Letter to the editors of the IJTLD addresses the issue of social stigma, a side effect of conventional contact tracing, and describes an approach which could help to reduce stigma and demystify COVID-19.
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This article was submitted on 7 April 2020 and accepted for publication on 14 April. Read the full text for more information, including the acknowledgments and citations.
Authors: G. Sotgiu, G. Carta, L. Suelzu, D. Carta, G B. Migliori.
We read with interest the article by Nguyen et al. on the importance of adapting tuberculosis (TB) contact investigation strategies to the current COVID-19 epidemic, which has hit low-, middle-, and high-income countries.
The identification of close contacts of infected cases is a necessary public health intervention to reduce the incidence of infected cases and deaths. Infected people can spread the virus in the community through sneezing and coughing. This needs to be adequately managed through reliable public health measures (e.g., use of surgical masks, social distancing, home or hospital confinement) to contain ongoing viral transmission. However, a side effect of conventional contact tracing, which is well documented in high TB incidence settings, is social stigma. The detection of the source and/or index case (single patient and/or family members) can favour a “witch-hunt” hysteria, particularly in villages and small towns. The fear of being stigmatised in this way leads to a delay in presentation and/or under-detection of contagious patients. The lack of appropriate medical care increases the risk of clinical complications and death, and the failure to isolate infectious sources leads to unchecked propagation of the virus within the community.
Social stigma is often associated with discrimination and exclusion, and is usually associated with a low level of education. However, cases of social stigma have also been described in high-income countries, with higher than average levels of education. The current COVID-19 pandemic has raised fears in the general population, mainly because of a large number of uncertainties over the novel coronavirus, including how contagious it is, the role of asymptomatic cases and fomites in transmission, and the highly variable course of the disease. Misinformation via traditional media—and especially via social media—can increase the risk of stigmatisation and undesirable behaviours (e.g., physical and psychological violence).
Health education is one of the key ways in which to address stigmatisation. The WHO defines health education as any combination of learning experiences tailored to support persons and communities to improve their health by improving their knowledge and affecting their behaviours and attitudes. An example of this approach comes from the small Italian town of Trinità d’Agultu e Vignola in Northern Sardinia (population 2,208). The residents decided to address the challenges of COVID-19-related misinformation and social stigma through health education of the local population. The mayor, the councillor for tourism and a few citizens sought the assistance of specialists in epidemiology and respiratory infectious diseases to organise live online events for the community (the so-called “Trinità health educational model”). The primary aim of this interactive programme was to explain the key features of the COVID-19 epidemic (natural history of the infection, detection of vulnerable groups in the community, personal protective equipment, contagiousness, risk of social stigma and discrimination) to change or prevent dangerous behaviours and attitudes. The professional expert provided a short briefing on SARS-CoV-2 features, and this was followed by a question and answer session, where every citizen could ask questions on an issue of concern and receive a direct answer from the speaker (Table in full text). Sessions were organised on two consecutive Saturday afternoons in March and April 2020. The events were promoted to the local community using official and other channels (e.g., the Council website, Facebook and WhatsApp groups), and were well attended, with many questions (more than 60 per session) being raised and discussed.
There has been a positive and enthusiastic response to the sessions, and subsequent messages on social networks appear more positive about the epidemic than those posted prior to the events. Furthermore, representatives of the municipality have received fewer messages of concern over the epidemic. The mayors of a number of other small towns in Italy have since decided to implement similar educational sessions on public health. We believe that the broader adoption of this approach would help to reduce stigma and demystify COVID-19. We encourage all countries to engage with their communities through a similar series of educational sessions.