptional situations, there may be legitimate reasons to override an individual’s refusal of a diagnostic,
p.000028: therapeutic, or preventive measure that has proven to
p.000028: be safe and effective and is part of the accepted medical standard of care. Decisions on whether to override a refusal
p.000028: should be grounded in the following considerations:
p.000028:
...

p.000039: drug-resistant bacteria), or research (e.g. during clinical trials of new diagnostics, vaccines or interventions). Such
p.000039: samples are sent to laboratories on site or other laboratories, either domestically or internationally, for analysis.
p.000039:
p.000039: Biospecimens collected during the management of an infectious disease outbreak offer researchers important
p.000039: opportunities to understand the outbreak pathogen better and to develop diagnostic, therapeutic, and preventive
p.000039: measures that
p.000039:
p.000039: may mitigate the harm of similar outbreaks in the future. At the same time, long-term storage of biospecimens involves
p.000039: potential risks to individuals and communities.
p.000039: Risks to individuals primarily relate to the unwanted disclosure of personal information. This can be minimized by
p.000039: protecting the confidentiality of individuals’ identities, but confidentiality may be difficult to protect when only a
p.000039: small number of people are being tested. Moreover, even when individual confidentiality can be adequately protected,
p.000039: some individuals or communities might still be uncomfortable making their biospecimens available for future use,
p.000039: especially if such use is not subject to community control. Particular concerns can arise when specimens are
p.000039:
p.000039:
p.000039:
p.000039:
p.000039:
p.000039:
p.000039:
p.000039:
p.000039:
p.000039: transferred abroad without the originating country’s prior agreement. Addressing these concerns requires time-consuming
p.000039: but necessary relationship-building, consultation, and education, as well as the establishment of policies, practices,
p.000039: and institutions capable of commanding public confidence and trust.
p.000040: 40
p.000040: In addition to the general principles discussed elsewhere in this document, specific considerations relevant to the
p.000040: long-term storage of biological specimens collected during infectious disease outbreaks include the following:
p.000040:
p.000040: • Provision of information — Before individuals are asked to provide biospecimens during an infectious disease
p.000040: outbreak, they should be given access to information about the
p.000040: purpose of the collection, whether their samples will be stored and, if so, the ways in which their specimens might be
p.000040: used in the future. When feasible and consistent with public health objectives, individuals should be asked to provide
p.000040: informed consent or be given the opportunity to opt out of the long-term storage of their specimens. Seeking informed
p.000040: consent is particularly important if there is any possibility that the specimens may later be used for research
p.000040: purposes.
p.000040:
p.000040: • Community engagement — Individuals and organizations involved in the long-term storage of biospecimens collected
p.000040: during infectious disease outbreaks should engage representatives of the local community in a dialogue about the
p.000040: process. Community representatives should be involved in the development of policies regarding future use of the
p.000040: samples, including measures to ensure that equitable access is provided to any benefits that result from using the
p.000040: samples in research.
p.000040:
...

Social / employees

Searching for indicator employees:

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p.000015: revise their decisions based on information they receive. Reaching out to the community early, and allowing for
p.000015: consideration of
p.000015: the interests of all people who will
p.000015: 16 potentially be affected, can play an important role in building trust and empowering communities to
p.000015: be involved in a genuine dialogue.
p.000015:
p.000015: • Transparency — The ethical principle of transparency requires that decision-makers publicly explain the basis for
p.000015: decisions in language that is
p.000015: linguistically and culturally appropriate.
p.000015: When decisions must be made in the face of uncertain information, the uncertainties should be explicitly acknowledged
p.000015: and conveyed to the public.
p.000015:
p.000015: • Accountability — The public should know who is responsible for making
p.000015: and implementing decisions in relation to the outbreak response, and how they can challenge decisions they believe are
p.000015: inappropriate.
p.000015:
p.000015: The media will play an important role in any infectious disease outbreak response effort. It is therefore important to
p.000015: ensure that the media has access to accurate and timely information about the disease and its management. Governments,
p.000015: nongovernmental organizations, and
p.000015: academic institutions should make efforts to support media training in relevant scientific concepts and techniques for
p.000015: communicating risk information without raising unnecessary alarm. Media training is important for public health sector
p.000015: employees who may interact with media covering public health issues.
p.000015: In turn, the media has a responsibility to provide accurate, factual, and balanced reporting. This is an important
p.000015: component of media ethics.
p.000015:
p.000015:
p.000015: Cholera outbreak in Sierra Leone
p.000015: Source: Fid Thompson
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015: 3. Situations of particular vulnerability
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000017: 17
p.000017: Questions addressed:
p.000017:
p.000017: • Why are some individuals and groups considered particularly vulnerable during infectious disease outbreaks?
p.000017: • How can vulnerability affect a person’s ability to access services during infectious disease outbreaks?
p.000017: • How can vulnerability affect a person’s willingness and ability to share and receive information during an
p.000017: infectious disease outbreak?
p.000017: • Why are stigmatization and discrimination particular risks during infectious disease outbreaks?
p.000017: • In what ways might vulnerable persons suffer disproportionate burdens from infectious disease response efforts,
p.000017: or have a greater need for resources?
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
...

p.000043: the training, tools, and resources necessary to minimize the risks to the extent reasonably possible. This includes
p.000043: complete and accurate information known about the nature
p.000043: of the pathogen and infection control measures, updated information on the epidemiological situation at the local
p.000043: level, and the provision of personal protective equipment. Regular screening of frontline workers should be put
p.000043: in place to detect any infection as quickly as possible, in order to initiate immediate care and minimize the risk of
p.000043: transmission to colleagues, patients, families, and community members.
p.000043:
p.000043: • Priority access to health care — Frontline workers who become sick, as well as any immediate family members who
p.000043: become ill through contact with the worker, should be ensured access to the highest level of care reasonably available.
p.000043: In addition, countries should consider giving frontline workers and their families priority access to vaccines
p.000043: and other treatments as they become available.
p.000043:
p.000043: • Appropriate remuneration — Frontline workers should be given fair remuneration for their work. Governments should
p.000043: ensure that public sector workers are paid in
p.000043: a timely manner, and make efforts to ensure that actors in the private and nongovernmental sectors fulfil their own
p.000043: obligations to pay their employees and contractors. Fair remuneration for frontline workers includes the provision of
p.000043: financial support during periods in which workers are unable to carry out their normal responsibilities because of an
p.000043: infection acquired on the job.
p.000043:
p.000043: • Support for reintegrating into the community — Frontline workers may experience stigma and discrimination,
p.000043: particularly those involved in unpopular measures such as infection control or burials not conducted according to
p.000043: the traditional customs. Governments should make efforts to reduce the risk of stigmatization and discrimination and
p.000043: help such workers to reintegrate into the community, including by providing job placement assistance and relocation to
p.000043: other communities if needed.
p.000043:
p.000043: • Assistance to family members — Assistance should be provided to families of frontline workers who need to remain
p.000043: away from home in order
p.000043: to carry out their responsibilities or to recuperate from illness. Death benefits should be provided to family members
p.000043: of frontline workers who die in the line of duty, including those who were volunteers or “casual workers.”
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
...

Social / gender

Searching for indicator gender:

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p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001: Table of Contents
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001: Foreword ............................................................................................................ 3
p.000001: 1
p.000001: Acknowledgements 4
p.000001: Introduction 7
p.000001: Guidelines 12
p.000001: 1. Obligations of governments and the international community 13
p.000001: 2. Involving the local community
p.000015: 15
p.000015: 3. Situations of particular vulnerability
p.000017: 17
p.000017: 4. Allocating scarce resources
p.000020: 20
p.000020: 5. Public health surveillance
p.000023: 23
p.000023: 6. Restrictions on freedom of movement 25
p.000023: 7. Obligations related to medical interventions for the diagnosis, treatment,
p.000023: and prevention of infectious disease
p.000028: 28
p.000028: 8. Research during infectious disease outbreaks 30
p.000028: 9. Emergency use of unproven interventions outside of research 35
p.000028: 10. Rapid data sharing
p.000038: 38
p.000038: 11. Long-term storage of biological specimens collected during infectious
p.000038: disease outbreaks
p.000039: 39
p.000039: 12. Addressing sex- and gender-based differences 41
p.000039: 13. Frontline response workers’ rights and obligations 43
p.000039: 14. Ethical issues in deploying foreign humanitarian aid workers 47
p.000039: References 50
p.000039: Annex 1. Ethics guidance documents consulted in developing Guidance for managing ethical issues in infectious disease
p.000039: outbreaks 52
p.000039: Annex 2. Participants at meetings to formulate Guidance for managing ethical issues in infectious disease outbreaks
p.000055: 55
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055: Foreword
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055: Infectious disease outbreaks are periods of great uncertainty. Events unfold, resources and capacities that are often
p.000055: limited
p.000055: are stretched yet further, and decisions for a public health response must be made quickly, even though the evidence
p.000055: for decision-making may be scant. In such a situation, public health officials, policy-makers, funders, researchers,
p.000055: field epidemiologists, first responders, national
p.000055: ethics boards, health-care workers, and public health practitioners need a moral compass
p.000055: to guide them in their decision-making. Bioethics puts people at the heart of the problem, emphasizes the principles
...

p.000025: for a period following the end of confinement. In addition, efforts should be made to support the social and
p.000025: professional reintegration of individuals for whom confinement is no longer necessary, including measures to reduce
p.000025: stigmatization and discrimination.
p.000025:
p.000025: • Due process protections — Mechanisms should be in place to allow individuals whose liberty has been restricted to
p.000025: challenge the appropriateness of those restrictions, the way they are enforced, and the conditions under which the
p.000025: restrictions are carried out. If it is not feasible to provide full due process protection before the restrictions are
p.000025: implemented in an emergency scenario, mechanisms for review and appeal should be made
p.000025: available without excessive delay. All persons involved in decisions to restrict individuals’ freedom of movement
p.000025: should be accountable for any abuses of authority.
p.000025:
p.000025: • Equitable application — Restrictions on freedom of movement should be
p.000025: applied in the same manner to all 27
p.000025: persons posing a comparable public health risk. Thus, individuals should not be subject to greater or lesser
p.000025: restrictions for reasons unrelated to the
p.000025: risks they may pose to others, including membership in any disfavoured or favoured social group or class (for example,
p.000025: groups defined by gender, ethnicity, or religion). In addition, policy- makers should seek to ensure that restrictions
p.000025: are not applied in a manner that imposes a disproportionate burden on vulnerable segments of society.
p.000025:
p.000025: • Communication and transparency —
p.000025: Policy-makers and public health officials should engage communities in a dialogue about any restrictions on freedom of
p.000025: movement and solicit community members’ views on how restrictions can be carried out with the least possible burden.
p.000025: They should also provide regular updates on the implementation of such measures,
p.000025: both to the public at large and to those whose movement has been restricted. Communication strategies should be
p.000025: designed to avoid the stigmatization
p.000025: of individuals whose liberty has been restricted and to protect their privacy and confidentiality, particularly in the
p.000025: media.
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025:
p.000025: 7. Obligations related to medical interventions for the diagnosis, treatment, and prevention of infectious disease
p.000028: 28
p.000028:
p.000028:
p.000028: Questions addressed:
p.000028:
p.000028: • What quality and safety standards should govern the administration of medical interventions offered during
p.000028: infectious disease outbreaks?
...

p.000040: conduct critical research.
p.000040: If it is necessary to transfer specimens internationally, appropriate governance mechanisms and regulatory systems
p.000040: should be established to ensure that representatives of the country where the specimens were collected are involved in
p.000040: decisions about the specimens’ use. The international community should make efforts to strengthen countries’ capacity
p.000040: to maintain biospecimens within their own borders.
p.000040:
p.000040: • Material transfer agreements — Biospecimens should not be transferred outside of the countries from which they
p.000040: are collected without formal material transfer agreements. Such agreements should specify the purpose of the transfer,
p.000040: certify the specimen donor's consent as appropriate, provide for adequate confidentiality protection, cover the
p.000040: physical security of the specimens, require that the country
p.000040: of origin is acknowledged in future research reporting, and guarantee that the benefits of any subsequent use of the
p.000040: specimens will be shared with the communities from which the samples were obtained. Material transfer agreements should
p.000040: be developed with the involvement of persons responsible for the care of patients and the taking of samples,
p.000040: representatives of affected communities and patients, and relevant government officials and ethics committees.
p.000040:
p.000040:
p.000040:
p.000040:
p.000040:
p.000040:
p.000040:
p.000040:
p.000040: 12. Addressing sex- and gender-based differences
p.000040:
p.000040:
p.000040:
p.000041: 41
p.000041: Questions addressed:
p.000041:
p.000041: • How are sex and gender relevant to infectious disease outbreaks?
p.000041: • How can sex and gender be incorporated into public health and surveillance?
p.000041: • How can social and cultural practices relevant to gender roles affect infectious disease outbreaks?
p.000041: • How should appropriate reproductive health-care services be safely provided during an infectious disease
p.000041: outbreak?
p.000041: • How are sex and gender relevant to communication strategies during outbreaks?
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: Sex (biological and physiological characteristics) and gender (socially constructed roles, behaviours, activities, and
p.000041: attributes)20 can influence the spread, containment, course, and consequences of infectious disease outbreaks. Sex and
p.000041: gender differences have been associated with differences in susceptibility to infection, levels of health care
p.000041: received, and in the course and outcome of illness.21 Addressing sex and gender differences in infectious disease
p.000041: outbreak planning and response efforts requires attention to the following considerations:
p.000041:
p.000041: • Sex- and gender-inclusive surveillance programmes — Public health surveillance should systematically collect
p.000041: disaggregated information on sex, gender, and pregnancy status, both to identify differential risks and
p.000041: modes of transmission, and to monitor any differential impact of an infectious disease outbreak and the interventions
p.000041: used to control it. This information is particularly important for pregnant women and their offspring.
p.000041:
p.000041: • Ensuring the availability of high- quality reproductive health-care services — Whether or not they are currently
p.000041: pregnant, women of childbearing age should have access to the full range of high-quality
p.000041: reproductive health-care services during an infectious disease outbreak. These services should be organized and
p.000041: delivered in a manner that does not stigmatize persons who use them or expose them to a heightened risk of infection
p.000041: with the outbreak pathogen. If there is evidence that an infectious
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: disease creates special risks for pregnant women or their fetus, both men and women should be informed of these risks
p.000041: and have access to safe methods to minimize them, along with reproductive counselling services.
p.000041:
p.000041: • Sex- and gender-inclusive research
p.000041: 42 strategies — Researchers should make efforts to ensure that studies do not disproportionately
p.000041: favour a particular sex or gender, and that women who are or might become pregnant are not inappropriately excluded
p.000041: from research participation. During an outbreak, research on experimental treatments and preventive measures should
p.000041: seek to identify any sex- or gender-related differences in outcomes.
p.000041:
p.000041: • Attention to social and cultural practices — Gender-related roles and practices can affect all aspects of
p.000041: infectious disease outbreaks, including
p.000041: individuals’ risk of becoming infected, the consequences of infection, their use of health services and other
p.000041: health-seeking behaviours, and their vulnerability to interpersonal violence.
p.000041: Policy-makers and outbreak responders should identify and respond to these factors, drawing when possible
p.000041: on relevant anthropological and sociological research.
p.000041:
p.000041: • Sex- and gender-sensitive communication strategies —
p.000041: Entities responsible for developing and implementing communication strategies should be sensitive to sex- and gender-
p.000041: based differences in how individuals have access to and respond to health- related information. Separate messages and
p.000041: communication strategies may be needed to provide relevant information to particular subgroups, such as pregnant women
p.000041: or nursing mothers.
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: Influenza in India
p.000041: Source: Tom Pietrasik, WHO
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041:
p.000041: 13. Frontline response workers’ rights and obligations
p.000041:
p.000041:
p.000041:
p.000043: 43
p.000043: Questions addressed:
p.000043:
p.000043: • What obligations exist to protect the health of frontline workers who participate in infectious disease outbreak
p.000043: response efforts?
p.000043: • What obligations exist to provide material support to frontline workers who participate in infectious disease
p.000043: outbreak response efforts?
p.000043: • To what extent do these obligations extend to the workers’ family?
p.000043: • What should be taken into account in determining whether individuals have an obligation to serve as frontline
p.000043: workers during infectious disease outbreaks?
p.000043: • What special obligations do workers in the health-care sector have during infectious disease outbreaks?
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
...

p.000050: July 2016).
p.000050:
p.000050: 15 Research ethics in international epidemic response. Geneva: World Health Organization; 2009 (WHO/HSE/GIP/ITP/10.1;
p.000050: www.who.int/ethics/gip_research_ethics_.pdf, accessed 23 July 2016).
p.000050:
p.000050: 16 Developing global norms for sharing data and results during public health emergencies. Geneva: World Health
p.000050: Organization; 2015 (www.who.int/medicines/ebola-treatment/ blueprint_phe_data-share-results/en/, accessed 23 July
p.000050: 2016).
p.000050:
p.000050: 17 Overlapping publications. International Committee of Medical Journal Editors (www.
p.000050: icmje.org/recommendations/browse/publishing-and-editorial-issues/overlapping- publications.html, accessed 23 July
p.000050: 2016).
p.000050:
p.000050: 18 Ethical issues related to study design for trials on therapeutics for Ebola Virus Disease.
p.000050: 2014. Report of the WHO Ethics Working Group meeting, 20–21 October 2014. Geneva: World Health Organization; 2014
p.000050: (WHO/HIS/KER/GHE/14.2; http://apps.who.int/iris/ bitstream/10665/137509/1/WHO_HIS_KER_GHE_14.2_eng.pdf, accessed 23
p.000050: July 2016).
p.000050:
p.000050: 19 Dye C, Bartolomeos K, Moorthy V, Kieny MP. Data sharing in public health emergencies: a call to researchers. Bull
p.000050: World Health Organ. 2016;1:94(3):158. doi: 10.2471/ BLT.16.170860
p.000050: (www.who.int/bulletin/volumes/94/3/16-170860.pdf?ua=1).
p.000050:
p.000050: 20 Gender, women and health. In: WHO [website]. Geneva: World Health Organization
p.000050: (http://apps.who.int/gender/whatisgender/en/, accessed 23 July 2016).
p.000050:
p.000050: 21 Addressing sex and gender in epidemic-prone infectious diseases. Geneva: World Health Organization; 2007
p.000050: (www.who.int/csr/resources/publications/SexGenderInfectDis.pdf).
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050: Annex 1. Ethics guidance documents that contributed to the Guidance for managing ethical issues in infectious disease
p.000050: outbreaks
p.000050:
p.000050:
p.000050: WHO guidance documents
p.000050:
p.000050: 52 Addressing ethical issues in pandemic influenza planning: Discussion papers. Geneva: World Health
p.000050: Organization; 2008 (WHO/HSE/EPR/GIP/2008.2, WHO/IER/ETH/2008.1; http://apps.
p.000050: who.int/iris/bitstream/10665/69902/1/WHO_IER_ETH_2008.1_eng.pdf?ua=1).
p.000050:
p.000050: Ethical considerations for use of unregistered interventions for Ebola viral disease. Report of an advisory panel to
p.000050: WHO. Geneva: World Health Organization; 2014 (WHO/HIS/KER/ GHE/14.1;
p.000050: http://apps.who.int/iris/bitstream/10665/130997/1/WHO_HIS_KER_GHE_14.1_ eng.pdf?ua=1).
p.000050:
p.000050: Ethical considerations in developing a public health response to pandemic influenza. Geneva: World Health Organization;
p.000050: 2007 (WHO/CDS/EPR/GIP/2007.2; http://www.who.int/ csr/resources/publications/WHO_CDS_EPR_GIP_2007_2c.pdf?ua=1).
p.000050:
p.000050: Ethical issues related to study design for trials on therapeutics for Ebola virus disease. WHO Ethics Working Group
p.000050: Meeting, 20–21 October 2014. Geneva: World Health Organization; 2014 (WHO/HIS/KER/GHE/14.2;
p.000050: http://apps.who.int/iris/bitstream/10665/137509/1/WHO_ HIS_KER_GHE_14.2_eng.pdf?ua=1).
p.000050:
...

