Alongside fighting the virus is fighting misinformation
CLINICAL MATTERS
Dr. Edsel Maurice T. Salvana
Misinformation and disinformation have made the COVID-19 pandemic much more difficult to deal with from a scientific standpoint. The uncertainty that is inherent to a new virus coupled with the need for scientists to constantly recalibrate the evidence have been exploited by antivaxxers and epistemic trespassers. Evidence-based medicine clearly has limits, especially in the face of an unknown threat, and so policies sometimes need to be urgently decided with less than ideal data.
Those of us tasked to advise the government response have had to work with incomplete information, and to adjust on the fly as new information trickles in. On top of this uncertainty, the virus continues to mutate and behave differently, necessitating changes in recommendations which internet trolls use to attack otherwise scientifically justifiable actions.
One of the best ways to guard against fake news is to constantly educate the public. True scientists and doctors are always open to new findings and are willing to set aside previous advice when better evidence emerges. An informed public is much more resilient against biased and deceptive reporting, and experts don’t have to work as hard going after fake news.
Here are a few ways to better understand and act on information, with some recent real-life examples.
- Understand the limits of the current evidence. Sometimes a leap of faith is justified, and sometimes it is best to change a previous recommendation.
An early example of inadequate evidence leading to a recommendation, which eventually got modified, is the use of face masks by asymptomatic people. Based on what was known about COVID-19 early on, most scientists assumed that SARS-CoV-2 behaved in much the same way as the original SARS virus. SARS was only contagious when someone was symptomatic, and there was no reason to assume COVID-19 was any different. At that time the best evidence for surgical masks was for preventing transmission of virus from an infected person, and there was little evidence that surgical masks could prevent infection when worn by a healthy person. Due to these facts, the World Health Organization (WHO) and the United States Centers for Disease Control (CDC) did not recommend wearing of surgical masks for the general public unless they had symptoms.
As more data was gathered on transmission dynamics and viral loads in presymptomatic and asymptomatic individuals, it became clear that individuals without symptoms were able to transmit virus, though not as efficiently as symptomatic individuals. The scientific community then embraced mask wearing for everyone, and this has helped to greatly decrease community transmission of COVID-19.
Having learned our lesson that insisting on waiting for stronger evidence could be detrimental to public health, the use of face shields was recommended in the Philippines by various expert groups in order to serve as another layer of protection. There is good prospective clinical data from India as well as data modeling on virus transmission from multiple sources that show that adding an extra layer on top of the mask further increases protection. Even if the virus does manage to get through, the multiple layers of protection will decrease the number of infectious particles inhaled. The less virus inhaled, the less likely someone will develop severe disease. The use of face shields on top of face masks may very well be one of the factors that has led to the Philippines having one of the lowest deaths per million cases worldwide, despite having a relatively high case load.
It therefore does not make sense that some groups are calling for scrapping the face shield requirement just as more infectious variants are starting to appear. After learning our lesson with not using face masks at the start of the pandemic, why would we then reject the current evidence for face shields when the delay in use of face masks likely cost lives early on? Is it not better to err on the side of caution, especially with reports that the Delta variant can be transmitted in under a minute? I for one, despite being fully vaccinated, am keeping my face shield and face mask on.
Those pushing ivermectin are using a similar argument, that delay in use of ivermectin will result in more deaths if more data were required before use. The question they ask is why we should not use ivermectin if there is some evidence that it may be of benefit. There are many differences between face shields and ivermectin, foremost of which is that one does not ingest face shields (I hope). Ivermectin, even at the usual doses for treating worms, has been known to occasionally cause serious neurologic side effects. The proposed doses for COVID-19 are about five times higher than that used for worms. Going over the latest evidence and a recent meta-analysis from the journal Clinical Infectious Diseases, there is no strong evidence of any benefit. Weighing this against the potential harm, WHO, CDC, and the local specialty medical societies do not recommend using ivermectin for prophylaxis or treatment of COVID-19. The major difference between face shields and ivermectin in terms of recommendation is the potential for harm with the latter.
What about compassionate use? Compassionate use is for medications that are not yet approved for a particular indication but have some evidence backing up efficacy. This needs to be weighed against the risk of not giving the drug, in other words severe or life-threatening illness. Therefore, use of ivermectin for prophylaxis, asymptomatic or mild disease under compassionate use is not appropriate. For severe disease, this can be a judgement call. Use of remdesivir and favipiravir are also judgement calls. In other words, it’s a case-to-case basis for very sick patients, and the doctor takes responsibility.
Other medications used early on for compassionate use for COVID-19 included hydroxychloroquine, lopinavir/ritonavir, and interferon. These were quickly dropped as more stringent studies showed that none of these helped with recovery or survival.
- Learn to detect cherry-picking, when data are skewed toward a conclusion that a writer wants to support. Differentiate news from opinion.
Cherry picking data involves taking only the data points that support a writer’s thesis or preformed assertion. This leaves out or minimizes inconsistent information, and highlights and magnifies evidence that supports the favored point of view.
Many Western media outlets released sensationalist headlines stating that there were surges of COVID-19 in countries using Chinese vaccines. These reports conveniently left out the fact that COVID-19 cases, especially from the Delta variant, were likewise surging in many countries that used non-Chinese vaccines. Moreover, a closer look at the cases showed that many of the cases of COVID-19 were either unvaccinated or partially vaccinated, and the breakthrough cases among the fully vaccinated were mild or asymptomatic.
One report of an outbreak among Indonesian healthcare workers who were fully vaccinated with Sinovac asserted that over 300 got sick and “dozens” were hospitalized, without clarifying how many were exposed, and how many unvaccinated patients in comparison fell ill. Many outlets used this report to assert that Chinese vaccines were not effective against the Delta variant, when it was unclear whether these individuals were even infected with the Delta variant. Incomplete data and jumping to conclusions undermine vaccine confidence, ultimately costing lives.
- Epistemic trespassing muddles issues.
Epistemic trespassing is defined as a situation where someone with competence or expertise in one field moves onto a different field and passes judgment, despite lacking knowledge and skill in the other field.
This is different from when lay people in social media disagree with doctors, since there is a clear delineation of expertise in this situation. Nevertheless, antivaxxers with little or no training in medicine regularly dispute scientifically sound information. This in itself is very harmful because some of these people are social media influencers who can spread inaccurate and dangerous information.
A real-world example of epistemic trespassing is when an expert in one field of medicine confidently dispenses advice on prevention and treatment of a disease in another field. The fields specialized for treating COVID-19 are infectious diseases and pulmonology. Therefore a surgeon proposing an antihelminthic to treat a virus, contradicting the recommendations of the infectious diseases professional society, is an egregious example of overstepping the bounds of expertise. Persons outside the healthcare professions are less likely to differentiate doctors according to subspecialty and may accept inappropriate recommendations that can cause a lot of harm.
With the volume of information available on social media and mainstream media, the challenge is no longer a lack of data, but proper curation. Learning to sift through the sometimes contradictory assertions and recommendations is the key to surviving in this age of information. A healthy amount of skepticism toward each post and tidbit of news is necessary to inoculate ourselves against half-truths and lies.