As the coronavirus disease 2019 (COVID-19) crisis enters its next phase, attention turns to the widespread testing programs needed to resume and maintain normal life activities. Effective prevention and surveillance require testing for active infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and for antibodies that indicate prior infection and potential immunity. There is an established approach for infected individuals: mild cases self-isolate; and severe cases receive treatment. But what is the appropriate response for people with positive antibody tests?

Rallying cries around COVID-19 have shifted from “flatten the curve” to “reopen America.” After weeks of restrictions on movement, commerce, and social connections across most areas of the country, the tantalizing possibility of relaxing current measures in time for summer baseball and beach parties eroded the resolve of many communities in lockdown. At least 30 states have already moved to reopen some businesses or loosen stay-at-home orders against the warnings of health experts. In the context of a growing array of roadmaps intended to guide policy makers toward the next phase of the response, there is another rallying cry that needs to be heard most loudly right now: “Fund public health.”

Digital epidemiology—the use of data generated outside the public health system for disease surveillance—has been in use for more than a quarter century [see supplementary materials (SM)]. But several countries have taken digital epidemiology to the next level in responding to COVID-19. Focusing on core public health functions of case detection, contact tracing, and isolation and quarantine, we explore ethical concerns raised by digital technologies and new data sources in public health surveillance during epidemics. For example, some have voiced concern that trust and participation in such approaches may be unevenly distributed across society; others have raised privacy concerns. Yet counterbalancing such concerns is the argument that “sometimes it is unethical not to use available data”; some trade-offs may be not only ethically justifiable but ethically obligatory. The question is not whether to use new data sources—such as cellphones, wearables, video surveillance, social media, internet searches and news, and crowd-sourced symptom self-reports—but how.

In times of emergency, many legal strictures can flex. For example, to enable hospitals to respond to Covid-19, the Department of Health and Human Services (HHS) recently waived a swath of federal regulatory requirements. But though officials’ emergency powers are extensive, the ability to discard antidiscrimination protections is not among them. A hallmark of our legal system is that our commitment to prohibiting invidious discrimination remains steadfast even in times of emergency.

During the severe acute respiratory syndrome (SARS) outbreak in 2003, Taiwan reported 346 confirmed cases and 73 deaths. Of all known infections, 94% were transmitted inside hospitals. Nine major hospitals were fully or partially shut down, and many doctors and nurses quit for fear of becoming infected. The Taipei Municipal Ho-Ping Hospital was most severely affected. Its index patient, a 42-year-old undocumented hospital laundry worker who interacted with staff and patients for 6 days before being hospitalized, became a superspreader, infecting at least 20 other patients and 10 staff members. The entire 450-bed hospital was ordered to shut down, and all 930 staff and 240 patients were quarantined within the hospital. The central government appointed the previous Minister of Health as head of the Anti-SARS Taskforce. Ultimately the hospital was evacuated; the outbreak resulted in 26 deaths. Events surrounding the hospital’s evacuation offer important lessons for hospitals struggling to cope with the COVID-19 pandemic, which has been caused by spread of a similar coronavirus.

BACKGROUND

Research has consistently identified firearm availability as a risk factor for suicide. However, existing studies are relatively small in scale, estimates vary widely, and no study appears to have tracked risks from commencement of firearm ownership.

METHODS

We identified handgun acquisitions and deaths in a cohort of 26.3 million male and female residents of California, 21 years old or older, who had not previously acquired handguns. Cohort members were followed for up to 12 years 2 months (from October 18, 2004, to December 31, 2016). We used survival analysis to estimate the relationship between handgun ownership and both all-cause mortality and suicide (by firearm and by other methods) among men and women. The analysis allowed the baseline hazard to vary according to neighborhood and was adjusted for age, race and ethnic group, and ownership of long guns (i.e., rifles or shotguns).

RESULTS

A total of 676,425 cohort members acquired one or more handguns, and 1,457,981 died; 17,894 died by suicide, of which 6691 were suicides by firearm. Rates of suicide by any method were higher among handgun owners, with an adjusted hazard ratio of 3.34 for all male owners as compared with male nonowners (95% confidence interval [CI], 3.13 to 3.56) and 7.16 for female owners as compared with female nonowners (95% CI, 6.22 to 8.24). These rates were driven by much higher rates of suicide by firearm among both male and female handgun owners, with a hazard ratio of 7.82 for men (95% CI, 7.26 to 8.43) and 35.15 for women (95% CI, 29.56 to 41.79). Handgun owners did not have higher rates of suicide by other methods or higher all-cause mortality. The risk of suicide by firearm among handgun owners peaked immediately after the first acquisition, but 52% of all suicides by firearm among handgun owners occurred more than 1 year after acquisition.

CONCLUSIONS

Handgun ownership is associated with a greatly elevated and enduring risk of suicide by firearm. (Funded by the Fund for a Safer Future and others.)

As Covid-19 continues to exact a heavy toll, development of a vaccine appears the most promising means of restoring normalcy to civil life. Perhaps no scientific breakthrough is more eagerly anticipated. But bringing a vaccine to market is only half the challenge; also critical is ensuring a high enough vaccination rate to achieve herd immunity. Concerningly, a recent poll found that only 49% of Americans planned to get vaccinated against SARS-CoV-2.

Reopening colleges and universities during the coronavirus disease 2019 (COVID-19) pandemic poses a special challenge worldwide. At the start of the pandemic, Taiwan took proactive steps to contain the virus and implemented 124 action items in 5 weeks, resulting in only 446 confirmed cases, 7 deaths, and no domestic case for 67 consecutive days as of 18 June 2020. To accomplish this, the Taiwanese government adopted the strategy of strict border control and containment in the crucial first 3 months of the pandemic.

Millions of Americans have experienced the coronavirus pandemic directly, as they or their loved ones suffered through infection. But for most of us, the experience is defined by weeks and months on end stuck at home. The shut-ins are testing the safety of our home environments. Stress and isolation combined with another feature of American life — easy access to firearms — could form a deadly brew. Last week we released results of a new study — the largest ever on the connection between suicide and handgun ownership — in The New England Journal of Medicine revealing that gun owners were nearly four times as likely to die by suicide than people without guns, even when controlling for gender, age, race and neighborhood.

Nearly 120 million children in 37 countries are at risk of missing their measlescontaining vaccine (MCV) shots this year, as preventive and public health campaigns take a back seat to policies put in place to contain coronavirus disease 2019 (COVID-19). In March, the World Health Organization (WHO) issued guidelines indicating that mass vaccination campaigns should be put on hold to maintain physical distancing and minimize COVID-19 transmission. The disruption of immunization services, even for short periods, will lead to more susceptible individuals, more communities with less than the 95% MCV coverage needed for herd immunity, and therefore more measles outbreaks globally. A mere 15% decrease in routine measles vaccinations—a plausible result of lockdowns and disruption of health services—could raise the burden of childhood deaths by nearly a quarter of a million in poorer countries. Solutions for COVID-19, especially among the global poor, cannot include forgoing vaccinations.