Social / parents

Searching for indicator parents:

(return to top)
p.000017: proactively reach out to the concerned population wherever they are.
p.000017:
p.000017: • Impact of stigmatization and discrimination — Members of socially disadvantaged groups often face considerable
p.000017: stigma and discrimination, which can be exacerbated in public health emergencies characterized by fear and distrust.
p.000017: Those responsible for infectious disease outbreak response should ensure that all individuals are treated fairly and
p.000017: equitably regardless of their social status or perceived “worth” to society. They should also take measures to prevent
p.000017: stigmatization and social violence.
p.000017:
p.000017: • Disproportionate burdens of outbreak response measures — Even when public health measures
p.000017: are designed with the best of intentions, they can inadvertently place a disproportionate burden on particular
p.000017: populations. For example, quarantine orders that require individuals to stay
p.000017: in their homes can have devastating consequences for persons who need to leave their homes to obtain basic
p.000017: necessities such as clean water or food. Similarly, social distancing measures such as school closures can place
p.000017: disproportionate burdens on children who depend on going to school to access regular meals, as well as on working
p.000017: parents who may have no one available to provide child care.
p.000017:
p.000017: • Greater need for resources — Accommodating the needs of individuals whose situation makes them particularly
p.000017: vulnerable sometimes requires the use of additional resources.
p.000017: In some cases, additional resources are relatively minimal, such as when an interpreter is hired to make
p.000017: a community engagement forum accessible to members of a linguistic minority group. In other cases, they may be more
p.000017: substantial, such as when mobile health teams are assembled to dispatch vaccines and treatments to hard-to-reach rural
p.000017: areas. It is legitimate to take costs into consideration in determining whether a particular accommodation is
p.000017: warranted; indeed, the goal of maximizing utility demands that such assessments be made.
p.000017: However, despite the importance of conserving limited resources, the ethical principle of equity may sometimes justify
p.000017: providing greater resources to persons who have greater needs.
p.000017:
p.000017: • Heightened risk of violence — Infectious disease outbreaks can
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017:
p.000017: exacerbate social unrest, increase criminality, and induce violent behaviour, especially against vulnerable groups such
p.000017: as minority populations
...

Social / philosophical differences/differences of opinion

Searching for indicator opinion:

(return to top)
p.000001:
p.000001: value
p.000001: public health ethics
p.000001: procedural justice
p.000001:
p.000001: equity
p.000001:
p.000001: principle
p.000001: public good
p.000001: value dignity
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001: Guidance for Managing Ethical Issues
p.000001: in Infectious Disease Outbreaks
p.000001:
p.000001:
p.000001:
p.000001: WHO Library Cataloguing-in-Publication Data
p.000001:
p.000001: Guidance for managing ethical issues in infectious disease outbreaks.
p.000001:
p.000001: 1.Disease Outbreaks. 2.Communicable Diseases. 3.Ethics. I.World Health Organization. ISBN 978 92 4 154983 7
p.000001: (NLM classification: WA 105)
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001: © World Health Organization 2016
p.000001:
p.000001: All rights reserved. Publications of the World Health Organization are available on the WHO website
p.000001: (http://www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27,
p.000001: Switzerland (tel.: +41 22 791 3264;
p.000001: fax: +41 22 791 4857; email: bookorders@who.int).
p.000001:
p.000001: Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial
p.000001: distribution– should be addressed to WHO Press through the WHO website
p.000001: (http://www.who.int/about/licensing/copyright_form/index.html).
p.000001: The designations employed and the presentation of the material in this publication do not imply the expression of any
p.000001: opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory,
p.000001: city or area or of its
p.000001: authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent
p.000001: approximate border lines for which there may not yet be full agreement.
p.000001: The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or
p.000001: recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors
p.000001: and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
p.000001: All reasonable precautions have been taken by the World Health Organization to verify the information contained in this
p.000001: publication. However, the published material is being
p.000001: distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and
p.000001: use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising
p.000001: from its use.
p.000001:
p.000001: Printed in Spain
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001: Table of Contents
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001: Foreword ............................................................................................................ 3
p.000001: 1
p.000001: Acknowledgements 4
p.000001: Introduction 7
p.000001: Guidelines 12
...

p.000050:
p.000050: Ethics of using convalescent whole blood and convalescent plasma during the Ebola epidemic: Interim guidance for ethics
p.000050: review committees, researchers, national health authorities and blood transfusion services. Geneva: World Health
p.000050: Organization; 2015 (http://apps.who.int/iris/bitstream/10665/161912/1/WHO_HIS_KER_GHE_15.1_eng. pdf?ua=1&ua=1).
p.000050:
p.000050: Ethics in epidemics, emergencies and disasters: Research, surveillance and patient care: Training manual. Geneva: World
p.000050: Health Organization; 2015 (http://apps.who.int/iris/ bitstream/10665/196326/1/9789241549349_eng.pdf?ua=1).
p.000050:
p.000050: Guidance on ethics of tuberculosis prevention, care and control. Geneva: World Health Organization; 2010
p.000050: (http://apps.who.int/iris/bitstream/10665/44452/1/9789241500531_ eng.pdf?ua=1).
p.000050:
p.000050: Research ethics in international epidemic response: WHO Technical Consultation. Geneva: World Health Organization; 2009
p.000050: (www.who.int/ethics/gip_research_ethics_.pdf).
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050: Standards and operational guidance for ethics review of health-related research with human participants. Geneva: World
p.000050: Health Organization; 2011 (http://apps.who.int/iris/ bitstream/10665/44783/1/9789241502948_eng.pdf?ua=1&ua=1).
p.000050:
p.000050: National guidance/opinion papers
p.000050:
p.000050: Allocation of ventilators in an influenza pandemic: Planning document. New York State Task Force on Life and the Law;
p.000050: 2007 (www.cidrap.umn.edu/sites/default/files/public/
p.000050: php/196/196_guidance.pdf).
p.000053: 53
p.000053:
p.000053: Altevogt BM, Stroud C, Hanson S, Hanfling D, Gostin LO, editors. Guidance for establishing crisis standards of care for
p.000053: use in disaster situations: A letter report. Washington: National Academies Press; 2009
p.000053: (www.nap.edu/read/12749/chapter/1).
p.000053:
p.000053: Ethical issues raised by a possible influenza pandemic. Opinion No. 106. Paris: National Consultative Ethics Committee
p.000053: for Health and Life Sciences; 2009 (www.ccne-ethique.fr/ sites/default/files/publications/avis_106_anglais.pdf).
p.000053:
p.000053: Ethics and Ebola: Public health planning and response. Washington DC: Presidential Commission for the Study of
p.000053: Bioethical Issues.; 2015 (http://bioethics.gov/sites/default/files/ Ethics-and-Ebola_PCSBI_508.pdf).
p.000053:
p.000053: Ethical guidelines in Pandemic Influenza - Recommendations of the Ethics Subcommittee of the Advisory Committee to the
p.000053: Director, United States Centers for Disease Control and Prevention. Ethical guidelines in pandemic influenza. Atlanta:
p.000053: Centers for Disease Control and Prevention; 2007 (www.cdc.gov/od/science/integrity/phethics/docs/panflu_ethic_
p.000053: guidelines.pdf).
p.000053:
p.000053: Ethics Subcommittee of the Advisory Committee to the Director, United States Centers for Disease Control and
p.000053: Prevention. Ethical guidance for public health emergency preparedness and response: Highlighting ethics and values in
p.000053: vital public health service. Atlanta: Centers for Disease Control and Prevention; 2008
p.000053: (www.cdc.gov/od/science/integrity/phethics/docs/
p.000053: white_paper_final_for_website_2012_4_6_12_final_for_web_508_compliant.pdf).
p.000053:
p.000053: Ethics Subcommittee of the Advisory Committee to the Director, United States Centers for Disease Control and
...

Searching for indicator philosophy:

(return to top)
p.000059: Dr Rita Helfand, Centers for Disease Control and Prevention, United States of America Dr Simon Jenkins, Research
p.000059: Fellow, University of Birmingham Project on the ethical challenges experienced by British military healthcare
p.000059: professionals in the Ebola region, United Kingdom
p.000059: Dr Pretesh Kiran, Assistant Professor, Community Health; Convener, Disaster Management Unit, St Johns National Academy
p.000059: of Health Sciences, India
p.000059: 60 Dr Markus Kirchner, Department for Infectious Disease Epidemiology, Robert Koch Institute,
p.000059: Germany
p.000059: Dr Katherine Littler, Senior Policy Adviser, Wellcome Trust, United Kingdom
p.000059: Professor Samuel McConkey, Head, International Health and Tropical Medicine, Royal College of Surgeons, Ireland
p.000059: Dr Farhat Moazam, Founding Chairperson, Center of Biomedical Ethics and Culture, Sindh Institute of Urology and
p.000059: Transplantation, Pakistan
p.000059: Dr Robert Nelson, Deputy Director and Senior Pediatric Ethicist, Office of Pediatric Therapeutics, Food and Drug
p.000059: Administration, United States of America
p.000059: Professor Alistair Nichol, Consultant Anaesthetist, School of Medicine and Medical Sciences, and EU projects,
p.000059: University College Dublin, Ireland
p.000059: Professor Lisa Schwartz, Arnold Johnson Chair in Health Care Ethics, Ethics in Health Care, McMaster University, Canada
p.000059: Professor Michael Selgelid, Director, Centre for Human Bioethics, Monash University, Australia Dr Kadri Simm, Associate
p.000059: Professor of Practical Philosophy, University of Tartu, Estonia
p.000059: Dr Aissatou Touré, Head, Immunology Department, Institut Pasteur de Dakar and Member, National Ethics Committee,
p.000059: Senegal
p.000059: Professor Ross Upshur, Canada Research Chair in Primary Care Research; Professor, Department of Family and Community
p.000059: Medicine and Dalla Lana School of Public Health, University of Toronto, Canada
p.000059: Dr Maria Van Kerkhove, Centre for Global Health, Institut Pasteur, France
p.000059: Dr Aminu Yakubu, Department of Health Planning and Research, Federal Ministry of Health, Nigeria
p.000059:
p.000059: Resource person
p.000059: Professor Carl Coleman (Rapporteur), Professor of Law and Academic Director, Division of Online Learning, Seton Hall
p.000059: University, New Jersey, United States of America
p.000059:
p.000059: WHO headquarters Secretariat, Geneva, Switzerland
p.000059: Dr Vânia de la Fuente-Núñez, Technical Officer, Global Health Ethics, Department of Knowledge, Ethics and Research
p.000059: Dr Andreas Reis, Technical Officer, Global Health Ethics, Department of Knowledge, Ethics and Research
p.000059: Dr Abha Saxena, Coordinator, Global Health Ethics, Department of Knowledge, Ethics and Research
p.000059:
p.000059:
p.000059:
p.000059:
p.000059:
p.000059:
p.000059:
p.000059:
...

Economic / Economic/Poverty

Searching for indicator poor:

(return to top)
p.000013: surveillance and prevention activities.
p.000013: Together, these actions can substantially reduce the spread of diseases with epidemic potential. In addition, they help
p.000013: assure that an effective public health response will be possible if an epidemic occurs. Governments have an ethical
p.000013: obligation to ensure the long-term capacity of the systems necessary to carry out effective epidemic prevention and
p.000013: response efforts.
p.000013:
p.000013: Countries have obligations not only to persons within their own borders but also to the broader international
p.000013: community. As the United Nations Committee on
p.000013:
p.000013: Economic, Social and Cultural Rights has recognized, “given that some diseases are easily transmissible beyond the
p.000013: frontiers of a State, the international community has a collective responsibility to address this problem. The
p.000013: economically developed States Parties have a special responsibility
p.000013: and interest to assist the poorer developing States in this regard.”9
p.000013:
p.000013: These obligations reflect the practical reality that infectious disease outbreaks do not respect national borders, and
p.000013: that an outbreak in one country can put the rest of the world at risk.
p.000013:
p.000013: Countries’ obligations to consider the needs of the international community do not arise solely in times of emergency.
p.000013: Instead, they require ongoing attention to ameliorate the social determinants of poor
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013: health that contribute to infectious disease outbreaks, including poverty, limited access to education, and inadequate
p.000013: systems of water and sanitation.
p.000013:
p.000013: The following are key elements of the obligations of governments and the international community:
p.000014: 14
p.000014: • Ensuring the sufficiency of national public health laws — As discussed later in this document, certain public
p.000014: health interventions that might be necessary during an infectious disease outbreak (e.g. restrictions on freedom of
p.000014: movement) depend on having a clear legal basis for government action, as well as a system in place to provide oversight
p.000014: and review. All countries should review their public health laws to ensure that they give the government sufficient
p.000014: authority to respond effectively to an epidemic while also providing individuals with appropriate human rights
p.000014: protections.
p.000014:
p.000014: • Participating in global surveillance and preparedness efforts —
p.000014: All countries must carry out their responsibilities under the IHR to participate in global surveillance efforts in a
p.000014: truthful and transparent manner. This includes providing prompt notification of events that may constitute a public
p.000014: health emergency of international concern, regardless
p.000014: of any negative consequences that may be associated with notification, such as a possible reduction in trade or
...

p.000020: access to general health-care services due to a combination of a greater number of patients and the sickness and death
p.000020: of health-care workers. As
p.000020: a result, deaths from tuberculosis, human immunodeficiency virus (HIV), and malaria increased dramatically during this
p.000020: period.10
p.000020:
p.000020: Governments, health-care facilities, and others involved in response efforts should
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020: prepare for such situations by developing guidelines on the allocation of scarce resources in outbreak situations. Such
p.000020: guidelines should be developed through an open and transparent process involving broad stakeholder input and, to the
p.000020: extent
p.000020: possible, should be incorporated into formal written documents that establish clear priorities and procedures. Those
p.000020: involved
p.000020: in developing these guidelines should be guided by the following considerations:
p.000020:
p.000020: • Balancing considerations of utility and equity — Resource allocation decisions should be guided by the ethical
p.000020: principles of utility and equity. The principle of utility requires allocating resources to maximize benefits and
p.000020: minimize burdens, while the principle of equity requires attention to the fair distribution of benefits
p.000020: and burdens. In some cases, an equal distribution of benefits and burdens may be considered fair, but in others, it may
p.000020: be fairer to give preference to groups that are worse off, such as the poor, the sick, or the vulnerable. It is not
p.000020: always be possible to achieve fully both utility and equity. For example, establishing treatment centres in large urban
p.000020: settings promotes the value of utility because it makes it possible to treat a large number of people with relatively
p.000020: few resources. However, such
p.000020: an approach may be in tension with the principle of equity if it means that fewer resources will be directed to
p.000020: isolated communities in remote rural areas.
p.000020: There is no single correct way to resolve potential tensions between utility
p.000020: and equity; what is important is that decisions are made through an inclusive and transparent process that takes into
p.000020: account local circumstances.
p.000020: • Defining utility on the basis of health-related considerations —
p.000020: In order to apply the ethical principle of utility, it is first necessary to identify the type of outcomes that will be
p.000020: counted as improvements to welfare. In general, the focus should be on the health-related benefits of allocation
p.000020: mechanisms, whether defined in terms 21
p.000020: of the total number of lives saved, the total number of life years saved, or the total number of quality-adjusted life
p.000020: years saved. For this reason,
p.000020: while it might be ethical to prioritize persons who are essential to manage an outbreak, it is not appropriate to
p.000020: prioritize persons based on social value considerations unrelated to carrying out critical services necessary for
p.000020: society.
p.000020:
...

