Pandemic and infodemic: the role of academic journals and preprints

"Elle ne pouvait être que le témoignage de ce qu'il avait fallu accomplir et que, sans doute, devraient accomplir encore, contre la terreur et son arme inlassable,…Car il savait ce que cette foule en joie ignorait, et qu'on peut lire dans les livres, que le bacille de la peste ne meurt ni ne disparaît jamais, qu'il peut rester pendant des dizaines d'années endormi….la peste réveillerait ses rats et les enverrait mourir dans une cité heureuse." (Albert Camus "La Pestes", 1947)

“It could be only the record of what had had to be done, and what assuredly would have to be done again in the never ending fight against terror and its relentless onslaughts,…He knew what those jubilant crowds did not know but could have learned from books: that the plague bacillus never dies or disappears for good; that it can lie dormant for years and years…it would rouse up its rats again and send them forth to die in a happy city.” ("The Plague", translation by Stuart Gilbert)

In March 2020, the World Health Organization (WHO) has declared coronavirus infectious disease-2019 (COVID-19) outbreak a pandemic. It had soon become clear that this virus was highly contagious and the mortality rate was high, so that reliable information became urgently required to treat patients and to prevent the risk of cross-transmission of infection to other patients and to healthcare workers. We healthcare workers had taken all possible efforts to save patients, but it was not an easy task, because the flames of fear about the epidemic were being fanned by “infodemic”: rumors and misinformation disseminated by mass media, social media, and even by governments.

Infodemic, a portmanteau of “information” and “epidemic”, refers to the rapid spread of information—both accurate and inaccurate—about something, such as a disease. This word was coined by David J. Rothkopf during the outbreak of severe acute respiratory syndrome (SARS) and first used in his following commentary made in The Washington Post in 2003 [1].

“SARS is the story of not one epidemic but two, and the second epidemic, the one that has largely escaped the headlines, has implications that are far greater than the disease itself. That is because it is not the viral epidemic but rather an "information epidemic" that has transformed SARS,…into a global economic and social debacle…What is more, the information epidemic—or "infodemic"—has made the public health crisis harder to control and contain.”

(Rothkopf DJ: The Washington Post. 11th May, 2003) [1]

Tedros Adhanom Ghebreyesus, the Director-General of the WHO, stated shortly before declaring pandemic (on 15th February, 2020) that “…we’re not just fighting an epidemic; we’re fighting an infodemic” [2]. This was followed by the statement that “[f]ake news spreads faster and more easily than this virus, and is just as dangerous”. Nevertheless, since the WHO's declaration of the pandemic, some mass media advocated PCR testing to everyone, and promoted numerous “effective” preventative and treatment methods of COVID-19, and some social media platforms discouraged vaccination, but these were largely not evidence-based [3].

So, how healthcare workers have managed infodemic? Source of information included scientific articles which have gone through peer-review, those not peer-reviewed, textbooks, governmental statements, mass media reports, and social media information. To practice evidence-based clinical decision making, it was necessary to gain access to reliable sources of information, such as peer-reviewed randomized controlled studies, meta-analyses, and systematic reviews.

One major practical problem with obtaining reliable information had been that considerable time was required until randomized controlled studies and systematic reviews were published in peer-review journals. Therefore, until these have become available, it was necessary to obtain information from statements made by academic societies, or reports made by healthcare workers on the social media. Nevertheless, caution was required in incorporating these information to aid clinical decision making. For example, one anesthesiologist designed an acrylic “Aerosol box” (or aerosol containment device) as a part of personal protective equipment (PPE) during airway management, and shared his idea on social media. This idea was picked up by an influential medical journal [4], and the use of such a device has rapidly spread worldwide, without being formally assessed for its effectiveness, efficacy and safety. However, subsequent studies have indicated that any “aerosol containment device” would make airway management more difficult, and the use of the device may not decrease, but even increase, the risk of healthcare workers being exposed to a high concentration of viral aerosols [5]. This example clearly indicates that healthcare workers have needed to keep updating their knowledge with new studies published in peer-review journals, to make sure that daily clinical practice is based on the currently available evidence.

So, what efforts have clinical researchers made to accelerate publication of medical articles during the pandemic? One effective method heavily used during this pandemic was publicizing their studies as preprints. Preprints are scientific manuscripts which the authors posted online, before submitting them to peer-review journals. Paul Ginsparg, a physicist, was the first to launch a preprint server, aiχiv.org (pronounce it “archive”), in 1991 [6]. This was well accepted by physicists who previously distributed paper copies of their drafts by post to peer researchers.