Searching for indicator poverty:

(return to top)
p.000013: obligation to ensure the long-term capacity of the systems necessary to carry out effective epidemic prevention and
p.000013: response efforts.
p.000013:
p.000013: Countries have obligations not only to persons within their own borders but also to the broader international
p.000013: community. As the United Nations Committee on
p.000013:
p.000013: Economic, Social and Cultural Rights has recognized, “given that some diseases are easily transmissible beyond the
p.000013: frontiers of a State, the international community has a collective responsibility to address this problem. The
p.000013: economically developed States Parties have a special responsibility
p.000013: and interest to assist the poorer developing States in this regard.”9
p.000013:
p.000013: These obligations reflect the practical reality that infectious disease outbreaks do not respect national borders, and
p.000013: that an outbreak in one country can put the rest of the world at risk.
p.000013:
p.000013: Countries’ obligations to consider the needs of the international community do not arise solely in times of emergency.
p.000013: Instead, they require ongoing attention to ameliorate the social determinants of poor
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013: health that contribute to infectious disease outbreaks, including poverty, limited access to education, and inadequate
p.000013: systems of water and sanitation.
p.000013:
p.000013: The following are key elements of the obligations of governments and the international community:
p.000014: 14
p.000014: • Ensuring the sufficiency of national public health laws — As discussed later in this document, certain public
p.000014: health interventions that might be necessary during an infectious disease outbreak (e.g. restrictions on freedom of
p.000014: movement) depend on having a clear legal basis for government action, as well as a system in place to provide oversight
p.000014: and review. All countries should review their public health laws to ensure that they give the government sufficient
p.000014: authority to respond effectively to an epidemic while also providing individuals with appropriate human rights
p.000014: protections.
p.000014:
p.000014: • Participating in global surveillance and preparedness efforts —
p.000014: All countries must carry out their responsibilities under the IHR to participate in global surveillance efforts in a
p.000014: truthful and transparent manner. This includes providing prompt notification of events that may constitute a public
p.000014: health emergency of international concern, regardless
p.000014: of any negative consequences that may be associated with notification, such as a possible reduction in trade or
p.000014: tourism. The obligation to provide
p.000014: prompt notification to the international community stems not only from the text of the IHR but also from the ethical
p.000014: principles of solidarity and reciprocity. In addition, countries should develop
...

Searching for indicator social status:

(return to top)
p.000017:
p.000017:
p.000017:
p.000017:
p.000017: • Need for effective alternative communication strategies — Some types of vulnerability can impede
p.000017: an individual’s ability to transmit or receive information. Communication barriers can stem from a wide range of
p.000017: factors including, but not limited to, illiteracy, unfamiliarity with the
p.000017: 18 local or official language(s), vision or
p.000017: hearing impairments, social isolation, or lack of access to Internet and other communication services. These barriers
p.000017: make it difficult for individuals to receive necessary public health messages
p.000017: or to participate fully in community engagement activities. To overcome these barriers, messages should be delivered in
p.000017: multiple formats (e.g. radio, text messages, billboards, cartoons) as well as direct oral communication with key
p.000017: stakeholders. Health authorities should not assume that the public will search for information; instead, they should
p.000017: proactively reach out to the concerned population wherever they are.
p.000017:
p.000017: • Impact of stigmatization and discrimination — Members of socially disadvantaged groups often face considerable
p.000017: stigma and discrimination, which can be exacerbated in public health emergencies characterized by fear and distrust.
p.000017: Those responsible for infectious disease outbreak response should ensure that all individuals are treated fairly and
p.000017: equitably regardless of their social status or perceived “worth” to society. They should also take measures to prevent
p.000017: stigmatization and social violence.
p.000017:
p.000017: • Disproportionate burdens of outbreak response measures — Even when public health measures
p.000017: are designed with the best of intentions, they can inadvertently place a disproportionate burden on particular
p.000017: populations. For example, quarantine orders that require individuals to stay
p.000017: in their homes can have devastating consequences for persons who need to leave their homes to obtain basic
p.000017: necessities such as clean water or food. Similarly, social distancing measures such as school closures can place
p.000017: disproportionate burdens on children who depend on going to school to access regular meals, as well as on working
p.000017: parents who may have no one available to provide child care.
p.000017:
p.000017: • Greater need for resources — Accommodating the needs of individuals whose situation makes them particularly
p.000017: vulnerable sometimes requires the use of additional resources.
p.000017: In some cases, additional resources are relatively minimal, such as when an interpreter is hired to make
p.000017: a community engagement forum accessible to members of a linguistic minority group. In other cases, they may be more
...

p.000020: potentially exposed to much higher risks of infection than persons living in the community.
p.000020:
p.000020: • Fulfilling reciprocity-based obligations to those who contribute to infectious disease outbreak response efforts
p.000020: — The ethical principle of reciprocity implies that society should support persons who face a disproportionate burden
p.000020: or risk in protecting the public good. This principle justifies giving priority access to scarce resources to persons
p.000020: who
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020: assume risks to their own health or life to contribute to outbreak response efforts.
p.000020:
p.000020: • Providing supportive and palliative care to persons unable to access life- saving resources — Even when it is not
p.000020: possible to provide life-saving medical
p.000020: 22 resources to all who could benefit from
p.000020: them, efforts should be made to ensure that no patients are abandoned. One way to do this is to ensure that adequate
p.000020: resources are directed to providing supportive and palliative care.
p.000020:
p.000020: The application of allocation principles should take into account the following considerations:
p.000020:
p.000020: • Consistent application — Allocation principles should be applied in
p.000020: a consistent manner, both within individual institutions and, to the extent possible, across geographic areas.
p.000020: Decision-making tools should be developed to ensure that like cases are treated alike, and that no person receives
p.000020: better or worse treatment due to his or her social status or other factors not explicitly recognized in
p.000020: the allocation plan. Efforts should be made to avoid unintended systemic discrimination in the choice or application of
p.000020: allocation methods.
p.000020:
p.000020: • Resolution of disputes — Mechanisms should be developed to resolve disagreements about the application of
p.000020: allocation principles;
p.000020: these mechanisms should be designed to ensure that anyone who believes that allocation principles have been applied
p.000020: inappropriately has access to impartial and accountable review processes, and has the opportunity to be heard.
p.000020: • Avoiding corruption — Corruption in the health-care sector may be exacerbated during infectious disease
p.000020: outbreaks if large numbers of individuals are competing for access
p.000020: to limited resources. Efforts should be made to ensure that persons involved in the application of allocation systems
p.000020: do not accept or give bribes or engage in other corrupt activities.
p.000020:
p.000020: • Separation of responsibilities — To the extent possible, the interpretation of allocation principles should not
p.000020: be entrusted to clinicians who have pre-existing professional relationships that create an ethical obligation to
p.000020: advocate for the
p.000020: interests of specific patients or groups.
p.000020: Instead, decisions should be made by appropriately qualified clinicians
p.000020: who have no personal or professional reasons to advocate for one patient or group over another.
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020: 5. Public health surveillance
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000023: 23
p.000023: Questions addressed:
p.000023:
...

General/Other / Dependent

Searching for indicator dependent:

(return to top)
p.000020: isolated communities in remote rural areas.
p.000020: There is no single correct way to resolve potential tensions between utility
p.000020: and equity; what is important is that decisions are made through an inclusive and transparent process that takes into
p.000020: account local circumstances.
p.000020: • Defining utility on the basis of health-related considerations —
p.000020: In order to apply the ethical principle of utility, it is first necessary to identify the type of outcomes that will be
p.000020: counted as improvements to welfare. In general, the focus should be on the health-related benefits of allocation
p.000020: mechanisms, whether defined in terms 21
p.000020: of the total number of lives saved, the total number of life years saved, or the total number of quality-adjusted life
p.000020: years saved. For this reason,
p.000020: while it might be ethical to prioritize persons who are essential to manage an outbreak, it is not appropriate to
p.000020: prioritize persons based on social value considerations unrelated to carrying out critical services necessary for
p.000020: society.
p.000020:
p.000020: • Paying attention to the needs of vulnerable populations — In applying the ethical principle of equity, special
p.000020: attention should be given to individuals and groups that are the most vulnerable to discrimination, stigmatization, or
p.000020: isolation, as discussed in Guideline 3.
p.000020: Particular consideration must be given to individuals who are confined in institutional settings, where they are highly
p.000020: dependent on others and
p.000020: potentially exposed to much higher risks of infection than persons living in the community.
p.000020:
p.000020: • Fulfilling reciprocity-based obligations to those who contribute to infectious disease outbreak response efforts
p.000020: — The ethical principle of reciprocity implies that society should support persons who face a disproportionate burden
p.000020: or risk in protecting the public good. This principle justifies giving priority access to scarce resources to persons
p.000020: who
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020: assume risks to their own health or life to contribute to outbreak response efforts.
p.000020:
p.000020: • Providing supportive and palliative care to persons unable to access life- saving resources — Even when it is not
p.000020: possible to provide life-saving medical
p.000020: 22 resources to all who could benefit from
p.000020: them, efforts should be made to ensure that no patients are abandoned. One way to do this is to ensure that adequate
p.000020: resources are directed to providing supportive and palliative care.
p.000020:
p.000020: The application of allocation principles should take into account the following considerations:
p.000020:
p.000020: • Consistent application — Allocation principles should be applied in
p.000020: a consistent manner, both within individual institutions and, to the extent possible, across geographic areas.
p.000020: Decision-making tools should be developed to ensure that like cases are treated alike, and that no person receives
...

General/Other / Developing Country

Searching for indicator underdeveloped:

(return to top)
p.000006: Working Group, which was charged with developing ethics guidance on issues and concerns as they arose in
p.000006: the course of the epidemic. It became increasingly apparent that the ethical issues raised by Ebola mirrored concerns
p.000006: that had arisen in other global infectious disease outbreaks, including severe acute respiratory syndrome (SARS),
p.000006: pandemic influenza, and multidrug-resistant tuberculosis. However, while WHO has issued ethical guidance
p.000006: on some of these outbreaks,2,3,4,5 prior guidance has only focused on the specific pathogen in isolation. The purpose
p.000006: of this document is to look beyond issues specific to particular epidemic pathogens and instead focus on the
p.000006: cross-cutting ethical issues that apply to infectious disease outbreaks generally. In addition to setting forth general
p.000006: principles, it examines how these principles can be adapted to different epidemiological and social circumstances.
p.000006:
p.000006: While many of the ethical issues that arise in infectious disease outbreaks are the same as those that arise in other
p.000006: areas of public health, the context of 7
p.000006: an outbreak has particular complexities. Decisions during an outbreak need to be made on an urgent basis, often in the
p.000006: context of scientific uncertainty, social and institutional disruption, and an overall climate of fear and distrust.
p.000006: Invariably,
p.000006: the countries most affected by outbreaks have limited resources, underdeveloped legal and regulatory structures, and
p.000006: health systems that lack the resilience to deal with crisis situations. Countries that experience natural disasters and
p.000006: armed conflicts are particularly at risk, as these circumstances simultaneously increase the risk of infectious disease
p.000006: outbreaks while
p.000006: decreasing needed resources and access to health care. Moreover, infectious disease outbreaks can generate or
p.000006: exacerbate social crises that can weaken already fragile health systems. Within such contexts, it
p.000006: is not possible to satisfy all urgent needs simultaneously, forcing decision-makers to weigh and prioritize potentially
p.000006: competing ethical values. Time pressures and resource constraints may force action without
p.000006: the thorough deliberation, inclusiveness and transparency that a robust ethical decision-making process demands.
p.000006:
p.000006: This guidance document on ethical issues that arise specifically in the context of infectious disease outbreaks aims to
p.000006: complement existing guidance on ethics in public health. It should therefore be read in conjunction with more general
p.000006: guidance on issues such as public health surveillance,
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006: research with human participants, and addressing the needs of vulnerable populations.
p.000006:
p.000006: Setting up decision-making systems and procedures in advance is the best way to ensure that ethically appropriate
p.000006: decisions will be made if an outbreak
...

General/Other / Impaired Autonomy

Searching for indicator autonomy:

(return to top)
p.000006: heard), transparency (providing clear and accurate information about the basis for decisions and the process by which
p.000006: they are made), inclusiveness/community engagement (ensuring all relevant stakeholders are able to participate in
p.000006: decisions), accountability (allocating and enforcing responsibility
p.000006: for decisions), and oversight (ensuring appropriate mechanisms for monitoring and review).
p.000006:
p.000006: Beneficence — Beneficence refers to acts that are done for the benefit of others, such as efforts to relieve
p.000006: individuals’ pain and suffering. In the public health context, the principle of beneficence underlies society’s
p.000006: obligation to meet the basic needs of individuals and communities, particularly humanitarian needs such as nourishment,
p.000006: shelter, good health, and security.
p.000006:
p.000006: Utility — The principle of utility states that actions are right insofar as they promote the well-being of individuals
p.000006: or communities. Efforts to maximize utility require consideration of proportionality (balancing the potential benefits
p.000006: of an activity against any risks of harm) and
p.000006: efficiency (achieving the greatest benefits at the lowest possible cost).
p.000006:
p.000006: Respect for persons — The term “respect for persons” refers to treating individuals in ways that are fitting to and
p.000006: informed by a recognition of our common humanity, dignity and inherent rights. A central
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006: aspect of respect for persons is respect for autonomy, which requires letting individuals make their own choices based
p.000006: on their values and preferences. Informed consent, a process in which a competent individual authorizes a course of
p.000006: action based on sufficient relevant information, without coercion or undue inducement, is one
p.000006: way to operationalize this concept. Where individuals lack decision-making capacity, it may be necessary for others to
p.000006: be charged with protecting their interests. Respect for persons also includes paying attention to values such as
p.000006: privacy and confidentiality, as well as social, religious and cultural beliefs and important relationships, including
p.000006: family bonds. Finally, respect for persons requires transparency and truth-telling in the context of carrying out
p.000006: public health and research activities.
p.000006:
p.000006: LibertyLiberty includes a broad range of social, religious and political freedoms, such as freedom of movement,
p.000006: freedom of peaceful assembly, and freedom of speech. Many aspects of liberty are protected as fundamental human rights.
p.000006:
p.000006: Reciprocity — Reciprocity consists of making a “fitting and proportional return” for contributions that people have
p.000006: made.6 Policies that encourage reciprocity can
...

p.000035: an emergency basis outside clinical trials, provided:
p.000035:
p.000035: 1) no proven effective treatment exists;
p.000035:
p.000035: 2) it is not possible to initiate clinical studies immediately;
p.000035:
p.000035: 3) data providing preliminary support of the intervention’s efficacy and safety are available, at least from laboratory
p.000035: or animal studies, and use of the intervention outside clinical trials has been suggested by an appropriately qualified
p.000035: scientific advisory committee on the basis of a favourable risk–benefit analysis;
p.000035:
p.000035: 4) the relevant country authorities, as well as an appropriately qualified ethics committee, have approved such use;
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035: 5) adequate resources are available to ensure that risks can be minimized;
p.000035:
p.000035: 6) the patient’s informed consent is obtained; and
p.000035:
p.000035: 7) the emergency use of the intervention is monitored and the results are documented
p.000035: 36 and shared in a timely manner with the
p.000035: wider medical and scientific community.
p.000035:
p.000035: As explained in prior WHO guidance, the use of experimental interventions under these circumstances is referred to as
p.000035: “monitored emergency use of unregistered and experimental interventions” (MEURI).18
p.000035:
p.000035: Ethical basis for MEURI — MEURI is justified by the ethical principle of respect for patient autonomy — i.e. the right
p.000035: of individuals to make their own risk–benefit assessments in light of their personal values, goals and health
p.000035: conditions.
p.000035: It is also supported by the principle of beneficence — providing patients with available and reasonable opportunities
p.000035: to improve their condition, including measures that can plausibly mitigate extreme suffering and enhance survival.
p.000035:
p.000035: Scientific basis for MEURI — Countries should not authorize MEURI unless
p.000035: it has first been recommended by an appropriately qualified scientific advisory committee especially established for
p.000035: this purpose. This committee should base its recommendations on a rigorous review of all data available from
p.000035: laboratory, animal and human studies of the intervention to assess the risk–benefit of MEURI in the context of the
p.000035: risks for patients who do not receive MEURI.
p.000035:
p.000035: MEURI should be guided by the same ethical principles that guide use of
p.000035: unproven compounds in clinical trials, including the following:
p.000035:
p.000035: • Importance of ethical oversight — MEURI is intended to be an exceptional measure for situations in which
p.000035: initiating a clinical trial is not feasible, not as a means to circumvent ethical oversight of the use of unproven
p.000035: interventions. Thus, mechanisms should be established to ensure that MEURI is subject to ethical oversight.
p.000035:
p.000035: • Effective resource allocation — MEURI should not preclude or delay the initiation of clinical research into
p.000035: experimental products. In addition, it should not divert attention or resources from the implementation of effective
p.000035: clinical care and/or public health measures that may be crucial to control an outbreak.
...

General/Other / Public Emergency

Searching for indicator emergency:

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p.000001: distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and
p.000001: use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising
p.000001: from its use.
p.000001:
p.000001: Printed in Spain
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001: Table of Contents
p.000001:
p.000001:
p.000001:
p.000001:
p.000001:
p.000001: Foreword ............................................................................................................ 3
p.000001: 1
p.000001: Acknowledgements 4
p.000001: Introduction 7
p.000001: Guidelines 12
p.000001: 1. Obligations of governments and the international community 13
p.000001: 2. Involving the local community
p.000015: 15
p.000015: 3. Situations of particular vulnerability
p.000017: 17
p.000017: 4. Allocating scarce resources
p.000020: 20
p.000020: 5. Public health surveillance
p.000023: 23
p.000023: 6. Restrictions on freedom of movement 25
p.000023: 7. Obligations related to medical interventions for the diagnosis, treatment,
p.000023: and prevention of infectious disease
p.000028: 28
p.000028: 8. Research during infectious disease outbreaks 30
p.000028: 9. Emergency use of unproven interventions outside of research 35
p.000028: 10. Rapid data sharing
p.000038: 38
p.000038: 11. Long-term storage of biological specimens collected during infectious
p.000038: disease outbreaks
p.000039: 39
p.000039: 12. Addressing sex- and gender-based differences 41
p.000039: 13. Frontline response workers’ rights and obligations 43
p.000039: 14. Ethical issues in deploying foreign humanitarian aid workers 47
p.000039: References 50
p.000039: Annex 1. Ethics guidance documents consulted in developing Guidance for managing ethical issues in infectious disease
p.000039: outbreaks 52
p.000039: Annex 2. Participants at meetings to formulate Guidance for managing ethical issues in infectious disease outbreaks
p.000055: 55
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055: Foreword
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055: Infectious disease outbreaks are periods of great uncertainty. Events unfold, resources and capacities that are often
p.000055: limited
p.000055: are stretched yet further, and decisions for a public health response must be made quickly, even though the evidence
p.000055: for decision-making may be scant. In such a situation, public health officials, policy-makers, funders, researchers,
p.000055: field epidemiologists, first responders, national
p.000055: ethics boards, health-care workers, and public health practitioners need a moral compass
p.000055: to guide them in their decision-making. Bioethics puts people at the heart of the problem, emphasizes the principles
p.000055: that should guide health systems, and provides the moral rationale for making choices, particularly in a crisis.
p.000055:
p.000055: I therefore welcome the development of the Guidance for managing ethical issues in infectious disease outbreaks, which
p.000055: will be key to embedding ethics within the integrated global alert and response system for epidemics and other public
p.000055: health emergencies. The publication will also
p.000055: support and strengthen the implementation and uptake of policies and programmes in this context.
p.000055:
p.000055: Research is an integral part of the public health response – not only to learn about the current epidemic but also to
p.000055: build an evidence base for future epidemics. Research during
p.000055: an epidemic ranges from epidemiological and socio-behavioral to clinical trials and toxicity studies, all of which are
p.000055: crucial. I am pleased
p.000055: to see that the guidance touches upon this 3
p.000055: important area with advice, not only on research and emergency use of unproven interventions, but also on rapid data
p.000055: sharing see: http://www.who.int/ihr/procedures/ SPG_data_sharing.pdf?ua=1.
p.000055:
p.000055: The importance given to communication during an infectious disease outbreak can make or break public health efforts,
p.000055: and WHO takes this very seriously. This
p.000055: document outlines the ethical principles that should guide communication planning and implementation at every level
p.000055: from frontline workers to policy-makers.
p.000055:
p.000055: The guidance represents the work of an international group of stakeholders and experts, including public health
p.000055: practitioners in charge of response management at
p.000055: the local, national and international level; nongovernmental organization representatives; directors of funding
p.000055: agencies; chairs of ethics committees; heads of research laboratories; representatives
p.000055: of national regulatory agencies; patient representatives; and experts in public health ethics, bioethics, human rights,
p.000055: anthropology, and epidemiology. I am grateful for their support and input.
p.000055:
p.000055: Dr Marie‑Paule Kieny Assistant Director-General Health Systems and Innovation
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055: Acknowledgements
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055: 4 The Guidance document was produced under the overall direction of Abha Saxena, Coordinator of the Global
p.000055: Health Ethics team, supported by Andreas Reis and Maria Magdalena Guraiib.
p.000055:
p.000055: WHO is grateful to Carl Coleman for his role as lead writer, his analysis and synthesis of existing guidance documents,
...

p.000055:
p.000055: A special thanks to Vânia de la Fuente Núñez, who was responsible for managing the Ethics Working Group; and Michele
p.000055: Loi who coordinated the whole process.
p.000055: Former interns of the Global Health Ethics team Patrick Hummel (University of
p.000055: St Andrews, United Kingdom) and Corinna Klingler (University of Munich, Germany) deserve a special mention for
p.000055: undertaking a scoping review in relation to pregnancy
p.000055: and infectious diseases, which informed the development of guidance in this area.
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055: The guidance document would not have been possible without the generous support of the Wellcome Trust. The kind support
p.000055: of the following partners is also very gratefully acknowledged: 3U Global Health Partnership; Canadian Institutes of
p.000055: Health Research; Dublin City University; European Union Cooperation in Science and Technology; Monash University;
p.000055: University of Miami Miller School of Medicine Institute for Bioethics and Health Policy.
p.000055:
p.000006: 6
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006: Introduction
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006: This guidance grew out of concern at the World Health Organization (WHO) about ethical issues raised by the Ebola
p.000006: outbreak in West Africa in 2014–2016. The WHO Global Health Ethics Unit’s response to Ebola began in August 2014,
p.000006: immediately after it was declared a “public health emergency of international concern” pursuant to the International
p.000006: Health Regulations (2005) (IHR).1 That declaration led to the formation of an Ethics Panel, and later an Ethics
p.000006: Working Group, which was charged with developing ethics guidance on issues and concerns as they arose in
p.000006: the course of the epidemic. It became increasingly apparent that the ethical issues raised by Ebola mirrored concerns
p.000006: that had arisen in other global infectious disease outbreaks, including severe acute respiratory syndrome (SARS),
p.000006: pandemic influenza, and multidrug-resistant tuberculosis. However, while WHO has issued ethical guidance
p.000006: on some of these outbreaks,2,3,4,5 prior guidance has only focused on the specific pathogen in isolation. The purpose
p.000006: of this document is to look beyond issues specific to particular epidemic pathogens and instead focus on the
p.000006: cross-cutting ethical issues that apply to infectious disease outbreaks generally. In addition to setting forth general
p.000006: principles, it examines how these principles can be adapted to different epidemiological and social circumstances.
p.000006:
p.000006: While many of the ethical issues that arise in infectious disease outbreaks are the same as those that arise in other
p.000006: areas of public health, the context of 7
p.000006: an outbreak has particular complexities. Decisions during an outbreak need to be made on an urgent basis, often in the
p.000006: context of scientific uncertainty, social and institutional disruption, and an overall climate of fear and distrust.
p.000006: Invariably,
...

p.000006: of the benefits and burdens of epidemic response efforts.
p.000006:
p.000006: Solidarity — Solidarity is a social relation in which a group, community, nation
p.000006: or, potentially, global community stands together.7 The principle of solidarity justifies collective action in the
p.000006: face of common threats. It also supports efforts to overcome inequalities that undermine the welfare
p.000006: of minorities and groups that suffer from discrimination.
p.000006:
p.000006:
p.000006: Practical applications
p.000006:
p.000006: The application of ethical principles should be informed by evidence as far as it is
p.000006: available. For example, in determining 9
p.000006: whether a particular action contributes to utility, decision-makers should be guided by any available scientific
p.000006: evidence about the action’s expected benefits and harms.
p.000006: The more intrusive the proposed action, the greater the need for robust evidence that what is being proposed is likely
p.000006: to achieve its desired aim. When specific evidence is not available, decisions should be based
p.000006: on reasoned, substantive arguments and informed by evidence from analogous situations, to the extent possible.
p.000006:
p.000006: In balancing competing principles during infectious disease outbreaks, countries must respect their obligations under
p.000006: international human rights agreements. The Siracusa Principles on the Limitation and Derogation Provisions in the
p.000006: International Covenant on Civil and Political Rights
p.000006: (the “Siracusa Principles”)8 are a widely accepted framework for evaluating
p.000006: the appropriateness of limiting certain fundamental human rights in emergency situations. The Siracusa Principles
p.000006: provide that any restrictions on human rights must be carried out in accordance with the law and in pursuit of a
p.000006: legitimate objective of general interest. In addition, such restrictions must be strictly necessary and there must
p.000006: be no other, less intrusive means available to reach the same objective. Finally, any restrictions must be based on
p.000006: scientific evidence and not imposed in an arbitrary, unreasonable, or discriminatory manner.
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006:
p.000006: For both pragmatic and ethical reasons, maintaining the population’s trust in epidemic response efforts is of
p.000006: fundamental importance. This is possible only if
p.000006: policy-makers and response workers act in a trustworthy manner by applying
p.000006: procedural principles fairly and consistently, being open to review based on new
p.000006: 10 relevant information, and acting with the
p.000006: genuine input of affected communities.
p.000006: In addition, a synchronized approach is indispensable to the success of any
p.000006: response effort. All members of the global community need to act in solidarity, since all countries share a common
p.000006: vulnerability to the threat of infectious disease.
p.000006:
p.000006:
p.000006: How the Guidance was developed
p.000006: Many individuals have helped shape this guidance document, directly or indirectly, starting with the Ethics Panel that
p.000006: was convened by the Director-General on
...

p.000013: Governments can play a critical role in preventing and responding to infectious disease outbreaks by improving social
p.000013: and environmental conditions, ensuring well-functioning and accessible health systems, and engaging in public health
p.000013: surveillance and prevention activities.
p.000013: Together, these actions can substantially reduce the spread of diseases with epidemic potential. In addition, they help
p.000013: assure that an effective public health response will be possible if an epidemic occurs. Governments have an ethical
p.000013: obligation to ensure the long-term capacity of the systems necessary to carry out effective epidemic prevention and
p.000013: response efforts.
p.000013:
p.000013: Countries have obligations not only to persons within their own borders but also to the broader international
p.000013: community. As the United Nations Committee on
p.000013:
p.000013: Economic, Social and Cultural Rights has recognized, “given that some diseases are easily transmissible beyond the
p.000013: frontiers of a State, the international community has a collective responsibility to address this problem. The
p.000013: economically developed States Parties have a special responsibility
p.000013: and interest to assist the poorer developing States in this regard.”9
p.000013:
p.000013: These obligations reflect the practical reality that infectious disease outbreaks do not respect national borders, and
p.000013: that an outbreak in one country can put the rest of the world at risk.
p.000013:
p.000013: Countries’ obligations to consider the needs of the international community do not arise solely in times of emergency.
p.000013: Instead, they require ongoing attention to ameliorate the social determinants of poor
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013: health that contribute to infectious disease outbreaks, including poverty, limited access to education, and inadequate
p.000013: systems of water and sanitation.
p.000013:
p.000013: The following are key elements of the obligations of governments and the international community:
p.000014: 14
p.000014: • Ensuring the sufficiency of national public health laws — As discussed later in this document, certain public
p.000014: health interventions that might be necessary during an infectious disease outbreak (e.g. restrictions on freedom of
p.000014: movement) depend on having a clear legal basis for government action, as well as a system in place to provide oversight
p.000014: and review. All countries should review their public health laws to ensure that they give the government sufficient
p.000014: authority to respond effectively to an epidemic while also providing individuals with appropriate human rights
p.000014: protections.
p.000014:
p.000014: • Participating in global surveillance and preparedness efforts —
p.000014: All countries must carry out their responsibilities under the IHR to participate in global surveillance efforts in a
p.000014: truthful and transparent manner. This includes providing prompt notification of events that may constitute a public
p.000014: health emergency of international concern, regardless
p.000014: of any negative consequences that may be associated with notification, such as a possible reduction in trade or
p.000014: tourism. The obligation to provide
p.000014: prompt notification to the international community stems not only from the text of the IHR but also from the ethical
p.000014: principles of solidarity and reciprocity. In addition, countries should develop
p.000014: preparedness plans for infectious disease outbreaks and other potential disasters and provide guidance to relevant
p.000014: health-care facilities to implement the plans.
p.000014:
p.000014: • Providing financial, technical, and scientific assistance — Countries that have the resources to provide foreign
p.000014: assistance should support global epidemic preparedness and response efforts, including research and development on
p.000014: diagnostics, therapeutics, and vaccines for
p.000014: pathogens with epidemic potential. This support should supplement ongoing efforts to build local public health
p.000014: capacities and strengthen primary health care systems in countries at greatest risk of harm from infectious disease
p.000014: outbreaks.
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014: Avian Influenza in Indonesia
p.000014: Source: Gary Hampton, WHO
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014: 2. Involving the local community
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000015: 15
p.000015: Questions addressed:
p.000015:
...

p.000020: do not accept or give bribes or engage in other corrupt activities.
p.000020:
p.000020: • Separation of responsibilities — To the extent possible, the interpretation of allocation principles should not
p.000020: be entrusted to clinicians who have pre-existing professional relationships that create an ethical obligation to
p.000020: advocate for the
p.000020: interests of specific patients or groups.
p.000020: Instead, decisions should be made by appropriately qualified clinicians
p.000020: who have no personal or professional reasons to advocate for one patient or group over another.
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000020: 5. Public health surveillance
p.000020:
p.000020:
p.000020:
p.000020:
p.000020:
p.000023: 23
p.000023: Questions addressed:
p.000023:
p.000023: • What role does surveillance play in infectious disease outbreak response efforts?
p.000023: • Should surveillance activities be subject to ethical review?
p.000023: • What obligations do entities conducting surveillance activities have to protect the confidentiality of
p.000023: information collected?
p.000023: • Are there any circumstances under which individuals should be asked for consent to, or given the opportunity to
p.000023: opt out of, surveillance activities?
p.000023: • What obligations do those conducting surveillance activities have to disclose information they collect to the
p.000023: affected individuals and communities?
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023: Systematic observation and data collection are essential components of emergency response measures, both to guide the
p.000023: management of the current outbreak and to help prevent and respond to outbreaks in the future. Even if these activities
p.000023: are not characterized as research for regulatory purposes, an ethical analysis should
p.000023: be undertaken to ensure that personal information is protected from physical, legal, psychological, and other harm.
p.000023: Countries should consider organizing systems for ethical oversight of public health activities, commensurate with the
p.000023: activity objectives, methods, risks and benefits, as well as the extent to which the activity involves individuals or
p.000023: groups whose situation may make them vulnerable.
p.000023: Regardless of whether such systems are adopted, ethical analysis of public
p.000023: health activities should be consistent with accepted norms of public health ethics and conducted by individuals or
p.000023: entities that can be held accountable for their decisions.
p.000023:
p.000023: Ensuring high-quality, ethically appropriate surveillance is complicated by at least
p.000023: two factors. First, the law surrounding surveillance across jurisdictions may be unnecessarily complex or inconsistent.
p.000023: Second, surveillance activities will occur across jurisdictions with varying levels of resources, thus placing strains
p.000023: on the quality and reliability of the data. These
p.000023: issues are likely to be exacerbated during an infectious disease outbreak, creating an urgent need for careful planning
p.000023: and international collaboration. Specific issues that should be addressed include the following:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
...

p.000025: conditions of confinement should consider the heightened needs of vulnerable populations, as discussed
p.000025: in Guideline 3.)
p.000025:
p.000025: • Addressing financial and social consequences — Even short-term restrictions on freedom of movement can have
p.000025: significant — and possibly devastating —financial and social consequences for individuals, their families, and their
p.000025: communities. Countries should provide assistance to households that suffer financial
p.000025: losses as a result of inability to conduct business, loss of a job, damage to crops, or other consequences of
p.000025: restrictions on freedom of movement. In some cases, this support may need to continue
p.000025: for a period following the end of confinement. In addition, efforts should be made to support the social and
p.000025: professional reintegration of individuals for whom confinement is no longer necessary, including measures to reduce
p.000025: stigmatization and discrimination.
p.000025:
p.000025: • Due process protections — Mechanisms should be in place to allow individuals whose liberty has been restricted to
p.000025: challenge the appropriateness of those restrictions, the way they are enforced, and the conditions under which the
p.000025: restrictions are carried out. If it is not feasible to provide full due process protection before the restrictions are
p.000025: implemented in an emergency scenario, mechanisms for review and appeal should be made
p.000025: available without excessive delay. All persons involved in decisions to restrict individuals’ freedom of movement
p.000025: should be accountable for any abuses of authority.
p.000025:
p.000025: • Equitable application — Restrictions on freedom of movement should be
p.000025: applied in the same manner to all 27
p.000025: persons posing a comparable public health risk. Thus, individuals should not be subject to greater or lesser
p.000025: restrictions for reasons unrelated to the
p.000025: risks they may pose to others, including membership in any disfavoured or favoured social group or class (for example,
p.000025: groups defined by gender, ethnicity, or religion). In addition, policy- makers should seek to ensure that restrictions
p.000025: are not applied in a manner that imposes a disproportionate burden on vulnerable segments of society.
p.000025:
p.000025: • Communication and transparency —
p.000025: Policy-makers and public health officials should engage communities in a dialogue about any restrictions on freedom of
p.000025: movement and solicit community members’ views on how restrictions can be carried out with the least possible burden.
p.000025: They should also provide regular updates on the implementation of such measures,
p.000025: both to the public at large and to those whose movement has been restricted. Communication strategies should be
...