In contrast, before the outbreak of COVID-19 pandemic, clinical researchers were generally reluctant to adopt widespread sharing of preprints, probably because of concern that the potential harm that could result to patients, if medical treatment is based on findings that have not been vetted by peer reviewers. For example, the BMJ group opened a preprint server (ClinMedNetPrints.org) in 1999, but was closed in 2008, because only around 80 submissions were posted during this period [7]. The BMJ group, together with Cold Spring Harbor Laboratory and Yale University launched a new server, bioRχiv in 2013, and medRχiv in 2019 [7], but they were not actively used.

Outbreak of COVID-19 pandemic triggered clinical researchers to use actively preprint servers, and during the initial few years of the COVID-19 pandemic, more than 35,000 preprints, mainly related to COVID-19, have been posted to medRχiv. This marked increase in the posting of preprints indicates that clinical researchers have found benefits of preprints in the era of COVID-19 pandemic: research outcomes can be disseminated quickly, potentially speeding up research that may lead to the development of vaccines and treatments; quality of the draft can be improved by receiving feedback from a wider group of readers; the authors can claim priority of their discovery; and unlike articles published in subscription-based journals, all the preprints are freely available to anyone.

Because of these reasons, preprints have become potentially useful source of information. Nevertheless, healthcare workers should not, in principle, have use preprints for clinical decision making and policy formation. The medχRiv, for example, states in bold letters that “[t]hey should not be relied on to guide clinical practice or health-related behavior and should not be reported in news media as established information” (medχRiv Submission guide). In fact, a considerable number of preprints has already been retracted [8].

One possible problem for clinical researchers who uploaded their drafts to preprint servers is that some journals may refuse to publish the drafts, if they have already been published as preprints. For example, in anesthesia field, the Journal of Anesthesia [9] and the British Journal of Anaesthesia [8] do not regard preprints as prior publication, but the Anesthesiology does [10].

What then traditional peer-review journals have done to address the issue of the “two epidemics”? Journals, including the Journal of Anesthesia, have taken much efforts to accelerate the review process, to make a quick decision to accept or not accept for publication, and to publish accepted articles instantly as Epub ahead of prints. In addition, subscription-based journals, in principle, have made all the articles related to COVID-19 fee to read, download and share. The Journal of Anesthesia has actively published articles related to COVID-19, and published an issue containing “Special Feature on Anesthesia in the Time of COVID-19”. Some of these articles have been frequently cited (Table 1) [3, 5, 11–18], indicating that clinicians have regarded these articles as reliable source of information, for performing evidence-based treatment of patients with COVID-19.

Table 1.

Ten most frequently cited articles related to the COVID-19

First author	Title	Reference number
Hasanin A.	Evaluation of fluid responsiveness during COVID-19 pandemic: what are the remaining choices?	[11]
Zhang L.	Summary of 20 tracheal intubation by anesthesiologists for patients with severe COVID-19 pneumonia: retrospective case series	[12]
Hotta K.	Regional anesthesia in the time of COVID-19: a minireview	[13]
Saito T.	Aerosol containment device for airway management of patients with COVID-19: a narrative review	[5]
Hirota K.	Air contamination with SARS-CoV-2 in the operating room	[14]
Gai N.	Unique challenges in pediatric anesthesia created by COVID-19	[15]
Yamakage M.	Anesthesia in the times of COVID-19	[16]
Wong P.	Aligning difficult airway guidelines with the anesthetic COVID-19 guidelines to develop a COVID-19 difficult airway strategy: a narrative review	[17]
Asai T.	COVID-19: accurate interpretation of diagnostic tests—a statistical point of view	[3]
Burnett GW.	Managing COVID-19 from the epicenter: adaptations and suggestions based on experience	[18]

During the last few years, numerous studies related to COVID-19 have been published in peer-review journals, so it has increasingly been difficult for clinicians to find suitable articles to aid clinical decision making. Systematic reviews and clinical practice guidelines were urgently required, but those were not instantly available. To address this issue, some newer types of guidelines have been developed [19]: focused clinical practice guidelines, living clinical practice guidelines, or consensus statements. Journals have also actively published editorials as mini-review articles, and have actively used social media to pick up published articles which should be useful for clinicians.

So, have we managed to control pandemic and infodemic, and have the journals played crucial role in actively providing reliable information? A definite answer is yet to be provided, but it would be yes, as we are coming back to normal life. Should the journals now end their role in publishing articles related to COVID-19? The answer is definitely no. This is because another epidemic or pandemic will certainly occur, 100 years, 10 years, or even a few years later.

During the initial period of the outbreak of COVID-19, healthcare workers could use the knowledge that obtained during the SARS occurring in 2003 [20, 21]. Therefore, as Albert Camus wrote in his "La Pestes" ("The Plague"), the journals should keep publishing useful articles, to record what had had to be done, and what assuredly would have to be done in managing pandemic and infodemic. By doing so, healthcare workers would be able to utilize lessons from what we have achieved during the COVID-19 pandemic, to control effectively future pandemic and infodemic.

Data availability

There are no data obtained for this report.