p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030: benefits; that participants are selected fairly and participate voluntarily (in most situations following an explicit
p.000030: process of informed consent); that participants’ rights and well-being are sufficiently protected; and that studies
p.000030: undergo an
p.000030: adequate process of independent review. These internationally accepted norms and standards stem from the basic ethical
p.000030: principles of beneficence, respect for persons, and justice. They apply to all fields of research involving human
p.000030: beings, whether biomedical, epidemiological, public health or social science studies, and are explained in detail in
p.000030: numerous
p.000030: international ethics guidelines,11,12,13,14,15 all of which apply with full force in outbreak situations. All actors
p.000030: in research, including researchers, research institutions, research ethics committees, national regulators,
p.000030: international organizations, and commercial sponsors, have an obligation to ensure that these principles are upheld in
p.000030: outbreak situations. Doing this requires attention to the following considerations:
p.000030:
p.000030: • Role of local research institutions — When local researchers are available, they should be involved in the
p.000030: design, implementation, analysis, reporting
p.000030: and publication of outbreak-related research. Local researchers can help ensure that studies adequately respond to
p.000030: local realities and needs and that they can be implemented effectively without jeopardizing the emergency response.
p.000030: Involving local researchers in international research collaborations also contributes to building long-
p.000030: term research capacity in affected countries and promoting the value of international equity in science.
p.000030:
p.000030: • Addressing limitations in local research ethics review and scientific
p.000030: capacity — Countries’ capacity to engage in local research ethics review may be limited during outbreaks because of
p.000030: time constraints, lack of expertise, diversion of resources to outbreak response efforts, or pressure from public
p.000030: health authorities that undermines reviewers’ independence.
p.000030: International and nongovernmental 31
p.000030: organizations should assist local research ethics committees to overcome these challenges by, for example, sponsoring
p.000030: collaborative reviews involving representatives from multiple countries supplemented by external experts.
p.000030:
p.000030: • Providing ethics review in time- sensitive circumstances — The need for immediate action to contain an infectious
p.000030: disease outbreak may make it impossible to adhere to the usual timeframes for research ethics review. National research
p.000030: governance systems and the international community should anticipate this problem by developing mechanisms to ensure
p.000030: accelerated ethics review in emergency situations, without undermining any of the substantive protections that ethics
p.000030: review is designed to provide. One option is to
p.000030: authorize the advance review of generic protocols for conducting research in outbreak conditions, which can then
p.000030: be rapidly adapted and reviewed for particular contexts. Early discussion and collaboration with local research ethics
p.000030: committees can help ensure the project is viable and can facilitate local committees’ effective and efficient
p.000030: consideration of final protocols when an outbreak actually occurs.
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030: • Integrating research into broader outbreak response efforts — National authorities and international
p.000030: organizations should seek to coordinate research projects in order to set priorities that are consistent with broader
p.000030: outbreak response efforts, and to avoid unnecessary duplication of research
p.000030: 32 effort or competition among different
p.000030: sites. Researchers have an obligation to share information collected as part of a study if it is important for the
p.000030: ongoing response efforts, such as information about hidden cases and transmission chains or resistance to response
p.000030: measures. Persons who share the information and those who receive it should protect the confidentiality of personal
p.000030: information to the maximum
p.000030: extent possible. As part of the informed consent process, researchers should inform potential participants about
...

p.000030: processes compatible with international research ethics guidelines should be developed
p.000030: in consultation with local communities and implemented by locally recruited personnel. In addition, researchers should
p.000030: be well informed about the medical, psychological and social support systems available locally so that they can guide
p.000030: participants in need towards these services. In some situations, it may be necessary to develop rapid mechanisms for
p.000030: appointing proxy decision-makers, such as during outbreaks of diseases that affect cognitive abilities, or when
p.000030: an outbreak leaves a large number of children as orphans.
p.000030:
p.000030: • Gaining and maintaining trust — Failure to build and maintain community trust during the process of research
p.000030: design and implementation, or when disclosing preliminary results, will not only impede study recruitment and
p.000030: completion but may also undermine
p.000030: the uptake of any interventions proven to be efficacious. Engaging with affected communities before, during, and after
p.000030: a study is essential to build and maintain trust. In environments in which the public’s trust in government is fragile,
p.000030: researchers should remain as independent as possible from official public health activities. If government workers are
p.000030: themselves involved in
p.000030: conducting research, they should inform participants of this fact. Individuals who observe unethical practices carried
p.000030: out in the name of public health or emergency response efforts should promptly report them to ethics committees or
p.000030: other independent bodies.
p.000030: • Selecting an appropriate research 33
p.000030: methodology — Exposing research participants to risk is ethically unacceptable if the study is not designed in a manner
p.000030: capable of providing valid results. It is therefore imperative that all research be designed and conducted in a
p.000030: methodologically rigorous manner. In clinical trials,
p.000030: the appropriateness of features such as randomization, placebo controls, blinding or masking should be determined on a
p.000030: case-by-case basis, with attention to both the scientific
p.000030: validity of the data and the acceptability of the methodology to the community from which participants will be drawn.
p.000030: In studies relying on qualitative methods, the potential benefits of using methodologies such as focus groups (in which
p.000030: individual confidentiality cannot be guaranteed) or of interviewing traumatized victims should be balanced against the
p.000030: risks and burdens to the individuals involved.
p.000030:
p.000030: • Rapid data sharing: As WHO has previously recognized, every researcher who engages in generation of information
p.000030: related to a public health emergency or acute public health event with the potential to progress
p.000030: to an emergency has the fundamental moral obligation to share preliminary results once they are adequately quality
p.000030: controlled for release.16 Such information should be shared with
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030: public health officials, the study participants and affected population, and groups involved in wider international
p.000030: response efforts, without waiting for publication in scientific journals. Journals should facilitate
p.000030: this process by allowing researchers to rapidly disseminate information
p.000030: 34 with immediate implications for public
p.000030: health without losing the opportunity for subsequent consideration for publication in a journal.17
p.000030:
p.000030: • Assuring equitable access to the benefits of research — As
p.000030: recognized in existing international ethics guidelines, individuals and communities that participate in research
p.000030: should, where relevant, have access to any benefits that result from their participation. Research sponsors and host
p.000030: countries should agree in advance on mechanisms to ensure that any interventions found to be safe and effective in
p.000030: research will be made available to the local population without undue delay, including, when feasible, on a
p.000030: compassionate use basis before regulatory approval is finalized.
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030: Staff preparing to go into the Isolation Unit at Persahabatan Hospital, East Jakarta.
p.000030: Source: Jonathan Perugia
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030: 9. Emergency use of unproven interventions outside of research
p.000030:
p.000030:
p.000030:
p.000035: 35
p.000035: Questions addressed:
p.000035:
p.000035: • Under what circumstances is it ethically appropriate to offer patients unproven interventions outside clinical
p.000035: trials during infectious disease outbreaks?
p.000035: • How should such interventions be identified?
p.000035: • What type of ethical oversight should be conducted when unproven interventions are offered outside clinical
p.000035: trials during infectious disease outbreaks?
p.000035: • If such interventions are provided, what should individuals be told about them?
p.000035: • What obligations do persons administering unproven interventions outside clinical trials have to communicate with
p.000035: the community?
p.000035: • What obligations do persons administering unproven interventions outside clinical trials have to share the
p.000035: results?
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035: There are many pathogens for which no proven effective intervention exists. For some pathogens there may be
p.000035: interventions that have shown promising safety and efficacy in the laboratory and in relevant animal models but that
p.000035: have not yet
p.000035: been evaluated for safety and efficacy in humans. Under normal circumstances, such interventions undergo testing in
p.000035: clinical trials that are capable of generating reliable evidence about safety and efficacy. However, in the context of
p.000035: an outbreak characterized by high mortality, it can be ethically appropriate to offer individual patients experimental
p.000035: interventions on
p.000035: an emergency basis outside clinical trials, provided:
p.000035:
p.000035: 1) no proven effective treatment exists;
p.000035:
p.000035: 2) it is not possible to initiate clinical studies immediately;
p.000035:
p.000035: 3) data providing preliminary support of the intervention’s efficacy and safety are available, at least from laboratory
p.000035: or animal studies, and use of the intervention outside clinical trials has been suggested by an appropriately qualified
p.000035: scientific advisory committee on the basis of a favourable risk–benefit analysis;
p.000035:
p.000035: 4) the relevant country authorities, as well as an appropriately qualified ethics committee, have approved such use;
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035: 5) adequate resources are available to ensure that risks can be minimized;
p.000035:
p.000035: 6) the patient’s informed consent is obtained; and
p.000035:
p.000035: 7) the emergency use of the intervention is monitored and the results are documented
p.000035: 36 and shared in a timely manner with the
p.000035: wider medical and scientific community.
p.000035:
p.000035: As explained in prior WHO guidance, the use of experimental interventions under these circumstances is referred to as
p.000035: “monitored emergency use of unregistered and experimental interventions” (MEURI).18
p.000035:
p.000035: Ethical basis for MEURI — MEURI is justified by the ethical principle of respect for patient autonomy — i.e. the right
p.000035: of individuals to make their own risk–benefit assessments in light of their personal values, goals and health
p.000035: conditions.
p.000035: It is also supported by the principle of beneficence — providing patients with available and reasonable opportunities
p.000035: to improve their condition, including measures that can plausibly mitigate extreme suffering and enhance survival.
p.000035:
p.000035: Scientific basis for MEURI — Countries should not authorize MEURI unless
p.000035: it has first been recommended by an appropriately qualified scientific advisory committee especially established for
p.000035: this purpose. This committee should base its recommendations on a rigorous review of all data available from
p.000035: laboratory, animal and human studies of the intervention to assess the risk–benefit of MEURI in the context of the
p.000035: risks for patients who do not receive MEURI.
p.000035:
p.000035: MEURI should be guided by the same ethical principles that guide use of
p.000035: unproven compounds in clinical trials, including the following:
p.000035:
p.000035: • Importance of ethical oversight — MEURI is intended to be an exceptional measure for situations in which
p.000035: initiating a clinical trial is not feasible, not as a means to circumvent ethical oversight of the use of unproven
p.000035: interventions. Thus, mechanisms should be established to ensure that MEURI is subject to ethical oversight.
p.000035:
p.000035: • Effective resource allocation — MEURI should not preclude or delay the initiation of clinical research into
p.000035: experimental products. In addition, it should not divert attention or resources from the implementation of effective
p.000035: clinical care and/or public health measures that may be crucial to control an outbreak.
p.000035:
p.000035: • Minimizing risk — Administering unproven interventions necessarily involves risks, some of which will not be
p.000035: fully understood until further testing is conducted. However, any known risks associated with an intervention should be
p.000035: minimized to the extent reasonably possible (e.g. administration under hygienic conditions; using
p.000035: the same safety precautions that would be used during a clinical trial, with close monitoring and access to emergency
p.000035: medication and equipment; and providing necessary supportive treatment). Only investigational products manufactured
p.000035: according to good manufacturing practices should be used for MEURI.
p.000035:
p.000035: • Collection and sharing of meaningful data — Physicians overseeing MEURI have the same moral
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035: obligation to collect all scientifically relevant data on the safety and efficacy of the intervention as researchers
p.000035: overseeing a clinical trial. Knowledge generated through MEURI should be aggregated across patients if possible and
p.000035: shared transparently, completely and rapidly with the MEURI scientific advisory committee, public health authorities,
p.000035: physicians and researchers in the country, and the international medical and scientific community.
p.000035: Information should be described accurately, without overstating benefits or understating uncertainties or risks.
p.000035:
p.000035: • Importance of informed consent — Individuals who are offered MEURI should be made aware that the intervention
p.000035: might not benefit
p.000035: them and might even harm them. The process of obtaining informed consent to MEURI should be carried out in a
p.000035: culturally and linguistically sensitive manner, with an emphasis on the content and understandability of the
p.000035: information conveyed and the voluntariness of the patient’s decision.
p.000035: The ultimate choice of whether to receive the unproven intervention must rest with the patient, if the patient is
...

p.000035: MEURI must be sensitive to local norms and practices. One way to try to ensure such sensitivity is to use rapid
p.000035: “community engagement
p.000035: teams” to promote dialogue about the potential benefits and risks of receiving
p.000035: interventions that have not yet been tested in clinical trials.
p.000035:
p.000035: • Fair distribution in the face of scarcity — Compounds qualifying for MEURI may not be available in large
p.000035: quantities. In this situation, choices will have to be made about who receives
p.000035: each intervention. Countries should 37
p.000035: establish mechanisms for making these allocation decisions, taking into account the assessment of the MEURI Scientific
p.000035: Advisory Committee and the principles discussed in Guideline 4.
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035: 10. Rapid data sharing
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000038: 38
p.000038: Questions addressed:
p.000038:
p.000038: • Why is rapid data sharing essential during an infectious disease outbreak?
p.000038: • What are the key ethical issues related to rapid data sharing?
p.000038:
p.000038:
p.000038:
p.000038:
p.000038:
p.000038: The collection and sharing of data are essential parts of ordinary public health practice. During an infectious disease
p.000038: outbreak, data sharing takes on increased urgency because of the uncertain and ever-changing scientific information;
p.000038: the compromised response capacity of local health systems; and the heightened role of cross-border collaboration. For
p.000038: these reasons, “rapid data sharing is critical during an unfolding health emergency.”19
p.000038: The ethically appropriate and rapid sharing of data can help identify etiological factors, predict disease spread,
p.000038: evaluate existing and novel treatment, symptomatic care and preventive measures, and guide the deployment of limited
p.000038: resources.
p.000038:
p.000038: Activities that generate data include public health surveillance, clinical research studies, individual patient
p.000038: encounters (including MEURI), and epidemiological, qualitative, and environmental studies. All individuals and entities
p.000038: involved in these efforts should cooperate by sharing relevant and accurate data in a timely manner. As discussed in
p.000038: Guideline 8, efforts should be made to ensure that rapid sharing of information
p.000038:
p.000038: with immediate implications for public health does not preclude subsequent publication in a scientific journal.
p.000038:
p.000038: As part of ongoing pre-epidemic preparedness efforts, countries should review their laws, policies, and practices
p.000038: regarding data sharing to ensure that they adequately protect the confidentiality of personal information and address
p.000038: other relevant ethical questions like managing incidental findings, and dealing with disputes over the ownership or
p.000038: control of information.
p.000038:
p.000038:
p.000038:
p.000038:
p.000038:
p.000038:
p.000038:
p.000038:
p.000038: 11. Long-term storage of biological specimens collected during infectious disease outbreaks
p.000038:
p.000038:
p.000039: 39
p.000039: Questions addressed:
p.000039:
p.000039: • What are the benefits and risks associated with the long-term storage of biological specimens collected during
p.000039: infectious disease outbreaks?
p.000039: • What obligations do entities involved in the long-term storage of biological specimens collected during
...

p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: Earthquake Haiti 2010
p.000043: Source: Victor Ariscain, PAHO/WHO
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: 14. Ethical issues in deploying foreign humanitarian aid workers
p.000043:
p.000043:
p.000043:
p.000047: 47
p.000047: Questions addressed:
p.000047:
p.000047: • What ethical issues arise in assigning foreign workers for deployment during infectious disease outbreaks?
p.000047: • What obligations do sponsoring organizations have to prepare foreign aid workers adequately for their missions?
p.000047: • What obligations do sponsoring organizations have regarding the conditions of deployment?
p.000047: • What obligations do sponsoring organizations have to coordinate with local officials?
p.000047: • What obligations do foreign aid workers have before, during, and after deployment?
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047: Foreign governments and humanitarian aid organizations that deploy workers in infectious disease outbreaks have ethical
p.000047: obligations to both the workers themselves and the affected communities. These obligations include the following:
p.000047:
p.000047: • Coordination with local officials — Foreign governments and external humanitarian aid organizations should deploy
p.000047: workers following discussion and agreement with local officials about their roles and responsibilities or, if
p.000047: this is not possible, with international organizations like WHO. Organizations working in a particular area should
p.000047: register their presence as a foreign Emergency Medical Team (EMT) with
p.000047: the local government, and have ongoing discussions among themselves and with the local government to clarify and
p.000047: coordinate their roles
p.000047: and responsibilities and address any disparities in standards of practice. Efforts should be coordinated with local
p.000047: authorities and care providers to
p.000047: ensure that the foreign agency does not excessively draw resources away from other essential services.
p.000047:
p.000047: • Fairness in assigning foreign workers for deployment — Foreign aid workers should be deployed only if they are
p.000047: capable of providing necessary services not sufficiently available in the local setting. Assignment of foreign
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047: health workers should take into consideration their relevant skills and knowledge, as well as their linguistic and
p.000047: cultural competencies to meet mission objectives and understand and communicate with affected communities. It is
p.000047: inappropriate to deploy unqualified or unnecessary
p.000047: 48 workers solely to satisfy their personal
p.000047: or professional desire to be helpful (so-called “disaster tourism”).
p.000047:
p.000047: • Clarity about conditions of deployment — Prospective foreign aid workers should be given
p.000047: comprehensive information about the project’s expectations and risks so they can make informed decisions about whether
p.000047: or not they will be able to make appropriate contributions. In addition, foreign aid workers should be clearly
...

p.000050: 2007 (www.cidrap.umn.edu/sites/default/files/public/
p.000050: php/196/196_guidance.pdf).
p.000053: 53
p.000053:
p.000053: Altevogt BM, Stroud C, Hanson S, Hanfling D, Gostin LO, editors. Guidance for establishing crisis standards of care for
p.000053: use in disaster situations: A letter report. Washington: National Academies Press; 2009
p.000053: (www.nap.edu/read/12749/chapter/1).
p.000053:
p.000053: Ethical issues raised by a possible influenza pandemic. Opinion No. 106. Paris: National Consultative Ethics Committee
p.000053: for Health and Life Sciences; 2009 (www.ccne-ethique.fr/ sites/default/files/publications/avis_106_anglais.pdf).
p.000053:
p.000053: Ethics and Ebola: Public health planning and response. Washington DC: Presidential Commission for the Study of
p.000053: Bioethical Issues.; 2015 (http://bioethics.gov/sites/default/files/ Ethics-and-Ebola_PCSBI_508.pdf).
p.000053:
p.000053: Ethical guidelines in Pandemic Influenza - Recommendations of the Ethics Subcommittee of the Advisory Committee to the
p.000053: Director, United States Centers for Disease Control and Prevention. Ethical guidelines in pandemic influenza. Atlanta:
p.000053: Centers for Disease Control and Prevention; 2007 (www.cdc.gov/od/science/integrity/phethics/docs/panflu_ethic_
p.000053: guidelines.pdf).
p.000053:
p.000053: Ethics Subcommittee of the Advisory Committee to the Director, United States Centers for Disease Control and
p.000053: Prevention. Ethical guidance for public health emergency preparedness and response: Highlighting ethics and values in
p.000053: vital public health service. Atlanta: Centers for Disease Control and Prevention; 2008
p.000053: (www.cdc.gov/od/science/integrity/phethics/docs/
p.000053: white_paper_final_for_website_2012_4_6_12_final_for_web_508_compliant.pdf).
p.000053:
p.000053: Ethics Subcommittee of the Advisory Committee to the Director, United States Centers for Disease Control and
p.000053: Prevention. Ethical considerations for decision making regarding allocation of mechanical ventilators during a severe
p.000053: influenza pandemic or other public health emergency. Atlanta: Centers for Disease Control and Prevention; 2011
p.000053: (www.cdc. gov/about/pdf/advisory/ventdocument_release.pdf).
p.000053:
p.000053: Integrated national avian and pandemic influenza response plan, 2007–2009. In: Avian Influenza and the Pandemic
p.000053: Threats: Nigeria. Geneva: United Nations System Influenza Coordination Office
p.000053: (http://un-influenza.org/?q=content/Nigeria).
p.000053:
p.000053:
p.000053:
p.000053:
p.000053:
p.000053:
p.000053:
p.000053:
p.000053: National Advisory Board on Health Care Ethics. Ethical considerations related to preparedness for a pandemic. Helsinki:
p.000053: Ministry of Social Affairs and Health; 2005 (http://
p.000053: etene.fi/documents/1429646/1561478/2005+Statement+on+ethical+considerations+relate
p.000053: d+to+preparedness+for+a+pandemic.pdf/fc3f2412-acfc-4685-b427-ca710a43c103).
p.000053:
p.000053: National Ethics Advisory Committee. Getting through together: Ethical values for
p.000053: a pandemic. Wellington: Ministry of Health; 2007 (https://neac.health.govt.nz/system/files/
p.000053: documents/publications/getting-through-together-jul07.pdf).
p.000054: 54
p.000054: Notes on the interim US guidance for monitoring and movement of persons with potential Ebola virus exposure. Atlanta
p.000054: GA: Centers for Disease Control and Prevention; 2016 (www.
p.000054: cdc.gov/vhf/ebola/exposure/monitoring-and-movement-of-persons-with-exposure.html).
p.000054:
p.000054: Pandemic Influenza Ethics Initiative Workgroup. Meeting the challenge of pandemic influenza: Ethical guidance for
p.000054: leaders and health care professionals in the veterans health administration. Washington DC: National Center for Ethics
p.000054: in Health Care, Veterans Health Administration; 2010 (www.ethics.va.gov/docs/pandemicflu/Meeting_the_Challenge_of_
p.000054: Pan_Flu-Ethical_Guidance_VHA_20100701.pdf).
p.000054:
p.000054: Responding to pandemic influenza: The ethical framework for policy and planning. London: Department of Health; 2007
p.000054: (www.gov.scot/Resource/Doc/924/0054555.pdf).
p.000054:
p.000054: Stand on guard for thee: Ethical considerations in preparedness planning for pandemic influenza. Toronto: University of
p.000054: Toronto Joint Centre for Bioethics; 2005 (www.jcb. utoronto.ca/people/documents/upshur_stand_guard.pdf).
p.000054:
p.000054: Swiss Federal Office of Public Health. Swiss Influenza Pandemic Plan. Bern; 2013
p.000054: (www.bag.admin.ch/influenza/01120/01132/10097/10104/index.html?lang=en&download=
p.000054: NHzLpZeg7t,lnp6I0NTU042l2Z6ln1ad1IZn4Z2qZpnO2Yuq2Z6gpJCGenx6gWym162epYb g2c_JjKbNoKSn6A--).
p.000054:
p.000054: Venkat A, Wolf L, Geiderman JM, Asher SL, Marco CA, McGreevy J et al. Ethical issues in the response to Ebola virus
p.000054: disease in US emergency departments: a position paper of the American College of Emergency Physicians, the Emergency
p.000054: Nurses Association and the Society for Academic Emergency Medicine. J Emerg Nurs. 2015; Mar;41(2):e5-e16. doi:
p.000054: 10.1016/j.jen.2015.01.012 (www.ncbi.nlm.nih.gov/pubmed/25770003).
p.000054:
p.000054:
p.000054:
p.000054:
p.000054:
p.000054:
p.000054:
p.000054: Annex 2. Participants at meetings to formulate Guidance for managing ethical issues in infectious disease outbreaks
p.000054:
p.000054:
p.000054:
p.000054: Panel discussion: Ethical considerations for use of unregistered interventions
p.000054: for Ebola viral disease, World Health Organization, Geneva, 11 August 2014 55
p.000054:
p.000054: Advisors
p.000054: Dr Juan Pablo Beca, Professor, Bioethics Center, Universidad del Desarrollo, Chile
p.000054: Dr Helen Byomire Ndagije, Head, Drug Information Department, Ugandan National Drug Authority, Uganda
p.000054: Dr Philippe Calain (Chair), Senior Researcher, Unit of Research on Humanitarian Stakes and Practices, Médecins Sans
p.000054: Frontières, Switzerland
p.000054: Dr Marion Danis, Head, Ethics and Health Policy and Chief, Bioethics Consultation Service, National Institutes of
p.000054: Health, United States of America
p.000054: Professor Jeremy Farrar, Director, Wellcome Trust, United Kingdom Professor Ryuichi Ida, Chair, National Bioethics
p.000054: Advisory Committee, Japan
p.000054: Professor Tariq Madani, infectious diseases physician and clinical academic researcher, Saudi Arabia
p.000054: Professor Michael Selgelid, Director, Centre for Human Bioethics, Monash University, Australia
p.000054: Professor Peter Smith, Professor of Tropical Epidemiology, London School of Tropical Medicine and Hygiene, United
p.000054: Kingdom
...

General/Other / Relationship to Authority

Searching for indicator authority:

(return to top)
p.000013: and interest to assist the poorer developing States in this regard.”9
p.000013:
p.000013: These obligations reflect the practical reality that infectious disease outbreaks do not respect national borders, and
p.000013: that an outbreak in one country can put the rest of the world at risk.
p.000013:
p.000013: Countries’ obligations to consider the needs of the international community do not arise solely in times of emergency.
p.000013: Instead, they require ongoing attention to ameliorate the social determinants of poor
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013:
p.000013: health that contribute to infectious disease outbreaks, including poverty, limited access to education, and inadequate
p.000013: systems of water and sanitation.
p.000013:
p.000013: The following are key elements of the obligations of governments and the international community:
p.000014: 14
p.000014: • Ensuring the sufficiency of national public health laws — As discussed later in this document, certain public
p.000014: health interventions that might be necessary during an infectious disease outbreak (e.g. restrictions on freedom of
p.000014: movement) depend on having a clear legal basis for government action, as well as a system in place to provide oversight
p.000014: and review. All countries should review their public health laws to ensure that they give the government sufficient
p.000014: authority to respond effectively to an epidemic while also providing individuals with appropriate human rights
p.000014: protections.
p.000014:
p.000014: • Participating in global surveillance and preparedness efforts —
p.000014: All countries must carry out their responsibilities under the IHR to participate in global surveillance efforts in a
p.000014: truthful and transparent manner. This includes providing prompt notification of events that may constitute a public
p.000014: health emergency of international concern, regardless
p.000014: of any negative consequences that may be associated with notification, such as a possible reduction in trade or
p.000014: tourism. The obligation to provide
p.000014: prompt notification to the international community stems not only from the text of the IHR but also from the ethical
p.000014: principles of solidarity and reciprocity. In addition, countries should develop
p.000014: preparedness plans for infectious disease outbreaks and other potential disasters and provide guidance to relevant
p.000014: health-care facilities to implement the plans.
p.000014:
p.000014: • Providing financial, technical, and scientific assistance — Countries that have the resources to provide foreign
p.000014: assistance should support global epidemic preparedness and response efforts, including research and development on
p.000014: diagnostics, therapeutics, and vaccines for
p.000014: pathogens with epidemic potential. This support should supplement ongoing efforts to build local public health
p.000014: capacities and strengthen primary health care systems in countries at greatest risk of harm from infectious disease
p.000014: outbreaks.
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
p.000014:
...

p.000023: issues are likely to be exacerbated during an infectious disease outbreak, creating an urgent need for careful planning
p.000023: and international collaboration. Specific issues that should be addressed include the following:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023: • Protecting the confidentiality of personal information — The
p.000023: unauthorized disclosure of personal information collected during an infectious disease outbreak (including name,
p.000023: address, diagnosis, family history, etc.) can expose individuals to significant risk. Countries should
p.000023: 24 ensure that adequate protection exists
p.000023: against these risks, including laws that safeguard the confidentiality of information generated through
p.000023: surveillance activities, and that strictly limit the circumstances in which such information may be used or disclosed
p.000023: for purposes different from those for which it was initially collected. Use and sharing of non-aggregated surveillance
p.000023: data for research purposes must have the approval of a properly constituted and trained research ethics committee.
p.000023:
p.000023: • Assessing the importance of universal participation — Public health surveillance is typically conducted on a
p.000023: mandatory basis, without
p.000023: the possibility of individual refusal. Collecting surveillance information on a mandatory basis is ethically
p.000023: appropriate on the grounds of public
p.000023: interest if an accountable governmental authority has determined that universal participation is necessary to achieve
p.000023: compelling public health objectives.
p.000023: However, it should not be assumed that surveillance activities must always be carried out on a mandatory basis.
p.000023: Entities responsible for designing and approving surveillance programmes should consider the appropriateness of
p.000023: allowing individuals to opt out of particular surveillance activities, taking into account the nature and degree of
p.000023: individual risks involved and the extent to which allowing opt-outs
p.000023: would undermine the activity’s public health goals.
p.000023:
p.000023: • Disclosing information to individuals and communities — Regardless of whether individuals are given the choice to
p.000023: opt out of surveillance activities, the process of surveillance should be conducted on a transparent basis. At a
p.000023: minimum, individuals and communities should be aware of the type of information
p.000023: that will be gathered about them, the purposes for which this information will be used, and any circumstances under
p.000023: which the information collected may be shared with third parties. In addition, information about the outcome of the
p.000023: surveillance activity should be made available as soon as reasonably possible.
p.000023: Careful attention should be given to the manner in which this information is communicated, in order to minimize
p.000023: the risk that subjects of surveillance may face stigmatization or discrimination.
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023:
p.000023: 6. Restrictions on freedom of movement
p.000023:
p.000023:
p.000023:
p.000025: 25
p.000025: Questions addressed:
p.000025:
...

p.000025:
p.000025: • Addressing financial and social consequences — Even short-term restrictions on freedom of movement can have
p.000025: significant — and possibly devastating —financial and social consequences for individuals, their families, and their
p.000025: communities. Countries should provide assistance to households that suffer financial
p.000025: losses as a result of inability to conduct business, loss of a job, damage to crops, or other consequences of
p.000025: restrictions on freedom of movement. In some cases, this support may need to continue
p.000025: for a period following the end of confinement. In addition, efforts should be made to support the social and
p.000025: professional reintegration of individuals for whom confinement is no longer necessary, including measures to reduce
p.000025: stigmatization and discrimination.
p.000025:
p.000025: • Due process protections — Mechanisms should be in place to allow individuals whose liberty has been restricted to
p.000025: challenge the appropriateness of those restrictions, the way they are enforced, and the conditions under which the
p.000025: restrictions are carried out. If it is not feasible to provide full due process protection before the restrictions are
p.000025: implemented in an emergency scenario, mechanisms for review and appeal should be made
p.000025: available without excessive delay. All persons involved in decisions to restrict individuals’ freedom of movement
p.000025: should be accountable for any abuses of authority.
p.000025:
p.000025: • Equitable application — Restrictions on freedom of movement should be
p.000025: applied in the same manner to all 27
p.000025: persons posing a comparable public health risk. Thus, individuals should not be subject to greater or lesser
p.000025: restrictions for reasons unrelated to the
p.000025: risks they may pose to others, including membership in any disfavoured or favoured social group or class (for example,
p.000025: groups defined by gender, ethnicity, or religion). In addition, policy- makers should seek to ensure that restrictions
p.000025: are not applied in a manner that imposes a disproportionate burden on vulnerable segments of society.
p.000025:
p.000025: • Communication and transparency —
p.000025: Policy-makers and public health officials should engage communities in a dialogue about any restrictions on freedom of
p.000025: movement and solicit community members’ views on how restrictions can be carried out with the least possible burden.
p.000025: They should also provide regular updates on the implementation of such measures,
p.000025: both to the public at large and to those whose movement has been restricted. Communication strategies should be
p.000025: designed to avoid the stigmatization
...

p.000047: or not they will be able to make appropriate contributions. In addition, foreign aid workers should be clearly
p.000047: informed of the conditions of their deployment, including the level of health care they can expect if they become ill,
p.000047: the circumstances under
p.000047: which they will be repatriated, available insurance, and whether benefits will
p.000047: be provided to their families in case of illness or death.
p.000047:
p.000047: • Provision of necessary training and resources — Aid workers must be provided with appropriate
p.000047: training, preparation, and equipment to ensure that they can effectively carry out their mission with the lowest risks
p.000047: practicable. Training should include preparation in psychosocial and communication skills, and in understanding and
p.000047: respecting the local culture and traditions. Managers and organizations have an obligation to provide adequate support
p.000047: and guidance to the staff, both during their activity in the field and following
p.000047: their mission. This should include training and resources for managing challenging ethical issues, such as resource
p.000047: allocation decisions, triage, and inequities.
p.000047:
p.000047: • Ensuring the security and safety of aid workers — Organizations that deploy foreign aid workers have an
p.000047: obligation to take all necessary measures to ensure the workers’ security, particularly in situations of crisis; this
p.000047: obligation includes the provision of measures to reduce risks of exposure to infectious agents, contamination and
p.000047: violence. A clear chain of authority must be in place to provide oversight and ongoing advice. Individuals who object
p.000047: to assigned duties should have an opportunity for review and appeal, according to the norms of the organizations for
p.000047: which they work.
p.000047:
p.000047: Aid workers also have their own ethical obligations to patients, affected communities, their sponsoring
p.000047: organizations, and themselves. In addition to the obligations described in other sections of this document, obligations
p.000047: of foreign aid workers include the following:
p.000047:
p.000047: • Adequate preparation — Aid workers should take part in any training that is offered. If they believe that the
p.000047: training they have been given is inadequate, they should bring their concerns to
p.000047: the attention of their organization managers. Foreign aid workers deployed during crises and where resources are scarce
p.000047: should carefully consider whether they are prepared to deal with ethical issues that may lead to moral and
p.000047: psychological distress.
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047: • Adherence to assigned roles and responsibilities — Aid workers should understand the roles and responsibilities
p.000047: they have been asked to assume and should not, except in the most extreme circumstances, undertake tasks they have not
p.000047: been authorized to perform. In addition, they should provide clear and timely information to both their sponsoring
p.000047: organizations and local officials and should understand that,
p.000047: if they go beyond the tasks they have been authorized to perform, they will be accountable not only within their
p.000047: own organizations but also under applicable local standards and laws.
p.000047:
...

p.000054: Toronto Joint Centre for Bioethics; 2005 (www.jcb. utoronto.ca/people/documents/upshur_stand_guard.pdf).
p.000054:
p.000054: Swiss Federal Office of Public Health. Swiss Influenza Pandemic Plan. Bern; 2013
p.000054: (www.bag.admin.ch/influenza/01120/01132/10097/10104/index.html?lang=en&download=
p.000054: NHzLpZeg7t,lnp6I0NTU042l2Z6ln1ad1IZn4Z2qZpnO2Yuq2Z6gpJCGenx6gWym162epYb g2c_JjKbNoKSn6A--).
p.000054:
p.000054: Venkat A, Wolf L, Geiderman JM, Asher SL, Marco CA, McGreevy J et al. Ethical issues in the response to Ebola virus
p.000054: disease in US emergency departments: a position paper of the American College of Emergency Physicians, the Emergency
p.000054: Nurses Association and the Society for Academic Emergency Medicine. J Emerg Nurs. 2015; Mar;41(2):e5-e16. doi:
p.000054: 10.1016/j.jen.2015.01.012 (www.ncbi.nlm.nih.gov/pubmed/25770003).
p.000054:
p.000054:
p.000054:
p.000054:
p.000054:
p.000054:
p.000054:
p.000054: Annex 2. Participants at meetings to formulate Guidance for managing ethical issues in infectious disease outbreaks
p.000054:
p.000054:
p.000054:
p.000054: Panel discussion: Ethical considerations for use of unregistered interventions
p.000054: for Ebola viral disease, World Health Organization, Geneva, 11 August 2014 55
p.000054:
p.000054: Advisors
p.000054: Dr Juan Pablo Beca, Professor, Bioethics Center, Universidad del Desarrollo, Chile
p.000054: Dr Helen Byomire Ndagije, Head, Drug Information Department, Ugandan National Drug Authority, Uganda
p.000054: Dr Philippe Calain (Chair), Senior Researcher, Unit of Research on Humanitarian Stakes and Practices, Médecins Sans
p.000054: Frontières, Switzerland
p.000054: Dr Marion Danis, Head, Ethics and Health Policy and Chief, Bioethics Consultation Service, National Institutes of
p.000054: Health, United States of America
p.000054: Professor Jeremy Farrar, Director, Wellcome Trust, United Kingdom Professor Ryuichi Ida, Chair, National Bioethics
p.000054: Advisory Committee, Japan
p.000054: Professor Tariq Madani, infectious diseases physician and clinical academic researcher, Saudi Arabia
p.000054: Professor Michael Selgelid, Director, Centre for Human Bioethics, Monash University, Australia
p.000054: Professor Peter Smith, Professor of Tropical Epidemiology, London School of Tropical Medicine and Hygiene, United
p.000054: Kingdom
p.000054: Ms Jeanine Thomas, Patient Safety Champion, United States of America
p.000054: Professor Aisssatou Touré, Head, Immunology Department, Institut Pasteurde Dakar,,Senegal Professor Ross Upshur, Chair
p.000054: in Primary Care Research; Professor, Department of Family and Community Medicine and Dalla Lana School of Public
p.000054: Health, University of Toronto; Canada
p.000054:
p.000054: Resource persons
p.000054: Dr Daniel Bausch, Head, Virology and Emerging Infections Department, US Naval Medical Research Unit No. 6, Peru
p.000054: Professor Luciana Borio, Assistant Commissioner for Counterterrorism Policy; Director, Office of Counterterrorism and
p.000054: Emerging Threats, Food and Drug Administration, United States of America
p.000054: Dr Frederick Hayden, Professor of Clinical Virology and Professor of Medicine, University of Virginia School of
p.000054: Medicine, United States of America
...

General/Other / cioms guidelines

Searching for indicator cioms:

(return to top)
p.000050: Political Rights. Geneva: American Association for the International Commission of Jurists; 1985
p.000050: (http://icj.wpengine.netdna-cdn.com/wp-content/uploads/1984/07/Siracusa-
p.000050: principles-ICCPR-legal-submission-1985-eng.pdf, accessed 23 July 2016).
p.000050:
p.000050: 9 United Nations Economic and Social Council. General Comment No. 14: The right to Highest Attainable Standard of
p.000050: Health (Art. 12 of the International Covenant on Economic, Social and Cultural Rights). New York: United Nations
p.000050: Committee on Economic, Social and Cultural Rights (E/C. 12/2000/4 – 2000; www1.umn.edu/
p.000050: humanrts/gencomm/escgencom14.htm, accessed 23 July 2016).
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050: 10 Parpia AS, Ndeffo-Mbah ML, Wenzel NS, Galvani AP. Effects of response to the 2014–2015 Ebola outbreak on deaths
p.000050: from malaria, HIV/AIDS, and tuberculosis, West Africa. Emerg Infect Dis. 2016;22(3)
p.000050: (http://dx.doi.org/10.3201/eid2203.150977, accessed 23 July 2016).
p.000050:
p.000050: 11 Declaration of Helsinki – Ethical principles for medical research involving human subjects, revised October 2013
p.000050: Ferney-Voltaire: World Medical Association; 2013 (www.wma.net/ en/30publications/10policies/b3/index.html, accessed 23
p.000050: July 2016).
p.000050:
p.000050: 12 International ethical guidelines for biomedical research involving human subjects.
p.000050: Geneva: Council for International Organizations of Medical Sciences; 2002 (www.cioms. 51
p.000050: ch/publications/guidelines/guidelines_nov_2002_blurb.htm, accessed 23 July 2016).
p.000050:
p.000050: 13 Standards and operational guidance for ethics review of health-related research with human participants. Geneva:
p.000050: World Health Organization; 2011 (www.who.int/ethics/ publications/9789241502948/en/, accessed 23 July 2016).
p.000050:
p.000050: 14 Ethics in epidemics, emergencies and disasters: Research, surveillance and patient care.
p.000050: Geneva: World Health Organization; 2015 (who.int/ethics/publications/epidemics- emergencies-research/en/, accessed 23
p.000050: July 2016).
p.000050:
p.000050: 15 Research ethics in international epidemic response. Geneva: World Health Organization; 2009 (WHO/HSE/GIP/ITP/10.1;
p.000050: www.who.int/ethics/gip_research_ethics_.pdf, accessed 23 July 2016).
p.000050:
p.000050: 16 Developing global norms for sharing data and results during public health emergencies. Geneva: World Health
p.000050: Organization; 2015 (www.who.int/medicines/ebola-treatment/ blueprint_phe_data-share-results/en/, accessed 23 July
p.000050: 2016).
p.000050:
p.000050: 17 Overlapping publications. International Committee of Medical Journal Editors (www.
p.000050: icmje.org/recommendations/browse/publishing-and-editorial-issues/overlapping- publications.html, accessed 23 July
p.000050: 2016).
p.000050:
...

General/Other / cultural difference

Searching for indicator culturally:

(return to top)
p.000015:
p.000015: public communication with health authorities.
p.000015:
p.000015: • Situations of particular vulnerability — As discussed further in Guideline 3, special attention should be given
p.000015: to ensuring that persons who face heightened susceptibility to harm or injustice during infectious disease outbreaks
p.000015: are able to contribute to decisions about infectious disease outbreak planning and response. Public health officials
p.000015: should recognize that such persons might be distrustful of government and other institutions, and make special efforts
p.000015: to include them in community engagement plans.
p.000015:
p.000015: • Openness to diverse perspectives — Communication efforts should be designed to facilitate a genuine
p.000015: two-way dialogue, rather than as merely a means to announce decisions
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015: that have already been made. Decision-makers should be prepared to recognize and debate alternative approaches and
p.000015: revise their decisions based on information they receive. Reaching out to the community early, and allowing for
p.000015: consideration of
p.000015: the interests of all people who will
p.000015: 16 potentially be affected, can play an important role in building trust and empowering communities to
p.000015: be involved in a genuine dialogue.
p.000015:
p.000015: • Transparency — The ethical principle of transparency requires that decision-makers publicly explain the basis for
p.000015: decisions in language that is
p.000015: linguistically and culturally appropriate.
p.000015: When decisions must be made in the face of uncertain information, the uncertainties should be explicitly acknowledged
p.000015: and conveyed to the public.
p.000015:
p.000015: • Accountability — The public should know who is responsible for making
p.000015: and implementing decisions in relation to the outbreak response, and how they can challenge decisions they believe are
p.000015: inappropriate.
p.000015:
p.000015: The media will play an important role in any infectious disease outbreak response effort. It is therefore important to
p.000015: ensure that the media has access to accurate and timely information about the disease and its management. Governments,
p.000015: nongovernmental organizations, and
p.000015: academic institutions should make efforts to support media training in relevant scientific concepts and techniques for
p.000015: communicating risk information without raising unnecessary alarm. Media training is important for public health sector
p.000015: employees who may interact with media covering public health issues.
p.000015: In turn, the media has a responsibility to provide accurate, factual, and balanced reporting. This is an important
p.000015: component of media ethics.
p.000015:
p.000015:
p.000015: Cholera outbreak in Sierra Leone
p.000015: Source: Fid Thompson
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000015: 3. Situations of particular vulnerability
p.000015:
p.000015:
p.000015:
p.000015:
p.000015:
p.000017: 17
p.000017: Questions addressed:
p.000017:
...

p.000035: minimized to the extent reasonably possible (e.g. administration under hygienic conditions; using
p.000035: the same safety precautions that would be used during a clinical trial, with close monitoring and access to emergency
p.000035: medication and equipment; and providing necessary supportive treatment). Only investigational products manufactured
p.000035: according to good manufacturing practices should be used for MEURI.
p.000035:
p.000035: • Collection and sharing of meaningful data — Physicians overseeing MEURI have the same moral
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035: obligation to collect all scientifically relevant data on the safety and efficacy of the intervention as researchers
p.000035: overseeing a clinical trial. Knowledge generated through MEURI should be aggregated across patients if possible and
p.000035: shared transparently, completely and rapidly with the MEURI scientific advisory committee, public health authorities,
p.000035: physicians and researchers in the country, and the international medical and scientific community.
p.000035: Information should be described accurately, without overstating benefits or understating uncertainties or risks.
p.000035:
p.000035: • Importance of informed consent — Individuals who are offered MEURI should be made aware that the intervention
p.000035: might not benefit
p.000035: them and might even harm them. The process of obtaining informed consent to MEURI should be carried out in a
p.000035: culturally and linguistically sensitive manner, with an emphasis on the content and understandability of the
p.000035: information conveyed and the voluntariness of the patient’s decision.
p.000035: The ultimate choice of whether to receive the unproven intervention must rest with the patient, if the patient is
p.000035: in a condition to make the choice. If the patient is unconscious, cognitively impaired, or too sick to understand the
p.000035: information, proxy consent should be obtained from a family member or other authorized decision-maker.
p.000035:
p.000035: • Need for community engagement —
p.000035: MEURI must be sensitive to local norms and practices. One way to try to ensure such sensitivity is to use rapid
p.000035: “community engagement
p.000035: teams” to promote dialogue about the potential benefits and risks of receiving
p.000035: interventions that have not yet been tested in clinical trials.
p.000035:
p.000035: • Fair distribution in the face of scarcity — Compounds qualifying for MEURI may not be available in large
p.000035: quantities. In this situation, choices will have to be made about who receives
p.000035: each intervention. Countries should 37
p.000035: establish mechanisms for making these allocation decisions, taking into account the assessment of the MEURI Scientific
p.000035: Advisory Committee and the principles discussed in Guideline 4.
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035:
p.000035: 10. Rapid data sharing
p.000035:
...

General/Other / declaration of helsinki

Searching for indicator helsinki:

(return to top)
p.000050:
p.000050: 7 Dawson A, Jennings B. The place of solidarity in public health ethics. Public Health Reviews. 2012;34(1):65–79.
p.000050:
p.000050: 8 Siracusa Principles on the Limitation and Derogation Provision in the International Covenant on Civil and
p.000050: Political Rights. Geneva: American Association for the International Commission of Jurists; 1985
p.000050: (http://icj.wpengine.netdna-cdn.com/wp-content/uploads/1984/07/Siracusa-
p.000050: principles-ICCPR-legal-submission-1985-eng.pdf, accessed 23 July 2016).
p.000050:
p.000050: 9 United Nations Economic and Social Council. General Comment No. 14: The right to Highest Attainable Standard of
p.000050: Health (Art. 12 of the International Covenant on Economic, Social and Cultural Rights). New York: United Nations
p.000050: Committee on Economic, Social and Cultural Rights (E/C. 12/2000/4 – 2000; www1.umn.edu/
p.000050: humanrts/gencomm/escgencom14.htm, accessed 23 July 2016).
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050:
p.000050: 10 Parpia AS, Ndeffo-Mbah ML, Wenzel NS, Galvani AP. Effects of response to the 2014–2015 Ebola outbreak on deaths
p.000050: from malaria, HIV/AIDS, and tuberculosis, West Africa. Emerg Infect Dis. 2016;22(3)
p.000050: (http://dx.doi.org/10.3201/eid2203.150977, accessed 23 July 2016).
p.000050:
p.000050: 11 Declaration of Helsinki – Ethical principles for medical research involving human subjects, revised October 2013
p.000050: Ferney-Voltaire: World Medical Association; 2013 (www.wma.net/ en/30publications/10policies/b3/index.html, accessed 23
p.000050: July 2016).
p.000050:
p.000050: 12 International ethical guidelines for biomedical research involving human subjects.
p.000050: Geneva: Council for International Organizations of Medical Sciences; 2002 (www.cioms. 51
p.000050: ch/publications/guidelines/guidelines_nov_2002_blurb.htm, accessed 23 July 2016).
p.000050:
p.000050: 13 Standards and operational guidance for ethics review of health-related research with human participants. Geneva:
p.000050: World Health Organization; 2011 (www.who.int/ethics/ publications/9789241502948/en/, accessed 23 July 2016).
p.000050:
p.000050: 14 Ethics in epidemics, emergencies and disasters: Research, surveillance and patient care.
p.000050: Geneva: World Health Organization; 2015 (who.int/ethics/publications/epidemics- emergencies-research/en/, accessed 23
p.000050: July 2016).
p.000050:
p.000050: 15 Research ethics in international epidemic response. Geneva: World Health Organization; 2009 (WHO/HSE/GIP/ITP/10.1;
p.000050: www.who.int/ethics/gip_research_ethics_.pdf, accessed 23 July 2016).
p.000050:
...

p.000053: guidelines.pdf).
p.000053:
p.000053: Ethics Subcommittee of the Advisory Committee to the Director, United States Centers for Disease Control and
p.000053: Prevention. Ethical guidance for public health emergency preparedness and response: Highlighting ethics and values in
p.000053: vital public health service. Atlanta: Centers for Disease Control and Prevention; 2008
p.000053: (www.cdc.gov/od/science/integrity/phethics/docs/
p.000053: white_paper_final_for_website_2012_4_6_12_final_for_web_508_compliant.pdf).
p.000053:
p.000053: Ethics Subcommittee of the Advisory Committee to the Director, United States Centers for Disease Control and
p.000053: Prevention. Ethical considerations for decision making regarding allocation of mechanical ventilators during a severe
p.000053: influenza pandemic or other public health emergency. Atlanta: Centers for Disease Control and Prevention; 2011
p.000053: (www.cdc. gov/about/pdf/advisory/ventdocument_release.pdf).
p.000053:
p.000053: Integrated national avian and pandemic influenza response plan, 2007–2009. In: Avian Influenza and the Pandemic
p.000053: Threats: Nigeria. Geneva: United Nations System Influenza Coordination Office
p.000053: (http://un-influenza.org/?q=content/Nigeria).
p.000053:
p.000053:
p.000053:
p.000053:
p.000053:
p.000053:
p.000053:
p.000053:
p.000053: National Advisory Board on Health Care Ethics. Ethical considerations related to preparedness for a pandemic. Helsinki:
p.000053: Ministry of Social Affairs and Health; 2005 (http://
p.000053: etene.fi/documents/1429646/1561478/2005+Statement+on+ethical+considerations+relate
p.000053: d+to+preparedness+for+a+pandemic.pdf/fc3f2412-acfc-4685-b427-ca710a43c103).
p.000053:
p.000053: National Ethics Advisory Committee. Getting through together: Ethical values for
p.000053: a pandemic. Wellington: Ministry of Health; 2007 (https://neac.health.govt.nz/system/files/
p.000053: documents/publications/getting-through-together-jul07.pdf).
p.000054: 54
p.000054: Notes on the interim US guidance for monitoring and movement of persons with potential Ebola virus exposure. Atlanta
p.000054: GA: Centers for Disease Control and Prevention; 2016 (www.
p.000054: cdc.gov/vhf/ebola/exposure/monitoring-and-movement-of-persons-with-exposure.html).
p.000054:
p.000054: Pandemic Influenza Ethics Initiative Workgroup. Meeting the challenge of pandemic influenza: Ethical guidance for
p.000054: leaders and health care professionals in the veterans health administration. Washington DC: National Center for Ethics
p.000054: in Health Care, Veterans Health Administration; 2010 (www.ethics.va.gov/docs/pandemicflu/Meeting_the_Challenge_of_
p.000054: Pan_Flu-Ethical_Guidance_VHA_20100701.pdf).
p.000054:
p.000054: Responding to pandemic influenza: The ethical framework for policy and planning. London: Department of Health; 2007
p.000054: (www.gov.scot/Resource/Doc/924/0054555.pdf).
p.000054:
p.000054: Stand on guard for thee: Ethical considerations in preparedness planning for pandemic influenza. Toronto: University of
p.000054: Toronto Joint Centre for Bioethics; 2005 (www.jcb. utoronto.ca/people/documents/upshur_stand_guard.pdf).
p.000054:
...

General/Other / participants in a control group

Searching for indicator placebo:

(return to top)
p.000030: an outbreak leaves a large number of children as orphans.
p.000030:
p.000030: • Gaining and maintaining trust — Failure to build and maintain community trust during the process of research
p.000030: design and implementation, or when disclosing preliminary results, will not only impede study recruitment and
p.000030: completion but may also undermine
p.000030: the uptake of any interventions proven to be efficacious. Engaging with affected communities before, during, and after
p.000030: a study is essential to build and maintain trust. In environments in which the public’s trust in government is fragile,
p.000030: researchers should remain as independent as possible from official public health activities. If government workers are
p.000030: themselves involved in
p.000030: conducting research, they should inform participants of this fact. Individuals who observe unethical practices carried
p.000030: out in the name of public health or emergency response efforts should promptly report them to ethics committees or
p.000030: other independent bodies.
p.000030: • Selecting an appropriate research 33
p.000030: methodology — Exposing research participants to risk is ethically unacceptable if the study is not designed in a manner
p.000030: capable of providing valid results. It is therefore imperative that all research be designed and conducted in a
p.000030: methodologically rigorous manner. In clinical trials,
p.000030: the appropriateness of features such as randomization, placebo controls, blinding or masking should be determined on a
p.000030: case-by-case basis, with attention to both the scientific
p.000030: validity of the data and the acceptability of the methodology to the community from which participants will be drawn.
p.000030: In studies relying on qualitative methods, the potential benefits of using methodologies such as focus groups (in which
p.000030: individual confidentiality cannot be guaranteed) or of interviewing traumatized victims should be balanced against the
p.000030: risks and burdens to the individuals involved.
p.000030:
p.000030: • Rapid data sharing: As WHO has previously recognized, every researcher who engages in generation of information
p.000030: related to a public health emergency or acute public health event with the potential to progress
p.000030: to an emergency has the fundamental moral obligation to share preliminary results once they are adequately quality
p.000030: controlled for release.16 Such information should be shared with
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030: public health officials, the study participants and affected population, and groups involved in wider international
p.000030: response efforts, without waiting for publication in scientific journals. Journals should facilitate
p.000030: this process by allowing researchers to rapidly disseminate information
p.000030: 34 with immediate implications for public
p.000030: health without losing the opportunity for subsequent consideration for publication in a journal.17
p.000030:
p.000030: • Assuring equitable access to the benefits of research — As
...


Orphaned Trigger Words



p.000055: Health Ethics team, supported by Andreas Reis and Maria Magdalena Guraiib.
p.000055:
p.000055: WHO is grateful to Carl Coleman for his role as lead writer, his analysis and synthesis of existing guidance documents,
p.000055: and his incorporation of comments generated during preparatory meetings and the broader peer review process.
p.000055:
p.000055: Appreciation is extended to the many individuals and organizations who provided comments on drafts of the guidance
p.000055: document, including: Alice Desclaux, Institut de Recherche pour le Développement, France; Aminu Yakubu, Federal
p.000055: Ministry of Health, Nigeria; Annick Antierens, Médecins Sans Frontières,
p.000055: Belgium; Bagher Larijani, Endocrinology and Metabolism Research Center, Iran (Islamic Republic of); Brad Freeman,
p.000055: Washington University School of Medicine, USA;
p.000055: Catherine Hankins, Amsterdam Institute for Global Health and Development, Netherlands; Cheryl Macpherson, Bioethics
p.000055: Department, St. George’s University School of Medicine, Grenada; Claude Vergès, Universidad de Panamá, Panama; Drue
p.000055: H Barrett, Nicole J Cohen, and Rita F Helfand, Centers for Disease Control and Prevention, USA; Dirceu Greco, Federal
p.000055: University of Minas Gerais, Brazil; Edward Foday, Ministry of Health and Sanitation, Sierra Leone; Emilie Alirol,
p.000055: Geneva
p.000055: University Hospitals, Switzerland; Heather Draper, University of Birmingham, United Kingdom; Kenneth Goodman, Miller
p.000055: School of Medicine, University of Miami, USA; Morenike Oluwatoyin Ukpong, Obafemi Awolowo University, Nigeria; Paul
p.000055: Bouvier, International Committee of the Red Cross, Switzerland; Ruth Macklin, Albert Einstein College of Medicine, USA;
p.000055: Voo Tech Chuan, Centre for Biomedical Ethics, National University of Singapore, Singapore.
p.000055:
p.000055: The advice, comments and guidance of the following entities are also gratefully acknowledged: COST Action IS 1201:
p.000055: Disaster Bioethics (in particular Dónal O'Mathúna, Dublin City University, Ireland; the staff of the Nuffield Council
p.000055: on Bioethics, United Kingdom (in particular Hugh Whittall); Johns Hopkins Berman Institute of Bioethics, USA (in
p.000055: particular Nancy Kass and Jeffrey Kahn); the International Severe Acute Respiratory and Emerging Infection Consortium,
p.000055: United Kingdom and its members (in particular Alistair Nichol, Irish Critical Care–Clinical Research Core, University
p.000055: College Dublin, Ireland, and Raul Pardinaz-Solis, Centre for Tropical Medicine and Global Health,
p.000055: University of Oxford, United Kingdom); and the Secretariat of the National Committee of Bioethics, King Abdulaziz City
p.000055: for Science and Technology, Kingdom of Saudi Arabia.
p.000055:
p.000055: WHO appreciates the collaboration of the Chairperson (Christiane Woopen, then
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055: Chair of the German Ethics Council) and members of the Steering Committee of the Global Summit of National
p.000055: Ethics/Bioethics Committees, who provided the opportunity to present an earlier draft of the Guidance to
p.000055: representatives of 83 national ethics committees at the Summit in Berlin in March 2016. Their review and comments have
p.000055: been incorporated into this document.
p.000055:
p.000055: The document also benefited from the review of the Global Network of WHO Collaborating Centers on Bioethics. Special
p.000055: thanks go to Ronald Bayer, the outgoing Chair of this network, and Amy Fairchild, Chair of the Guideline Development
p.000055: Group for the ethics of public health surveillance (both from Mailman School of Public Health, Columbia University,
p.000055: USA), and to the incoming Chair of the network, Michael Selgelid, Center for Human Bioethics, Monash University,
p.000055: Australia. The critical review by these individuals ensured that the guidance document was consistent with other
p.000055: ongoing projects.
p.000055:
p.000055: Many frontline responders and WHO staff members who are routinely challenged during epidemic outbreaks provided
p.000055: valuable contributions based on their personal experiences; the document is much richer in its content as a result. The
p.000055: WHO Research Ethics Committee and the Public Health Ethics Consultative Group provided valuable inputs, drawing
p.000055: especially on their review of research and public health projects undertaken during the Ebola and Zika outbreaks.
p.000055:
p.000055: WHO gratefully acknowledges the input of Ross Upshur, University of Toronto, Canada (first chair of the Ethics Working
p.000055: Group), and the subsequent co-chairs Lisa Schwartz, McMaster University, Canada, and Aissatou Touré, Institut Pasteur
p.000055: de Dakar, Senegal.
p.000055: Both co-chairs spent countless hours with the Secretariat and the lead writer to review thoughtfully the many comments
p.000055: received and to give final shape to the document.
p.000055: Philippe Calain, Médecins Sans Frontières,
p.000055: Switzerland, Chair of the Ethics Panel and a member of various ethics working
p.000055: groups, continuously challenged the WHO Secretariat to look beyond science to the 5
p.000055: people affected by the outbreaks, their cultures and their societies.
p.000055:
p.000055: The guidance document specifically benefited from reviews of the following WHO staff: Juliet Bedford, Carla Saenz
p.000055: Bresciani, Ian Clarke, Rudi J J M Coninx, Pierre Formenty, Gaya Manori Gamhewage, Theo Grace, Paul Gully, Brooke Ronald
p.000055: Johnson JR, Annette Kuesel, Anaïs
p.000055: Legand, Ahmed Mohamed Amin Mandil, Bernadette Murgue, Tim Nguyen, Asiya Ismail Odugleh-Kolev, Martin Matthew Okechukwu
p.000055: Ota, Bruce Jay Plotkin, Annie Portela, Marie-Pierre Preziosi, Manju Rani, Nigel Campbell Rollins, Cathy Roth,
p.000055: Manisha Shridhar, Rajesh Sreedharan, David Wood, and Yousef Elbes.
p.000055:
p.000055: A special thanks to Vânia de la Fuente Núñez, who was responsible for managing the Ethics Working Group; and Michele
p.000055: Loi who coordinated the whole process.
p.000055: Former interns of the Global Health Ethics team Patrick Hummel (University of
p.000055: St Andrews, United Kingdom) and Corinna Klingler (University of Munich, Germany) deserve a special mention for
p.000055: undertaking a scoping review in relation to pregnancy
p.000055: and infectious diseases, which informed the development of guidance in this area.
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055:
p.000055: The guidance document would not have been possible without the generous support of the Wellcome Trust. The kind support
p.000055: of the following partners is also very gratefully acknowledged: 3U Global Health Partnership; Canadian Institutes of ...

p.000028: isolate the patient until he or she is no longer infectious, assuming it is feasible to do so in a humane manner.
p.000028:
p.000028: • Impact on community trust — Overriding individuals’ refusal of diagnostic, therapeutic, or preventive measures
p.000028: can backfire if it leads members of the community to become distrustful of health-care providers
p.000028: or the public health system. Benefits from imposing unwanted interventions should be balanced against possible harms
p.000028: caused by undermining trust in the health-care system.
p.000028:
p.000028: Objections to diagnostic, therapeutic, or preventive measures should not be overridden without giving the individual
p.000028: notice and an opportunity to raise his or her objections before an impartial decision- maker, such as a court,
p.000028: interdisciplinary review panel, or other entity not involved in the initial decision. The burden should be on the
p.000028: proposer of the intervention to show that the expected public health benefits justify overriding the individual’s
p.000028: choice.
p.000028: The process for resolving objections should be conducted in an open and transparent manner, consistent with the
p.000028: principles discussed in Guideline 2.
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028:
p.000028: 8. Research during infectious disease outbreaks
p.000028:
p.000028:
p.000028:
p.000030: 30
p.000030: Questions addressed:
p.000030:
p.000030: • What is the appropriate role of research during an infectious disease outbreak?
p.000030: • How might the circumstances surrounding infectious disease outbreaks affect the ethical review of research
p.000030: proposals?
p.000030: • How might the circumstances surrounding infectious disease outbreaks affect the process of informed consent to
p.000030: research?
p.000030: • What methodological designs are appropriate for research conducted during infectious disease outbreaks?
p.000030: • How should research be integrated into broader outbreak response efforts?
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030: During an infectious disease outbreak there is a moral obligation to learn as much as possible as quickly as possible,
p.000030: in order to inform the ongoing public health response, and to allow for proper scientific evaluation of new
p.000030: interventions being tested. Such an approach will also improve preparedness for similar future outbreaks. Carrying out
p.000030: this obligation requires carefully designed and ethically conducted scientific research. In addition to clinical trials
p.000030: evaluating diagnostics, treatments or preventive measures such as vaccines, other types
p.000030: of research — including epidemiological, social science, and implementation
p.000030: studies — can play a critical role in reducing morbidity and mortality and addressing the
p.000030: social and economic consequences caused by the outbreak.
p.000030:
p.000030: Research conducted during an infectious disease outbreak should be designed and implemented in conjunction with other
p.000030: public health interventions. Under no circumstances should research compromise the public health response to an
p.000030: outbreak or the provision of appropriate clinical care. All clinical trials must be prospectively registered in an
p.000030: appropriate clinical trial registry.
p.000030:
p.000030: As in non-outbreak situations, it is essential to ensure that studies are scientifically
p.000030: valid and add social value; that risks are reasonable in relation to anticipated
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030:
p.000030: ...

p.000043: workers during infectious disease outbreaks?
p.000043: • What special obligations do workers in the health-care sector have during infectious disease outbreaks?
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: An effective infectious disease outbreak response depends on the contribution of
p.000043: a diverse range of frontline workers, some of whom may be working on a volunteer basis. These workers often assume
p.000043: considerable personal risk to carry out their jobs. Within the health-care sector, frontline workers range from
p.000043: health-care professionals
p.000043: with direct patient care responsibilities to traditional healers, ambulance drivers,
p.000043: laboratory workers, and hospital ancillary staff. Outside the health sector, individuals such as sanitation workers,
p.000043: burial teams, domestic humanitarian aid workers, and persons who carry out contact-tracing also play critical roles.
p.000043: Some of these workers may be among the least advantaged members of society, and have little control over the type of
p.000043: duties they are asked to
p.000043: perform. It is essential that frontline workers’ rights and obligations be clearly established during the pre-outbreak
p.000043: planning period,
p.000043: in order to ensure that all actors are aware of what can reasonably be expected if an outbreak occurs.
p.000043:
p.000043: Workers with certain professional qualifications, such as physicians, nurses, and funeral directors, may have a duty to
p.000043: assume a certain level of personal risk as part of their professional or employment commitments. Many frontline workers
p.000043: are not subject to any such obligations, and their assumption of risk must therefore be regarded as beyond the call of
p.000043: duty (i.e. “supererogatory”). This is particularly true for sanitation workers, burial teams, and community health
p.000043: workers, many of whom
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043:
p.000043: may have precarious employment contracts with no social protection, or work on
p.000043: a volunteer basis.
p.000043:
p.000043: Regardless of whether a particular individual has a pre-existing duty to assume
p.000043: heightened risks during an infectious disease outbreak, once a worker has taken on these
p.000043: 44 risks, society has a reciprocal obligation to
p.000043: provide necessary support. At a minimum, fulfilment of society’s reciprocal obligations to frontline workers requires
p.000043: the following actions:
p.000043:
p.000043: • Minimizing the risk of infection —
p.000043: Individuals should not be expected to take on risky work assignments
p.000043: during an infectious disease outbreak unless they are provided with
p.000043: the training, tools, and resources necessary to minimize the risks to the extent reasonably possible. This includes
p.000043: complete and accurate information known about the nature
p.000043: of the pathogen and infection control measures, updated information on the epidemiological situation at the local
p.000043: level, and the provision of personal protective equipment. Regular screening of frontline workers should be put
p.000043: in place to detect any infection as quickly as possible, in order to initiate immediate care and minimize the risk of ...

p.000047: to assigned duties should have an opportunity for review and appeal, according to the norms of the organizations for
p.000047: which they work.
p.000047:
p.000047: Aid workers also have their own ethical obligations to patients, affected communities, their sponsoring
p.000047: organizations, and themselves. In addition to the obligations described in other sections of this document, obligations
p.000047: of foreign aid workers include the following:
p.000047:
p.000047: • Adequate preparation — Aid workers should take part in any training that is offered. If they believe that the
p.000047: training they have been given is inadequate, they should bring their concerns to
p.000047: the attention of their organization managers. Foreign aid workers deployed during crises and where resources are scarce
p.000047: should carefully consider whether they are prepared to deal with ethical issues that may lead to moral and
p.000047: psychological distress.
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047: • Adherence to assigned roles and responsibilities — Aid workers should understand the roles and responsibilities
p.000047: they have been asked to assume and should not, except in the most extreme circumstances, undertake tasks they have not
p.000047: been authorized to perform. In addition, they should provide clear and timely information to both their sponsoring
p.000047: organizations and local officials and should understand that,
p.000047: if they go beyond the tasks they have been authorized to perform, they will be accountable not only within their
p.000047: own organizations but also under applicable local standards and laws.
p.000047:
p.000047: • Attention to appropriate infection control practices — Aid workers should be vigilant in adhering to infection
p.000047: control practices, both for their own protection and to prevent
p.000047: further transmission of disease. Aid 49
p.000047: workers should follow recommended protocols for monitoring symptoms and reporting their health status (including
p.000047: possible pregnancy), before, during and after their service.
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047: Influenza patient, Nepal
p.000047: Source: Tom Pietrasik, WHO
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047:
p.000047: References
p.000047:
p.000047:
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Appendix

Indicator List

IndicatorVulnerability
HIVHIV/AIDS
accessAccess to Social Goods
access to informationAccess to information
authorityRelationship to Authority
autonomyImpaired Autonomy
childChild
childbearing ageof childbearing age/fertile
childrenChild
ciomscioms guidelines
cognitiveCognitive Impairment
culturallycultural difference
dependentDependent
disabilityMentally Disabled
drugDrug Usage
educationeducation
emergenciespatients in emergency situations
emergencyPublic Emergency
employeesemployees
ethnicityEthnicity
familyMotherhood/Family
fetusFetus/Neonate
gendergender
helsinkideclaration of helsinki
hiv/aidsHIV/AIDS
homeProperty Ownership
illill
illnessPhysically Disabled
impairedCognitive Impairment
influenceDrug Usage
jobOccupation
languageLinguistic Proficiency
libertyIncarcerated
linguisticLinguistic Proficiency
mentallyMentally Disabled
militarySoldier
minorityRacial Minority
mothersMothers
officerPolice Officer
opinionphilosophical differences/differences of opinion
parentsparents
philosophyphilosophical differences/differences of opinion
placeboparticipants in a control group
politicalpolitical affiliation
poorEconomic/Poverty
povertyEconomic/Poverty
pregnantPregnant
propertyProperty Ownership
religionReligion
religiousReligion
restrictedIncarcerated
sickPhysically Ill
singleMarital Status
social statusEconomic/Poverty
stigmaThreat of Stigma
stigmatizationThreat of Stigma
threatThreat of Stigma
unconsciousUnconscious People
underdevelopedDeveloping Country
unionTrade Union Membership
violenceThreat of Violence
volunteersHealthy People
vulnerabilityvulnerable
vulnerablevulnerable
womenWomen

Indicator Peers (Indicators in Same Vulnerability)

IndicatorPeers
HIV['hiv/aids']
child['children']
children['child']
cognitive['impaired']
disability['mentally']
drug['influence']
hiv/aids['HIV']
home['property']
impaired['cognitive']
influence['drug']
language['linguistic']
liberty['restricted']
linguistic['language']
mentally['disability']
opinion['philosophy']
philosophy['opinion']
poor['poverty', 'socialXstatus']
poverty['poor', 'socialXstatus']
property['home']
religion['religious']
religious['religion']
restricted['liberty']
social status['poor', 'poverty']
stigma['threat', 'stigmatization']
stigmatization['stigma', 'threat']
threat['stigma', 'stigmatization']
vulnerability['vulnerable']
vulnerable['vulnerability']

Trigger Words

capacity

coercion

consent

cultural

developing

ethics

exploit

harm

justice

protect

protection

risk

sensitive

volunteer

welfare


Applicable Type / Vulnerability / Indicator Overlay for this Input

Vulnerability TypeVulnerabilityIndicator# Matches
Politicalpolitical affiliationpolitical4
Politicalvulnerablevulnerable15
Politicalvulnerablevulnerability10
HealthCognitive Impairmentcognitive1
HealthCognitive Impairmentimpaired1
HealthDrug Usagedrug10
HealthDrug Usageinfluence1
HealthHIV/AIDSHIV2
HealthHIV/AIDShiv/aids0
HealthHealthy Peoplevolunteers1
HealthMentally Disabledmentally2
HealthMentally Disableddisability1
HealthMotherhood/Familyfamily13
HealthPhysically Disabledillness4
HealthPhysically Illsick4
HealthPregnantpregnant5
HealthUnconscious Peopleunconscious1
Healthillill2
Healthof childbearing age/fertilechildbearing age1
Healthpatients in emergency situationsemergencies7
SocialAccess to Social Goodsaccess27
SocialAccess to informationaccess to information1
SocialChildchild1
SocialChildchildren3
SocialEthnicityethnicity1
SocialFetus/Neonatefetus1
SocialIncarceratedliberty8
SocialIncarceratedrestricted6
SocialLinguistic Proficiencylanguage2
SocialLinguistic Proficiencylinguistic3
SocialMarital Statussingle1
SocialMothersmothers1
SocialOccupationjob5
SocialPolice Officerofficer13
SocialProperty Ownershiphome6
SocialProperty Ownershipproperty1
SocialRacial Minorityminority2
SocialReligionreligion1
SocialReligionreligious2
SocialSoldiermilitary2
SocialThreat of Stigmastigma2
SocialThreat of Stigmathreat1
SocialThreat of Stigmastigmatization9
SocialThreat of Violenceviolence7
SocialTrade Union Membershipunion1
SocialWomenwomen8
Socialeducationeducation3
Socialemployeesemployees2
Socialgendergender21
Socialparentsparents1
Socialphilosophical differences/differences of opinionopinion3
Socialphilosophical differences/differences of opinionphilosophy1
EconomicEconomic/Povertypoor2
EconomicEconomic/Povertypoverty1
EconomicEconomic/Povertysocial status2
General/OtherDependentdependent1
General/OtherDeveloping Countryunderdeveloped1
General/OtherImpaired Autonomyautonomy2
General/OtherPublic Emergencyemergency26
General/OtherRelationship to Authorityauthority5
General/Othercioms guidelinescioms1
General/Othercultural differenceculturally2
General/Otherdeclaration of helsinkihelsinki2
General/Otherparticipants in a control groupplacebo1